Elsevier

The Lancet

Volume 370, Issue 9593, 29 September–5 October 2007, Pages 1164-1174
The Lancet

Series
Barriers to improvement of mental health services in low-income and middle-income countries

https://doi.org/10.1016/S0140-6736(07)61263-XGet rights and content

Summary

Despite the publication of high-profile reports and promising activities in several countries, progress in mental health service development has been slow in most low-income and middle-income countries. We reviewed barriers to mental health service development through a qualitative survey of international mental health experts and leaders. Barriers include the prevailing public-health priority agenda and its effect on funding; the complexity of and resistance to decentralisation of mental health services; challenges to implementation of mental health care in primary-care settings; the low numbers and few types of workers who are trained and supervised in mental health care; and the frequent scarcity of public-health perspectives in mental health leadership. Many of the barriers to progress in improvement of mental health services can be overcome by generation of political will for the organisation of accessible and humane mental health care. Advocates for people with mental disorders will need to clarify and collaborate on their messages. Resistance to decentralisation of resources must be overcome, especially in many mental health professionals and hospital workers. Mental health investments in primary care are important but are unlikely to be sustained unless they are preceded or accompanied by the development of community mental health services, to allow for training, supervision, and continuous support for primary care workers. Mobilisation and recognition of non-formal resources in the community must be stepped up. Community members without formal professional training and people who have mental disorders and their family members, need to partake in advocacy and service delivery. Population-wide progress in access to humane mental health care will depend on substantially more attention to politics, leadership, planning, advocacy, and participation.

Introduction

International public-health concerns for mental health have been accelerated by the World Development Report 19931 and the subsequent Global Burden of Disease report,2 which compared health conditions based on combined disability and mortality statistics. Although they did not make any explicit policy recommendations on mental health services, these reports showed, to the surprise and disbelief of many in the international public-health arena, the huge burden of disease imposed by mental disorders, not only in rich countries but also in low-income and middle-income countries.

Data on the global burden of disease prompted three high-profile international reports (table 1),3, 4, 5 and many important regional and national reports.6, 7, 8, 9, 10, 11, 12 Notably, one regional report12 was signed by all European ministers of health, including those from 27 low-income and middle-income countries in Eastern Europe. They committed to implementation of a detailed plan for service development, prevention of mental problems, and promotion of wellbeing.12

The global, high-level reports were largely concerned with the wellbeing of people affected by mental disorders: they called on decisionmakers to do everything in their power to organise care for those with mental disorders. One included extensive analysis of social factors in mental disorders, and mental wellbeing;3 another emphasised epidemiology and interventions for specific brain disorders;4 and the third focused especially on mental health policies and services.5 Despite these differences, the mental health service recommendations offered in these three reports are largely consistent (table 1). Their recommendations on services are of two kinds: direct recommendations to increase the availability of care, and recommendations on mental health system components to enable provision of more or better care, such as development of human resources or changes to mental health policy.

This Lancet Series has reviewed epidemiological evidence,13 availability of mental health resources,14 evidence for interventions in mental health,15 and the status of mental health system development in countries, including the extent of national-level progress in mental health service development.16 The Series reviewed the availability of mental health resources in 152 low-income and middle-income countries by analysis of data collected in 2001 and 2004.17, 18 The review16 suggests that improvements in the availability of mental health resources between 2001 (when two of the high-profile reports4, 5 were published) and 2004 were only slight. National-level successes (for example, case studies on Brazil,16 Chile,15 and Sri Lanka in panel 1) have occurred, though in most countries mental health service development continues to be fragmented and slow.16

Despite the wide dissemination of high-level reports3, 4, 5 and evidence for the range of mental health interventions reviewed earlier in this Series,15 progress in scaling-up has not been as hoped. What hinders progress? Is it simply insufficient donor interest? If so, why? Or do other political or technical barriers exist? We aim to address these complex questions here to inform the Lancet's call for action.26 Many of the barriers and lessons identified in this review will be common sense to experienced public-health experts, but the aim is to make them explicit, so that they become powerful tools for public mental health action.

Section snippets

Key barriers to service development

To understand the challenges to progress in the improvement of the quality and availability of mental health care in most low-income and middle-income countries, we surveyed a range of international experts and leaders. Our methods and results are reported in detail elsewhere,27 and panel 2 summarises the methods. We discuss the prevailing public-health priority agenda and its effect on funding; the complexity of and resistance to decentralisation of mental health services; challenges in

The public-health priority agenda and its implications for funding

In response to a question about available funds for mental health services, respondents said that mental health had a low position on public-health agendas at national and international levels. They were concerned that mental health was named neither as a Millennium Development Goal (MDG) nor as an MDG-related target, despite established links between mental disorders and MDGs.13

Absence from the international public-health agenda can block progress even when investment in mental health has been

Organisation of services

The way in which mental health services are organised affects treatment coverage for people with diverse mental disorders.36, 37 Respondents were asked how low-income and middle-income countries should invest their scarce resources for mental health care. Many respondents discussed decentralisation of tertiary-care institutions, development of community-based rehabilitation services, psychiatric care in general hospitals, and mental health care in primary-health care and other health-care

Human resources for mental health

One well-established barrier to scaling-up of mental health services is the inadequate number of people who are trained to provide care.14, 49 Respondents pointed out that in many countries poor working conditions and low status of the profession mean that few people enter the mental health professions. At the same time, higher salaries in private practice and overseas mean that scarce psychiatrists are encouraged to leave governmental employment. Moreover, mental health professionals—whether

Public mental health leadership

Respondents were concerned that many national mental health leaders have insufficient public-health skills, and that this might hinder rapid progress of service development. In the words of one respondent:

“Leadership cannot be expected from clinicians turned-by default-into-administrators/planners. Their views, experience, and training are not compatible with population-oriented mental health action”

I Levav (formerly of the WHO Regional Office for the Americas)

Mental health leaders in

Lessons learned

Many lessons can be drawn from our survey about barriers to mental health service reform. First, many of the barriers to progress in development of mental health services can be overcome by generation of sufficient political will to improve availability of and access to humane mental health care. The words “politics” and “political” were repeated 145 times in the answers of the 57 respondents in our survey, without being prompted by use in the survey questions. Political will, in this context,

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