|Functions of traditional mental hospital||Effects of transfer to community care|
|Physical assessment and treatment||May be better transferred to primary care or general health services|
|Active treatment for short-term and intermediate stays||Treatment maintained or improved, but results may not be generalizable|
|Long-term custody||Usually improved in residential homes for those who need long-term high support|
|Protection from exploitation||Some patients continue to be vulnerable to physical, sexual and financial exploitation|
|Day care and out-patient services||May be improved if local, accessible services are developed or may deteriorate if they are not; renegotiation of responsibilities is often necessary between health and social care agencies|
|Occupational, vocational and rehabilitation services||Improved in normal settings|
|Shelter, clothing, nutrition and basic income||At risk, so responsibilities and coordination must be clarified|
|Respite for family and carers||Usually unchanged: place of treatment at home, offset by potential for increased professional support to family|
|Research and training||New opportunities arise through decentralization|
|Source: Thornicroft G, Tansella M (2000). Balancing community-based and hospital-based mental health care: the new agenda. Geneva, Word Health Organization (unpublished document).|
Three key financing recommendations should be considered. The first is to release resources for the development of community services through partial hospital closure. The second is to use transitional funding for initial investment in new services, to facilitate movement from hospitals to the community. The third is to maintain parallel funding in order to continue the financing of a certain level of institutional care even after community-based services have been established.
Countries face problems in their attempts to create comprehensive mental health care because of the scarcity of funds. Although, in some countries, funds may be redirected or reinvested in community care as a result of de-institutionalization, this is rarely sufficient on its own. In other countries, it may be difficult to divert funds. For example, in South Africa, where budgets are integrated within the various levels of primary, secondary and tertiary care, even though a policy of de-institutionalization has been adopted it is difficult to move the money spent on hospital care to the primary care or community care level. Even if the money can be shifted out of the hospital budget, there is little guarantee that it will in fact be utilized for mental health programmes at the community level. Because of budgetary restrictions it is clear that comprehensive community care is unlikely to be a viable option without the support of primary and secondary care services.
The integration of mental health care into general health services, particularly at the primary health care level, has many advantages. These include: less stigmatization of patients and staff, as mental and behavioural disorders are being seen and managed alongside physical health problems; improved screening and treatment, in particular improved detection rates for patients presenting with vague somatic complaints which are related to mental and behavioural disorders; the potential for improved treatment of the physical problems of those suffering from mental illness, and vice versa; and better treatment of mental aspects associated with "physical" problems. For the administrator, advantages include a shared infrastructure leading to cost-efficiency savings, the potential to provide universal coverage of mental health care, and the use of community resources which can partly offset the limited availability of mental health personnel.
Integration requires a careful analysis of what is and what is not possible for the treatment and care of mental problems at different levels of care. For example, early intervention strategies for alcohol are more effectively implemented at the primary care level, but acute psychosis might be better managed at a higher level to benefit from the availability of greater expertise, investigatory facilities and specialized drugs. Patients should then be referred back to the primary level for ongoing management, as primary health care workers are best placed to provide continuous support to patients and their families.
The specific ways in which mental health should be integrated into general health care will to a great extent depend on the current function and status of primary, secondary and tertiary care levels within countries' health systems. Box 4.7 summarizes experiences of integration of services in Cambodia, India and the Islamic Republic of Iran. For integration to be successful, policy-makers need to consider the following.
Organization of mental health services in developing countries began comparatively recently. WHO supported the movement to dispense mental care within general health services in developing countries,1 and conducted a seven-year feasibility study of integration with primary health care in Brazil, Colombia, Egypt, India, the Philippines, Senegal and Sudan.
A number of countries have used this approach to organize essential mental health services. In developing countries with limited resources, this has meant a new beginning of care for people with mental disorders. India started training primary health care workers in 1975, forming the basis of the National Mental Health Programme formulated in 1982. Currently the government supports 25 district level programmes in 22 states.2 In Cambodia, the ministry of health trained a core group of personnel in community mental health, who in turn trained selected general medical staff at district hospitals.3 In the Islamic Republic of Iran, efforts to integrate mental health care started in the late 1980s and the programme has since been extended to the whole country, with services now covering about 20 million people.4 Similar approaches have been adopted by countries such as Afghanistan, Malaysia, Morocco, Nepal, Pakistan,5 Saudi Arabia, South Africa, the United Republic of Tanzania, and Zimbabwe. Some studies have been carried out to evaluate the impact of integration, but more are urgently needed.
1 World Health Organization (1975). Organization of mental health services in developing countries. Sixteenth report of the WHO Expert Committee on Mental Health, December 1974. Geneva, World Health Organization (WHO Technical Report Series, No. 564).
2 Srinivasa Murthy R (2000). Reaching the unreached. The Lancet Perspective, 356: 39.
3 Somasundaram DJ et al. (1999). Starting mental health services in Cambodia. Social Science and Medicine, 48(8): 10291046.
4 Mohit A et al. (1999). Mental health manpower development in Afghanistan: a report on a training course for primary health care physicians. Eastern Mediterranean Health Journal, 5: 231240.
5 Mubbashar MH (1999). Mental health services in rural Pakistan. In: Tansella M, Thornicroft G, eds. Common mental disorders in primary care. London, Routledge.
While it is clear that mental health should be financed from the same sources and with the same objectives for distributing the financial burden as health care in general, it is less clear what is the best way to direct funds to mental and behavioural disorders. Once funds have been raised and pooled, the issue arises of how rigidly to separate mental health from other items to be financed out of the same budget, or whether to provide a global budget for some constellation of institutions or services and allow the share used for mental health to be determined by demand, local decisions or other factors (bearing in mind that out-of-pocket spending is not pooled and is directed only by the consumer). At one extreme, line-item budgets which specify expenditure on every input for every service or programme are overly rigid and leave no discretion to administrators, so they almost guarantee inefficiency. They cannot readily be used to contract with private providers. Even within public facilities, they can lead to imbalance among inputs and make it hard to respond to changes in demand or need.
In spite of the lack of evidence, it is fair to say that these problems could probably be minimized by assigning global budgets, either to purchasing agencies which can contract out or to individual facilities. The advantages of such budgets include administrative simplicity, the encouragement of multi-agency decision-making, the encouragement of innovation via financial flexibility, and incentives for primary health care providers to collaborate with mental health care providers and to provide care at the primary care level.
However, if there is no budgeting according to end-use and no specific protection for particular services, the share going to mental health may continue to be very low, because of low apparent priority and the false impression that mental health is not important. This is a particular risk when the intention is to reform and expand mental health services relative to more established or better-funded services. To reduce that risk, a specific amount may be allocated to mental health, which cannot easily be diverted to other uses, while still allowing the managers of health facilities some flexibility in setting priorities among problems and treatments. "Ring-fencing" mental health resources in this way may be used to ensure their protection and stability over time. In particular, for countries with minimal current investment in mental health services, ring-fencing may be pertinent for indicating the priority accorded to mental health and for kick-starting a mental health programme. This need not imply a retreat from service organization, nor should it prevent mental health departments sharing in any additional funds that become available for health.
WHO recommends a limited set of essential drugs for the treatment and management of mental and behavioural disorders through its essential drugs list. However, it is common to find that many of these drugs are not available in developing countries. Data from the Atlas project suggest that about 25% of countries do not have commonly prescribed antipsychotic, antidepressant and antiepileptic drugs available at the primary care level.
Governments need to ensure that sufficient funds are allocated to purchase the basic essential psychotropic drugs and distribute them amongst the different levels of care, in accordance with the policy adopted. Where there is a policy of community care and integration into general health services, then not only must essential drugs be available at these levels, but also health workers need to be authorized to administer the drugs at these levels. Even where a primary care approach is adopted for the management of mental problems, a quarter of countries do not have the three essential drugs for the treatment of epilepsy, depression and schizophrenia available at the primary level. Drugs may be purchased under generic names from non-profit organizations, such as ECHO (Equipment for Charitable Hospitals Overseas) and the UNICEF Supply Division in Copenhagen, which supply drugs of good quality at low prices. In addition, WHO and Management Sciences for Health (2001) issue an annual drug price indicator guide of essential drugs, which includes addresses and prices of several reputable suppliers of different psychotropic drugs, at non-profit world-market wholesale prices.
Many mental disorders require psychosocial solutions. Thus links need to be established between mental health services and various community agencies at the local level so that appropriate housing, income support, disability benefits, employment, and other social service supports are mobilized on behalf of patients and in order that prevention and rehabilitation strategies can be more effectively implemented. In many poor countries, cooperation between sectors is often visible at the primary care level. In Zimbabwe, coordination between academics, public service providers and local community representatives at the primary care level led to the development of a culturally relevant community-based programme to detect, counsel and treat women suffering from depression. In the United Republic of Tanzania, an intersectoral strategy resulted in an innovative agricultural programme to rehabilitate persons suffering from mental and behavioural disorders (see Box 4.8).
In the United Republic of Tanzania, psychiatric agricultural rehabilitation villages encapsulate an intersectoral response by local communities, the mental health sector, and the traditional healing sector to the treatment and rehabilitation of people with severe mental illness in rural areas.1 Patients and relatives live within an existing village population of farmers, fishermen and craftsmen, and are treated by both the medical and traditional healing sectors. Mental health nurses, nursing assistants, and local artisans supervise therapeutic activities; a psychiatrist and a medical social worker provide weekly assistance and consultation; and the involvement of traditional healers depends on the expressed needs of individual patients and relatives. There are also plans for a more formal collaboration between traditional and mental health sectors, including regular meetings and seminars. Traditional healers have participated in community mental health training programmes and shared their knowledge and skills in treating patients; they could play an increased role in managing stress-related disorders in the community.
1 Kilonzo GP, Simmons N (1998). Development of mental health services in Tanzania: a reappraisal for the future. Social Science and Medicine, 47: 419428.
Regardless of a country's economic situation, there will always seem to be too few resources to fund activities, services and treatments. For mental health, as for health generally, choices must be made among a large number of services and a wide range of prevention and promotion strategies. These choices will, of course, have different effects on different mental health conditions and different population groups in need. But it is important to recognize that choices have ultimately to be made among key strategies, rather than among specific disorders.
What is known about the costs and results of different interventions, particularly in poor countries, is still quite limited. Where evidence does exist, great care must be taken in applying conclusions to settings other than the one that generated the evidence: costs can differ greatly, and so may outcomes, depending on the capacity of the health system to deliver the intervention. Even if more were known, there is no simple formula for deciding which interventions to emphasize, much less for determining how much to spend on each of them. Private out-of-pocket spending is under no one's control but that of the consumers, and private prepayment for mental health care is quite low in all but a few countries.
The crucial decision for governments is how to use public funds. Cost-effectiveness is an important consideration in several circumstances, but is never the only criterion that matters. Public funding also should take account of whether an intervention is a public or partly public good, meaning that it confers costs or benefits on people other than those receiving the service. Although maximizing efficiency in the allocation of resources is desirable, governments will need to trade some efficiency gains to reallocate resources in the pursuit of equity.
While, in general, mental health services should be evaluated and decisions made about public spending on the same basis as for other health services, there appear to be certain significant features that distinguish at least some of the possible interventions. One is that there can be large benefits to controlling some mental disorders. In contrast to the benefits that arise from control of communicable diseases, where treating one case may prevent others and immunization of most of the susceptible population also protects the non-immunized, the benefits arising from mental health care often appear in non-health forms, such as reduced accidents and injuries in the case of alcohol use or lower cost of some social services. These cannot be captured in a cost-effectiveness analysis but require some judgement of the overall social benefit from both health and non-health gains.
Another possibly significant difference derives from the chronic nature of some mental disorders. This makes them like some chronic physical conditions and unlike acute, unpredictable medical needs difficult to cover via private insurance and therefore especially appropriate for public insurance, whether explicit (as in social security) or implicit (via general taxation). Finally, while many health problems contribute to poverty, long-term mental disorders are particularly associated with inability to work and therefore with poverty, so that attention to the poor should be emphasized in budgets for mental health services.
Difficult as it may be to work out priorities from the variety of relevant criteria, any rational consideration of the issues just mentioned offers the opportunity to improve on arbitrary or merely historical allocation of resources. This is especially true if mental health care is to get substantially more public resources: expansion in equal proportions of whatever is currently financed is unlikely to be either efficient or equitable. Needs-based allocation is a more equitable means for distributing resources, but it presupposes agreement on a definition of "need". Moreover, needs by themselves are not priorities, because not every need corresponds to an effective intervention apart from the fact that what people need, and what they want or demand, may not coincide. This is a problem even for physical health problems when the consumer is competent to express his or her demand; it becomes more complicated when some mental disorder limits that competence.
As emphasized above, financing intended for mental health has actually to be devoted to services, and whether this occurs may depend on how funds are organized through budgets or purchasing agreements. One technique for making that connection is to specify some mental health services, chosen on the basis of the criteria just described, as part of an overall package of basic or essential interventions which the public sector in effect promises to finance, whether or not the budget specifies the amount to be devoted to each such service. The same approach can in principle be used in the regulation of private insurance, requiring insurers to include certain mental health services in the basic package that all clients' policies will cover. Because insurers have a strong incentive to select clients on the basis of risk (and potential clients have a strong incentive to hide their known risks and purchase insurance against them), it is much harder to enforce such a package in the private than in the public sector. Nonetheless some countries Brazil and Chile are examples among middle-income countries require private insurers to offer the same services that are guaranteed by public finance. Whether such a course is feasible in much poorer countries is doubtful because of the much lower coverage of private insurance and the lower regulatory capacity of governments. Deciding how far to try to impose public priorities on private payers or providers is always a complex question, perhaps more so for mental health than for physical problems. Data from Atlas show that insurance as a primary source of funding for mental health care is present only in about one-fifth of countries.
The foregoing discussion emphasizes the financial role of the public sector, even when it accounts for only a small share of total health spending, because that is where the desirable reforms in mental health seem easiest to undertake and because some features of mental health services are particularly suited to public funding. But there is no necessary connection between public money and public provision, although traditionally most governments have spent most or all of their health funds on their own providing institutions. Both because of the move towards decentralization and because giving public facilities a monopoly on public resources removes any competitive stimulus to efficiency or more responsive service, there is an increasing split in some countries between purchasing and provision of services, (WHO 2000c, Chapter 3).
While the theoretical benefits of introducing more competition and regulation as substitutes for direct public provision are clear, evidence on the success of such arrangements is still scanty. Developing countries often lack the resources and experience to regulate contractual arrangements between health care purchasers and providers, and to enforce the delivery of the services agreed upon in the contract when these services are perceived to be a low priority by the provider. Without such controls there is great potential for waste and even fraud. If this is the case for contracts with service providers for general health services, mental health services may be still more difficult to contract effectively because of the greater difficulty of measuring outcomes. In countries where mental health services have been previously unavailable or were only provided directly by the health department, a separate detailed contract for mental health services may be necessary. For all these reasons, separating funding from providing should be approached cautiously where mental health services are concerned. Nonetheless it is worth considering whenever there are nongovernmental or local government providers able to take over provision and there is enough capacity to supervise them. In many countries, public health outpatient facilities offer no mental health services because of a funding emphasis on hospital inpatient care. Separation of funding and provision may therefore be especially valuable as a way to promote the desirable shift from public psychiatric hospitals to care provided in the community. Shifting the public budget priority without involving nongovernmental providers may even be essentially impossible because of internal resistance to innovation and lack of the required skills and experience.
Where substantial private provision exists and is paid for privately without public funding or regulation, several problems arise that call for the exercise of stewardship. There is likely to be inadequate referral between unregulated mental health service providers such as traditional healers and outpatient mental health services located in primary care and district hospitals. The poor may consume large amounts of low-quality mental health care from unregulated private mental health care providers such as drug sellers, traditional healers, and unqualified therapists. The inability of government health departments to enforce the regulation of private outpatient services leaves users vulnerable to financial exploitation and ineffective treatment procedures for mental ailments that are not addressed by the public health system. Contracts for primary and secondary providers, guidelines for mental health service items and costs, and accreditation of the different ambulatory mental health care providers are potential responses to these problems that do not require governments to expand spending massively or take on all the responsibility for provision.
Governments should also consider regulating specific provider groups within the informal health sector, such as traditional healers. Such regulation might include the introduction of practice registration to protect patients from harmful interventions and to prevent fraud and financial exploitation. Considerable progress in integrating traditional medicine into general health policy is being made in China, Viet Nam and Malaysia (Bodekar 2001).
Managed care, an important health care delivery system in the United States, combines the role of purchasing and financing health care for a defined population. A major concern is that managed care concentrates more on cost reduction than on service quality, and that it shifts the costs of care, for those who cannot afford insurance, from the public health system to families or charitable institutions (Hoge et al. 1998; Gittelman 1998). For mental and behavioural disorders, managed care efforts to date have often failed to provide an adequate response to the need for medical treatment combined with a long-term social support and rehabilitation strategy, although there have been some notable exceptions. Furthermore, the expertise, skills, and comprehensiveness of services required by a managed care system are beyond the current capabilities of most developing countries (Talbott 1999).
In developing countries, the lack of specialists and health workers with the knowledge and skills to manage mental and behavioural disorders is an important barrier to providing treatment and care.
If health systems are to advance, time and energy need to be invested in assessing the numbers and types of professionals and workers required in the years to come. The ratio of mental health specialists to general health workers will vary according to existing resources and approaches to care. With the integration of mental health care into the general health system, the demand for generalists with training in mental health will increase and that for specialists will decrease, although a critical mass of mental health specialists will always be required to effectively treat and prevent these disorders.
There is a wide disparity in the type and numbers of the mental health workforce throughout the world. The median number of psychiatrists varies from 0.06 per 100 000 population in low income countries to 9 per 100 000 in high income countries (Figure 4.4). For psychiatric nurses, the median ranges from 0.1 per 100 000 in low income countries to 33.5 per 100 000 in high income countries (Figure 4.5). In almost half the world, there is fewer than one neurologist per million people. The situation for providers of care for children and adolescents is far worse.
The health workforce likely to be involved with mental health consists of general physicians, neurologists and psychiatrists, community and primary health care workers, allied mental health professionals (such as nurses, occupational therapists, psychologists and social workers), as well as other groups such as the clergy and traditional healers. Traditional healers are the main source of assistance for at least 80% of rural inhabitants in developing countries. They can be active case finders, and can facilitate referral and provide counselling, monitoring and follow-up care. The adoption of a system of integrated community-based care will require a redefinition of the roles of many health providers. A general health care worker may now have the additional responsibility of identifying and managing mental and behavioural disorders in the community, including screening and early intervention for tobacco, alcohol and other drug use, and a psychiatrist previously working in an institution may need to provide more training and supervision when moved to a community setting.
Decentralization of mental health services is also likely to have an impact on roles and responsibilities through the transfer of management and administration responsibilities to the local level. Redefinition of roles needs to be explicit, in order to ensure that new responsibilities are adopted more readily. Training is also required to provide the skills necessary to carry out new roles and responsibilities. Undoubtedly, the changing of roles will bring issues of power and control to the forefront, and these will act as barriers to change. For example, psychiatrists perceive and resist their own loss of power when other less experienced health workers are given the authority to manage mental disorders.
In developed and developing countries alike, undergraduate medical curricula need to be updated to ensure that graduating physicians are skilled in diagnosing and treating persons suffering from mental disorders. Recently Sri Lanka expanded the duration of training in psychiatry and included it as an examination subject in undergraduate medical education. Allied health professionals, such as nurses and social workers, require training to understand mental and behavioural disorders and the range of treatment options available, focusing on those areas most relevant to their work in the field. All courses should incorporate the application of evidence-based psychosocial strategies, and skill-building in the areas of administration and management, policy development and research methods. In developing countries, higher level educational opportunities are not always available; instead training is often undertaken in other countries. This has not always led to satisfactory outcomes: many trainees sent abroad do not return to their own countries and consequently their expertise is lost to the developing society. This needs to be addressed in the long term, through the setting up of centres of excellence for training and education within countries.
One promising approach is the use of the Internet to provide training and quick feedback by specialists on clinical diagnosis and management matters. Internet access is increasing rapidly in developing countries. Three years ago, only 12 countries in Africa had Internet access; now it is available in all African capital cities. Training must now include the use of information technology (Fraser et al. 2000).