Empowerment and partnership in mental health

The rights of people with mental disorders: WPA perspective

Human resources for mental health care: current situation and strategies for action

Human resources for mental health care in low- and middle-income countries are inadequate to meet the growing public health burden of neuropsychiatric disorders. Information on actual numbers is scarce, however. The aim of this study was to analyse the key human resource constraints and challenges facing Zambia's mental health care system, and the possible solutions. This study used both qualitative and quantitative methodologies. The WHO-AIMS Version 2.2 was utilized to ascertain actual figures on human resource availability. Semi-structured interviews and focus group discussions were conducted to assess key stakeholders’ perceptions regarding the human resource constraints and challenges. The results revealed an extreme scarcity of human resources dedicated to mental health in Zambia. Respondents highlighted many human resource constraints, including shortages, lack of post-graduate and in-service training, and staff mismanagement. A number of reasons for and consequences of these problems were highlighted. Dedicating more resources to mental health, increasing the output of qualified mental health care professionals, stepping up in-service training, and increasing political will from government were amongst the key solutions highlighted by the respondents. There is an urgent need to scale up human and financial resources for mental health in Zambia.

Mental disorders are a major public health challenge globally, contributing to 40% of the global burden of disease. Nevertheless, it remains highly neglected by health planners and policy makers, particularly in low and middle income countries (LMIC). Bangladesh, one of the low-income countries, suffers from a severe shortage of appropriately trained and an adequate number of human resources to provide mental health care. The authors reviewed available evidence on the dynamics of mental health services in LMIC like Bangladesh, with a view to help develop appropriate policies on human resources. This chapter critically examines the current situation of human resources for mental health in Bangladesh, and explores ways to further strengthen human resources so as to enhance mental health services in the country.

This paper summarizes the findings for the European Region of the WPA Task Force on Steps, Obstacles and Mistakes to Avoid in the Implementation of Community Mental Health Care. The article presents a description of the region, an overview of mental health policies and legislation, a summary of relevant research in the region, a precis of community mental health services, a discussion of the key lessons learned, and some recommendations for the future.

Global priorities of civil society for mental health services: findings from a 53 country survey.

A renewed agenda for global mental health

This paper summarizes the history of the development of Chinese mental health system; the current situation in the mental health field that China has to face in its effort to reform the system, including mental health burden, workforce and resources, as well as structural issues; the process of national mental health service reform, including how it was included into the national public health program, how it began as a training program and then became a treatment and intervention program, its unique training and capacity building model, and its outcomes and impacts; the barriers and challenges of the reform process; future suggestions for policy; and Chinese experiences as response to the international advocacy for the development of mental health.

The World Health Organization (WHO)'s Mental Health Atlas series has established itself as the single most comprehensive and most widely used source of information on the global mental health situation. The data derived from the latest Mental Health Atlas survey carried out in 2014 describes the availability and delivery of mental health services in the WHO's Member States, focussing on differences by country's income level. The data contained in this paper are mainly derived from questions relating to mental health service availability and uptake, as well as on financial and human resources for mental health. Results are presented as median values and analysed by World Bank income group. Interquartile ranges are also provided as measures of statistical dispersion. In total, 171 out of WHO's 194 Member States were able to at least partially complete the Atlas questionnaire. The results highlight a wide gap between high and low-medium income countries in a number of areas: for example, high-income countries have 20 times more beds in community-based inpatient units and 30 times more admissions; the rate of patients cared by outpatient facilities is 40 times higher; and there are 66 times more community outpatient contacts and 15 times more mental health staff at outpatient level. Overall resources for mental health are not distributed efficiently: globally about 60% of financial resources and over two-thirds of all available mental health staff are concentrated in mental hospitals, which serve only a small proportion of patients. Results indicate that outpatient care is the only effective means of increasing the coverage for mental disorders and is expanding, but it is strongly influenced by country income level. Two elements of the network of mental health facilities are particularly scarce in low- and middle-income countries: day treatment facilities and community residential facilities. The WHO Mental Health Atlas 2014 survey provides basic mental health information at the level of WHO's Member States, concerning mental health resources and activities. Atlas promotes the use of information, usually underestimated not only in low- and middle-income countries but also in high-income countries. Information is needed not only for monitoring the scaling up of the mental health system at country level, but also for improving transparency and accountability for users, families and the public.

The COPSI Trial: additional fidelity testing needed

Mexico, 2004: Global health needs a new research agenda

A renaissance in primary health care

This is a collection of policy briefs created and disseminated over the course of PRIME's grant period of eight years.Contained in this collection are the following policy briefs:PRIME Policy Brief 2. May 2013. Scale up of services for mental health in low-income and middle-income countries. Julian Eaton, Layla McCay, Maya Semrau, Sudipto, Chatterjee, Florence Baingana,Ricardo, Araya, Christina Ntulo,Graham, Thornicroft, Shekhar Saxena. PRIME Policy Brief 3. May 2013. Human Resources for mental health care: current situation and strategies for action. Ritsuko Kakuma, Harry Minas, Nadja van Ginneken, Mario R Dal Poz, Keshav Desiraju, Jodi E Morris, Shekhar Saxena, Richard M Scheffler. PRIME Policy Brief 4. November 2013.The acceptability and feasibility of task sharing for mental healthcare in low and middle income countries: a systematic review. Prianka Pamanathan, Mary J De Silva. PRIME Policy Brief 7. December 2014. Setting priorities for mental health care in Nepal: a formative study by Mark J D Jordans, Nagendra P Luitel, Mark Tomlinson and Ivan Komproee. PRIME Policy Brief 8. January 2015. Demand and access to mental health services: a qualitative formative study in Nepal by Natassia F Brenman, Nagendra P Luitel, Sumaya Mall and Mark J D Jordans. PRIME Policy Brief 9. March 2015. Psychiatric stigma and discrimination in South Africa: perspectives from key stakeholders by Catherine O Egbe, Carrie Brooker-Sumner, Tasneem, Kathree, One Selohilwe, Graham Thornicroft and Inge Petersen. PRIME Policy Brief 10. October 2015: British Journal Of Psychiatry Supplement. Integration of mental health into primary care in low- and middle income countries: the PRIME mental health care plans. PRIME Policy Brief 11. October 2017. A collaborative integrated package for common mental disorders as part of chronic care in South Africa.by Inge Petersen, Arvin Bhana, Lara Fairall, One Selohilwe, Tasneem Kathree, Emily Baron, Sujit D Rathod, Crick Lund. PRIME Policy Brief 12 November 2017 Proactive community case-finding to facilitate treatment seeking for mental disorders in Nepal by Mark JD Jordans, Brandon A Kohrt, Nagendra P Luitel, Crick Lund & Ivan H Komproee PRIME Policy Brief 13. May 2018. Social determinants of mental disorders and the Sustainable Development Goals: a systematic review of reviews by Crick Lund, Carrie Brooke-Sumner, Florence Baingana, Emily Claire Baron, Erica Breuer, Prabha Chandra, Johannes Haushofer, Helen Herrman, Mark Jordans, Christian Kieling, Maria Elena Medina-Mora, Ellen Morgan, Olayinka Omigbodun, Wietse Tol, Vikram Patel, Shekhar Saxena. PRIME Policy Brief 13. July 2018. Bridging the gap: the way forward for intersectoral provision of mental health services.by Carrie Brooke‑Sumner, Crick Lund & Inge Petersen. PRIME Policy Brief 16. August 2018. Treatment gap and barriers for mental health care: a cross-sectional community survey in Nepal. Nagendra P Luitel, Mark J D Jordans, Brandon A Kohrt, Sujit D Rathod & Ivan H Komproee PRIME Policy Brief 17. August 2018.Validation of the Brief Mental Health Screening Tool (BMH) Arvin Bhana, Ntokozo Mntambo, Gugu Gigaba, Merridy Grant, Dianne Ackerman, Zamasomi Luvuno, Ellen Ntswe & Inge Petersen. Implementation of PRIME mental health care plan in Sehore district, Madya Pradesh, India: outcomes and learnings. Scaling up mental health services in Madhya Pradesh through the ‘Mann-Kaksha’ model.

Wahlbeck's paper 1 provides a succinct and accurate overview of the public health approach to global mental health. Conceptually, public health incorporates not just evidence-based interventions from high-income countries, but also significant emphases on positive behavioral health, prevention, recovery, and social, cultural and environmental factors. Expanding global mental health to include positive behavioral health – and therefore all people – offers the advantage of attention to developmental needs, resilience, prevention, and recovery 2. The behavioral health field has ignored these issues and the related empirical research findings for too long. Relatedly, shifting from “mental health” to “behavioral health” could underscore the broad focus on healthy behaviors rather than a narrower focus on mental illness. As one ramification, mainstreaming behavioral health to the entire population may reduce stigma for those who experience the most severe disabilities. The practical implementations of the Movement for Global Mental Health have been criticized extensively 3. Despite its holistic and laudable rhetoric, implementation attempts have largely involved an expansion of Western evidence-based biomedical or psychological interventions delivered via lay health workers and have not been sensitive to cultures and communities. Local communities often object to the imposition of Western models of individual mental illness when the problems are widespread, the culture is not so individualistic, and behaviors are obviously related to war, poverty, gender discrimination, lack of opportunity, and so on. The failure to engage communities and understand cultural values and norms has sometimes worsened rather than relieved widespread community distress 4. The use of lay health workers helps to expand services and engender trust 5, but these workers typically make diagnoses and dispense medications or psychological therapies following a Western medical model. How could community engagement efforts align more closely with local culture? One basic strategy could be to start with local people on the ground. “Top-down” solutions (i.e., those developed by government experts) that are imposed on communities are often bureaucratic, reductionistic, overly prescriptive, and insensitive to local culture and context. The expensive and inefficient Veterans Administration Healthcare system in the U.S. is often cited as an example of the failure of top-down systems 6. By contrast, “ground-up” approaches (i.e., those developed by local stakeholders and communities) may better serve the goals of public mental health by valorizing local knowledge, competence, and resources. People on the ground – those experiencing behavioral health problems, their families, and their communities, aligned with local leaders, professionals, healers, and health workers – may in fact be in a better position to recognize local needs and resources, to understand local culture, to select and adapt appropriate evidence-based practices, and to innovate solutions. Local culture, however, may sometimes perpetuate stigma and even violations of human rights – hence the need for collaborations with professionals via mutual learning. Learning communities (multi-disciplinary groups focused on a specific health issue) have successfully combined local stakeholders with outside experts to discuss, select, and evaluate potential solutions 7. Community engagement could be enhanced on a global basis via several strategies. First, governments should give priority and funding to ground-up approaches. Community engagement in health care has a long and rich tradition, including principles and strategies for identifying and solving problems 8. Local community activation has in fact often produced positive changes and sometimes led to national and international health reforms: witness the women's health movement in the 1960s and the AIDS movement in the 1990s in the U.S.. Second, the field should recognize that people with behavioral health syndromes generally have goals that differ from those of professionals 9. Rather than more and more medications to reduce symptoms, people generally want support in finding meaningful functional roles. If local people (rather than industry, government, and the medical profession) were to choose services and goals, behavioral health would shift dramatically. For example, women who are oppressed and abused would be likely to emphasize education, advocacy, legal action, employment, and financial independence rather than poly-pharmacy. Third, healthcare systems should encourage people to develop natural resources, e.g., clubs, peer-support groups, spirituality, yoga, and other mindfulness-based therapies 10. These interventions, delivered by lay community members, are widely available in culturally specific forms and languages and can enhance prevention, resilience, treatment, and recovery. Government should encourage and strengthen these natural supports in local communities before assuming that more hospitals, professionals, and medications are the answer. Fourth, lay health care workers should be given the opportunity to collaborate with the people in their communities in selecting the medical and psychosocial interventions that they want and obtaining the training that they need to be effective 11. Likewise, they should be given the choice to veto or adapt interventions that are perceived as harmful or culturally insensitive. Such an approach may require extensive discussions within communities and suspension of Western hegemonic beliefs about the immutability of science-based interventions. Fifth, behavioral health technologies should be used to enhance all of these efforts in ways that maximize choice and cultural tailoring. A wide variety of web-based and mobile health applications are demonstrating effectiveness for prevention, empowerment, resilience, treatment, and maintenance 12. Low-income and middle-income countries are rapidly developing the connectivity that could facilitate widespread distribution, perhaps through lay health workers. Expanding and using these resources could helpfully overcome what is often perceived as the lack of a professional workforce while simultaneously empowering local communities. Global attention to positive behavioral health for all people is essential. We would not gainsay efforts to increase access to evidence-based interventions, but current efforts should include a meaningful understanding and respect for local cultures, communities, and resources.

Global pandemic perspectives: public health, mental health, and lessons for the future