Elsevier

The Lancet

Volume 378, Issue 9802, 29 October–4 November 2011, Pages 1592-1603
The Lancet

Series
Scale up of services for mental health in low-income and middle-income countries

https://doi.org/10.1016/S0140-6736(11)60891-XGet rights and content

Summary

Mental disorders constitute a huge global burden of disease, and there is a large treatment gap, particularly in low-income and middle-income countries. One response to this issue has been the call to scale up mental health services. We assess progress in scaling up such services worldwide using a systematic review of literature and a survey of key national stakeholders in mental health. The large number of programmes identified suggested that successful strategies can be adopted to overcome barriers to scaling up, such as the low priority accorded to mental health, scarcity of human and financial resources, and difficulties in changing poorly organised services. However, there was a lack of well documented examples of services that had been taken to scale that could guide how to replicate successful scaling up in other settings. Recommendations are made on the basis of available evidence for how to take forward the process of scaling up services globally.

Introduction

The past two decades have seen an unprecedented increase in efforts to address global inequalities in physical health care, particularly as part of the UN's Millennium Development Goals (MDGs) initiative. Resources targeting HIV/AIDS, tuberculosis, malaria, and maternal and child health have increased substantially. Development assistance for health grew from US$5·6 billion in 1990 to $21·8 billion in 2007,1 and there have been similar increases in education and social development activities. Less progress has been seen in the response to mental, neurological, and substance misuse disorders, despite the identification of the large treatment gap2, 3 and a consensus that improved access to mental health care could provide new hope for people with these disorders, especially in the poorest countries of the world.4, 5

Key messages

  • There are many examples of mental health initiatives being developed worldwide.

  • There is a need to scale up such services in low-income and middle-income countries so that more people can benefit; however, thus far very few innovative services have achieved this goal.

  • Barriers to the scaling up of services should be strategically and systematically considered and addressed. Key to this process is to involve all stakeholders, including decision makers to ensure their support and to facilitate sustainability of services, as well as people using mental health services.

  • Services should be both evidence-based and locally relevant, ensuring that they take into account all aspects of existing systems.

  • Assessment of examples of scaling up is important so that conclusions can be implemented in a practical way. These conclusions should be disseminated in a format that is accessible to implementers of services.

In 2007, The Lancet presented a Series of papers on global mental health that reviewed the global state of mental health systems,5, 6 summarised the evidence for effective treatments,7 identified barriers to service improvement,8 and examined existing and required resources for mental health care.9 The series concluded with a call for global action to increase access to mental health services—a process referred to as scaling up.10 In this report, we assess global progress in scaling up of mental health care in low-income and middle-income countries since 2007.

Definitions of scaling up typically refer to an objective with several common components: an increase in the number of people receiving services (coverage); an increase in the range of services offered; services that are built on a scientific evidence base, usually with a service model that has been shown to be effective in a similar context; services made sustainable through policy formulation, implementation, and financing (strengthening of health systems).

Scaling up has also been used to refer to a process, which includes mobilisation of political will, human resource development, an increase in the availability of essential medicines, and monitoring and evaluation.11 WHO has described scaling up as “deliberate efforts to increase the impact of health service innovations successfully tested in pilot or experimental projects so as to benefit more people and to foster policy and programme development on a lasting basis”.12

Much research on scaling up focuses on resource availability, identification of barriers, and service delivery issues.11 We have followed this outline in our report. Progress in scaling up of services could most accurately be measured by comparing change in effective coverage—ie, the proportion of people with a mental disorder who receive appropriate treatment.13 However, such information relating to coverage is not widely published in governmental or scientific literatures, particularly from low-income and middle-income countries.14, 15 The absence of available baseline prevalence and service use data in these countries makes accurate measurement of coverage impossible, although recent data suggest that across the range of mental disorders, only a third of people with mental health disorders are treated in high-resource countries, and as few as 2% of people with such conditions are treated in some low-income and middle-income countries.16, 17

We therefore used a combination of a systematic review of published literature and a survey of key informants (panel 1). We aimed to gather as comprehensive and up-to-date a view as possible of the extent of scaling up of mental health services in countries with low and middle incomes. Additionally, we have been able to identify many programmes from which we drew out themes related to challenges and practical solutions for making progress in scaling up of services.

The literature review and survey identified many examples of services being scaled up (see webappendix pp 10–19), but few met all of our criteria. There were some published descriptions of services that were scaled up to cover increased population numbers (eg, in Brazil,20 Chile,21 and China22), but most reports described early stages of reorganisation of services23, 24, 25 or preparation of policy and legislation.26 This outcome could in part be attributable to the length of time needed to plan, implement, and evaluate programmes. Almost half the respondents to the survey reported that progress in their country towards scaling up of services since 2007 had been “good” or “very good” (figure 2A).

Section snippets

Political will and the prioritisation of mental health

At the core of global27, 28 and national29, 30, 31 efforts to scale up services is the need for decision makers and political leaders to understand the issues, recognise their importance, and prioritise action to address mental health needs.32 Our survey identified some improvement in awareness of mental health issues among leaders during the past 3 years, with more than half of respondents reporting “more” or “much more” awareness (figure 2B). Yet about 40% of respondents, from 26 (44%)

Organisation of services

Existing structures into which mental health services fit often do not facilitate evidence-based interventions. The continued dominance of large psychiatric hospitals in many countries is at odds with the evidence, which suggests that most services should be delivered in decentralised locations,24, 58 with deinstitutionalisation39, 47 and integration between the community and hospitals,27, 41 and appropriate referral systems incorporating secondary and tertiary care.33, 59, 60 There still

Evaluation and effect

Although respondents accepted the importance of evaluation in principle, most programmes were not evaluated.79, 80, 81 In a systematic review of community mental health services in Africa, only a fifth of relevant programmes included any evaluation,59 and our findings accord with this assessment. Of the 56 respondents who described new mental health programmes in their countries, only 22 (39%) reported completed evaluations.

Most research into scaling up of services emphasises two issues: first,

Financial resource allocation

If services are to be scaled up, a substantial increase in resources and more efficient use of the resources that exist is needed.9 Absence of funding remains the dominant reported impediment to programme implementation.23, 25, 74, 83 Tracking of financial resource allocation is one key way to judge political commitment to scaling up of mental health services (panel 4). In some cases, increased allocations of funds have been achieved, as in Chile21 and Brazil.20

Access to evidence-based information: guidelines

The literature review and survey

Challenges and lessons learned

Five major barriers to scaling up of mental health services in countries with low and middle incomes have been previously identified:8 (1) absence of financial resources and government commitment; (2) overcentralisation; (3) challenges of integration of mental health care into primary care settings; (4) scarcity of trained mental health personnel; and (5) shortage of public health expertise among mental health leaders. We examine whether these barriers remain the crucial challenges, and

The way forward

A systemic and strategic approach to scaling up is needed (figure 3). Specific interventions to increase coverage of mental health services need to be part of a broader and integrated process. This approach will need strong advocacy for financial commitment and will need to ensure that relevant elements of health infrastructure are strengthened to allow services to be sustained in the long term.

Task sharing is the means to most efficiently use low numbers of trained personnel. A high proportion

References (94)

  • C Killion et al.

    Making mental health a priority in Belize

    Arch Psychiatr Nurs

    (2009)
  • V Patel et al.

    The Lancet's series on global mental health: 1 year on

    Lancet

    (2008)
  • A Rahman et al.

    Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial

    Lancet

    (2008)
  • R Beaglehole et al.

    Improving the prevention and management of chronic disease in low-income and middle-income countries: a priority for primary health care

    Lancet

    (2008)
  • N Siva

    Sri Lanka struggles with mental health burden

    Lancet

    (2010)
  • V Patel et al.

    Effectiveness of an intervention led by lay health counsellors for depressive and anxiety disorders in primary care in Goa, India (MANAS): a cluster randomised controlled trial

    Lancet

    (2010)
  • CJL Murray et al.

    Health metrics and evaluation: strengthening the science

    Lancet

    (2008)
  • Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys

    JAMA

    (2004)
  • R Kohn et al.

    The treatment gap in mental health care

    Bull World Health Organ

    (2004)
  • The World Health Report 2001. Mental health: new understanding, new hope

    (2001)
  • Scale up services for mental disorders: a call for action

    Lancet

    (2007)
  • LJ Mangham et al.

    Scaling up in international health: what are the key issues?

    Health Policy Plan

    (2010)
  • R Simmons et al.

    Introduction

  • JJ Mari et al.

    The 5/95 gap in the indexation of psychiatric journals of low- and middle-income countries

    Acta Psychiatr Scand

    (2010)
  • S Saxena et al.

    The 10/90 divide in mental health research: trends over a 10-year period

    Br J Psychiatry

    (2006)
  • Data: country and lending groups

  • World Health Organization Assessment Instrument for Mental Health Systems

    (2005)
  • MD Mateus et al.

    The mental health system in Brazil: policies and future challenges

    Int J Ment Health Syst

    (2008)
  • Y Xin et al.

    Integrating mental health into primary care: the policy maker's perspective and experience in China

    Int Psychiatry

    (2010)
  • F Kauye

    Management of mental health services in Malawi

    Int Psychiatry

    (2008)
  • F Kigozi

    Integrating mental health into primary health care—Uganda's experience: review

    South Afr Psychiatry Rev

    (2007)
  • J Ssebunnya et al.

    Integration of mental health into primary healthcare in a rural district in Uganda., MHaPP Research Programme Consortium

    Afr J Psychiatry

    (2010)
  • R Jenkins et al.

    Mental health policy and development in Egypt—integrating mental health into health sector reforms 2001–9

    Int J Mental Health Syst

    (2010)
  • Integrating mental health into primary care. A global perspective

    (2008)
  • B Saraceno

    Advancing the global mental health agenda

    Int J Public Health

    (2007)
  • R Thara et al.

    Community mental health in India: a rethink

    Int J Ment Health Syst

    (2008)
  • G Thornicroft et al.

    WPA guidance on steps, obstacles and mistakes to avoid in the implementation of community mental health care

    World Psychiatry

    (2010)
  • V Patel et al.

    Packages of care for mental, neurological, and substance use disorders in low- and middle-income countries

    PLoS Med

    (2009)
  • MS Van Heerden et al.

    Providing psychiatric services in general medical settings in South Africa—mental health-friendly services in mental health-friendly hospitals: editorial

    South Afr J Psychiatry

    (2008)
  • I Peterson et al.

    Planning for district mental health services in South Africa: a situation analysis of a rural district site

    Health Policy Plan

    (2009)
  • D Kiima et al.

    Mental health policy in Kenya—an integrated approach to scaling up equitable care for poor populations

    Int J Ment Health Syst

    (2010)
  • MA Omar et al.

    Mental health policy process: a comparative study of Ghana, South Africa, Uganda and Zambia

    Int J Ment Health Syst

    (2010)
  • Uganda: key facts

  • Annual health sector performance report. Financial year 2009/2010

    (2010)
  • V Patel et al.

    Reducing the treatment gap for mental disorders: a WPA survey

    World Psychiatry

    (2010)
  • Implementation Manual for the United Nations Convention on the Rights of Persons with Disabilities

  • Community mental health practice: seven essential features for scaling up in low- and middle-income countries

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