Mapping Mental Health Finances in Ghana, Uganda, Sri Lanka, India

Raja et al. International Journal of Mental Health Systems 2010, 4:11 http://www.ijmhs.com/content/4/1/11 RESEARCH Open Access MappingResearch mental health finances in Ghana, Uganda, Sri Lanka, India and Lao PDR Shoba Raja1, Sarah K Wood1, Victoria de Menil*2 and Saju C Mannarath1 Abstract Background: Limited evidence about mental health finances in low and middle-income countries is a key challenge to mental health care policy initiatives. This study aimed to map mental health finances in Ghana, Uganda, India (Kerala state), Sri Lanka and Lao PDR focusing on how much money is available for mental health, how it is spent, and how this impacts mental health services. Methods: A researcher in each region reviewed public mental health-related budgets and interviewed key informants on government mental health financing. A total of 43 key informant interviews were conducted. Quantitative data was analyzed in an excel matrix using descriptive statistics. Key informant interviews were coded a priori against research questions. Results: National ring-fenced budgets for mental health as a percentage of national health spending for 2007-08 is 1.7% in Sri Lanka, 3.7% in Ghana, 2.0% in Kerala (India) and 6.6% in Uganda. Budgets were not available in Lao PDR. The majority of ring-fenced budgets (76% to 100%) is spent on psychiatric hospitals. Mental health spending could not be tracked beyond the psychiatric hospital level due to limited information at the health centre and community levels. Conclusions: Mental health budget information should be tracked and made publically accessible. Governments can adapt WHO AIMS indicators for reviewing national mental health finances. Funding allocations work more effectively through decentralization. Mental health financing should reflect new ideas emerging from community based practice in LMICs. Background Mental Health Financing, which constitutes one module Although not the only obstacle, one of the primary barri- of the Mental Health Policy and Service Guidance Pack- ers to adequate mental health care is inappropriate men- age issued by the WHO in 2003. The guidance package tal health financing [1,2]. In ten years of delivering mental lays out eight sequential steps to good mental health health and development services across eight low and financing. The first two steps are to understand the broad middle income countries, BasicNeeds and its 42 imple- health financing context, and to map current resources menting partners, from both government and commu- and how they are used in the mental health system. nity sectors, have been challenged by the scarcity of resources. Our government partners, particularly those WHO ATLAS Data (Global & Regional Levels) within health ministries, share in the desire for greater Following its own guidance, the WHO preliminarily capacity - both human and material - so they can deliver mapped national budgets for mental health as one com- the mental health services being demanded by thousands ponent of its ATLAS project, which documents all men- of individuals and their families. tal health resources globally [4]. ATLAS questionnaires The World Health Organisation (WHO) asserts that were sent to a mental health focal point at the Ministry of "without adequate financing, mental health policies and Health in 191 countries. The questionnaires contained plans remain in the realm of rhetoric and good inten- three queries relating to mental health financing: 1) Is tions" [3]. This bold stance sets the tone for the report there a national budget line for mental health? (and if so, how much?); 2) How are mental health services * Correspondence: [email protected] financed?; and 3) Is mental illness considered a disability 2 BasicNeeds, 158 A Parade, Leamington Spa, Warwickshire, UK Full list of author information is available at the end of the article for public disability benefits? © 2010 Raja et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons At- BioMed Central tribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Raja et al. International Journal of Mental Health Systems 2010, 4:11 Page 2 of 14 http://www.ijmhs.com/content/4/1/11 The results of ATLAS study, particularly in answer to health [6]. Given that these regions encompass some of the first question about budgeting, gave the first good the lowest income countries in the world, 1% percent picture of the status of mental health financing globally. amounts to a small portion of a small pie. Out of all the countries surveyed, one in three (32%, n = That 36% of countries spend less than 1% of their health 61) had no specific budget for mental health [5]. budgets on mental health, when mental disorders repre- Although 130 countries reported having a mental health sent 13% of the global burden of disease, points to a strik- budget, only 89 of them were able to provide information ing disconnect between disease burden and health about their mental health budget. Of those 89 providing spending. More striking is that 53% of countries (n = 102) budgetary information, one in three (36%, n = 32) spent provided no information about spending on mental less than 1% of their health budget on mental health. health [6]. This finding suggests one of three possibilities: The ATLAS findings on the small government alloca- 1. no information was available about mental health tions for mental health are corroborated by data on the financing in these countries; 2. Information about mental WHO's mental health budget. In 2006/07 the WHO allo- health financing exists but was not transparent; 3. mental cated only 0.8% of its total operating budget to mental health was not a high enough priority for ministries to health, amounting to a total of US $14.9 million per year respond to the WHO survey. In either case, it is clear that [6], despite that neuropsychiatric disorders represents more research is needed into mental health financing in 13% of disease burden [7]. Since the WHO reflects the low income countries. priorities of its member states, their budget serves as fur- ther evidence that mental health financing is not yet a WHO AIMS Data (Country Level) priority for most countries (refer to figure 1). Building on the preliminary evidence from the ATLAS Regionally, those spending proportionally the least on study, in 2005 the WHO launched a new tool, called the mental health in the ATLAS study were predominantly Assessment Instrument for Mental Health Systems located in Africa and South-East Asia. Seventy nine per- (AIMS) [8]. Unlike ATLAS, which was collected from all cent (79%) of African countries and 63% of Asian coun- countries for the purpose of creating a global evidence tries spent less than 1% of their health budgets on mental base about mental health resources, AIMS is collected Figure 1 Neuropsychiatric disorders as a percent of WHO programme budget vs. percent of disease burden. Raja et al. International Journal of Mental Health Systems 2010, 4:11 Page 3 of 14 http://www.ijmhs.com/content/4/1/11 only by interested countries at the request of their health roeconomics in Ghana found that unclear national mental ministry with technical support from the WHO. Consid- health priorities contributed to inadequate funding for erably more thorough than ATLAS, the AIMS process mental health services (Appiah Kubi et al., unpublished). involves contacting people from many levels within the This pressing need for mental health financing informa- health system and takes an estimated 6 months to con- tion in Africa has clear policy implications for individual duct, including quality checks from the WHO regional countries. office. The AIMS tool is constructed along six domains, Access to psychiatric medicines in Africa is hampered and mental health financing constitutes one facet of the by inadequate supply and the cost of out-of-pocket pay- domain on policy and legislation. Where ATLAS col- ments for medicines [12]. Some countries, such as lected information on three financing indicators, six indi- Ghana, rely completely on donor funding for psychiatric cators are collected by AIMS, namely: 1) mental health medicines. When medicine is unavailable in the public expenditures by the government health department; 2) sector, prescribers, dispensers and users turn to the pri- expenditures on mental hospitals; 3) mental disorders in vate sector for needed psychiatric drugs. A 2006 compar- social insurance schemes; 4) free access to essential psy- ative analysis on the affordability of chronic disease chotropic medicines; 5) affordability of antipsychotic medication revealed that the lowest paid unskilled gov- medication; and 6) affordability of antidepressant medi- ernment worker in Kenya would need to work 20.2 days cation. to pay for one month's worth of generic fluoxetine [13]. In a first-of-its-kind study, Daniel Chisholm and col- However, government financing of psychiatric medicines leagues recently estimated the cost of implementing a has not yet been explored in depth. core package of mental health services at a high level of The three new WHO resources - the guidance package, coverage in low and middle income countries [9]. Draw- ATLAS and AIMS - have grounded the field of global ing data from the AIMS profiles of 12 countries, they cal- mental health with a baseline of financing data and a clear culated the cost of achieving 80% coverage for process for strengthening financing systems. Nonethe- schizophrenia and bipolar disorder and approximately less, these tools have certain limitations, as recognised by 30% coverage for depression and problem drinking. They the WHO themselves. The ATLAS data provides a good based their estimates on evidence-based interventions picture at global level, however at country level, its offered predominantly in primary care.

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