Global Mental Health: Finally Finding its Role in International Development

Dr Julian Eaton is an Assistant Professor at London School of Hygiene and Tropical Medicine and a Senior Mental Health Advisor for CBM. His research focuses on mental health in primary care, and specialises in regions of the Middle East, North Africa and Sub-Saharan Africa. In this blog, he tracks the growth of global mental health, outlines some of its challenges and critiques, and takes a look at where it might go from here.  

Those living with mental illness are some of the world’s most marginalised people, particularly in low and middle-income countries. Mental health conditions such as depression are the leading cause of disability worldwide, can cause immense suffering, and can prevent people from earning a living or participating in their community. Until recently, however, mental health was conspicuously absent from the fields of global health and international development.

At the turn of the millennium, there was no recognised field termed ‘Global Mental Health’.  Mental health did not feature in the Millennium Development Goals, and reform was far from the political agenda. Instead, small projects worked in an isolated way in low income settings, dangling upon precarious financing. Health systems in poorer countries were dominated by institutions, large specialist hospitals, and academics (who defined themselves as working either in international mental health, or culture and mental health). These bodies focused on cultural concepts around mental health, questioning the degree to which a common approach to addressing mental health needs was even appropriate or desirable.

There were several drivers to changing this status quo:

  • First, the need was quantified by a shift towards incorporating morbidity (or even disability) into the measurement of disease burden. When we moved from just valuing what kills people early, to considering years of life lived with disability, then the huge proportion of total global burden of disease attributable to mental conditions suddenly became apparent. Importantly this was not only empirically measured for the first time, but as it was readily comparable, the numbers screamed out an injustice of resources.
  • Second, effective interventions became better evidenced (through respected methodologies like trials), and a consensus was reached about a sensible framework for services reform – we had a challenge to the hopelessness that had been previously pervasive in the field.
  • Third, these developments contributed to an increasingly positive political will. Other elements that also contributed to this gradual acceptance of messages about mental health as a global development priority included key reports such as the World Health Report 2001 on Mental Health. There was a broad acceptance that it was appropriate to intervene – even neglectful not to – and that this could be done in a culturally appropriate way. Coupled with this was a greater acceptability of talking about mental health issues in the public space.

These positive changes in the academic, activist and political environments allowed for informal coalitions to emerge and gain traction in presenting a coherent message advocating for increased attention to mental health on the development agenda, and ultimately for greater investment. Probably the best place to find the emerging consensus articulated is in the Lancet Series on Global Mental Health (2007), most succinctly in the final Call to Action. This called for a mobilisation of resources, combined with focused research within the field, and implementation effort to a) close the treatment gap, and b) address the human rights abuses that characterise the experience of living with mental illness in many countries. A follow-up Lancet Series in 2011 takes many of these ideas forward, and is a good primer in Global Mental Health.

So, what has been achieved in the 10 years since the first Lancet series issued its Call to Action? A huge amount of growth has occurred in research in Global Mental Health. This has mainly focused on the aim of closing the treatment gap in terms of reform for increased service coverage; there has been a successful argument made that this requires a paradigmatic shift towards decentralised services, integrated particularly into primary health care, and run by non-specialists. An array of accessible, evidence-based guidelines have emerged to support this process, such as the WHO’s mhGAP resources, alongside practical training materials to support availability of pragmatic, psychological interventions that can be used for a wide range of common mental health conditions. Many countries have made significant progress in deinstitutionalisation, though huge gaps remain in provision of care, particularly for people with severe mental health conditions.

Mental health stakeholders in many countries have become better organised, for example, with coalitions and increased engagement with decision-makers. Organisations led by people affected by mental health issues remain in the early stages of development for many countries, but represent a radical and important departure from norms of power. Furthermore, through the Convention on the Rights of Persons with Disabilities, important new opportunities have arisen for stakeholders to have a voice in the structured processes of holding governments to account. The QualityRights toolkit supports capacity building in civil society for a truly transformative change that addresses the issues that really matter to people; being treated with dignity and having a say in decisions about treatment.

This is partly also reflected in more coherence within global alliances and networks for mental health; but these are still slightly diffuse, with no single global organisation taking the lead. This is likely a good thing given the diversity of voice. Inputs range from implementer networks like the Mental Health Innovation Network and, to service user organisations like the World Network of Users and Survivors and the Pan African Network or People with Psychosocial Disabilities. Further contributions range from advocacy networks like the Movement for Global Mental Health, and academic departments starting in schools of public health, like the Centre for Global Mental Health.

The most obvious demonstration of success in raising mental health on the global agenda is the fact that it is core to the Sustainable Development Goals, being identified specifically in Goal 3: Health and Wellbeing For All. Mental health also features in many other parts of the SDGs, and is an essential element of attaining Universal Health Coverage, and of realising the aspiration of leaving no-one behind. This is an important opportunity, given the SDG’s role in guiding priorities, and increased interest from both bilateral (DfID, USAID, GIZ etc), and also multilateral agencies reflects this (tough concrete investment is further down the line).

In April 2016, the World Bank held its first major meeting on mental health, Out of the Shadows, highlighting the increased recognition of the financial burden of mental ill health on families, businesses, and economies of countries. They estimated that the cost to the global economy was in the region of USD 2.5 trillion, and will rise to USD 6 trillion by 2030. Such estimates have placed mental health on the agenda at the World Economic Forum, and were echoed in a recent report, Thriving at Work, by the UK Government and Mind. A recognition of costs to society is an important step in galvanising investment in solutions.

Perhaps most importantly is a gradual shift in willingness for the general population to discuss mental health, and to challenge the environment in which stigma thrives. Public figures in sport, media and politics have contributed to this greater openness (which is still more evident in the global north than south). Several campaigns have aimed to do this using a structured, public health approach; Heads Together and Time to Change are UK-based examples. In 2017, World Health Day was devoted to mental health (for the first time since 2001), and the global ‘Depression Let’s Talk’ campaign did a good job of taking a common message, with local variation, to many countries.

So where do we go from here? The work is far from done – it is clear that there needs to be a broadening of the agenda to encompass more population-wide approaches to address some of the social determinants that lead to increases in prevalence of mental conditions in the first place. Suicide, which kills around a million people a year, and is the single leading cause of death in young people in many countries, is an example of an area where treatment only plays a small role. Housing, poverty, interpersonal violence, climate change, migration, pressure on students in education, etc, are all areas that affect mental health, and we need to understand how we can ensure that mental health as a global field engages with these issues.

A greater ability to talk about mental health as a contributor to living a good life, while not forgetting those already affected by ill health, will lead, I think, to a maturing of the field, and an opportunity to realise the potential that mental health has to contribute to global development.

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