Scaling up mental health services in developing countries is an essential part of any plan to improve mental health worldwide. However recent data suggests while 1 in 3 people with a mental health problem in wealthy nations receive treatment (in itself a huge shortfall in care), in developing countries it can be as few as 1 in 50. The fourth paper in The Lancet Series on Global Mental Health looks at progress made since the Lancet's landmark 2007 Series on the same subject. The paper is written by Dr Julian Eaton, who works with CBM International and is based in Abuja, Nigeria, and colleagues from many other countries.
A survey of 87 mostly developing countries has shown , encouragingly, 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. Many countries are also updating their mental health policy or legislation. Yet about 40% of respondents, from 26 (44%) of the countries surveyed, identified continuing poor awareness and low priority or poor commitment by political leaders as major barriers to development of mental health services.
Despite these positive signs from many countries, there is 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. Successful examples include the running of a mental health awareness campaign in Nigeria, that led to increased use of community mental health services; and the integration of mental health services into primary care in Uganda. This integration has seen a 75% increase in psychiatric nurses at district level since 2001, and 80% of all health sub-districts now have at least one antipsychotic, one antiepileptic, and one antidepressant drug. Mental health funding as a proportion of overall health spending has also increased from 0.7% to 4%.
There is growing evidence that lay people and other health workers can provide care traditionally given by psychiatrists. However, unless staff receive ongoing training and supervision, motivation to deliver mental health care is lost. Access to evidence based guidelines is also enabling developing countries to take positive action. WHO's mhGAP Intervention Guide for eight priority mental, neurological, and substance misuse disorders in non-specialised health settings was published in October, 2010.
Overall, the authors found that evidence that political leaders and decision makers are giving increased priority to mental health care in some countries, accompanied by an increase in funding by some international development and research agencies, although this change is not yet widespread. There has been some progress in reorganisation of services by decentralisation and integration into primary health care, in standardisation of models of service delivery (including through an increasing number of well designed trials of complex interventions), and in understanding of the policy environment needed to make scaling up more feasible. The authors say: "Task sharing is the means to most efficiently use low numbers of trained personnel…In many of the countries represented in our survey, the mere decentralisation of any mental health expertise to district level (rather than only the very largest cities) would have an enormous effect on access to care."
Global mental health is a growing discipline, and the tiny number of mental health professionals in low-income countries need to broaden their roles and engage in scaling up evidence-based services. If scaling up is to become a reality, there should be advocacy for greater resource allocation and more consistent evaluation of examples of scaling up, so that lessons learned can be implemented. Services should be both evidence-based and locally relevant.
They conclude: "Since 2007, a substantial amount of evidence has shown how feasible and effective services for people with mental illness in low-income and middle-income countries can be. Scaling up of such services can be achieved by tackling, in an integrated way, poor political will, scarcity of resources, and inefficiently organised services, so that care is made available to people who were previously unable to access it. The challenge remains to scale up these services so that an increased number of people benefit, but we have moved a long way in a short time towards this end."
Dr Julian Eaton, CBM International, West Africa Regional Office, Abuja, Nigeria. T) +234 8076909921 E) julian_eaton@cbm-westafrica.org
Journal
The Lancet