OUT OF THE SHADOWS

This report was written by Seth Mnookin (MIT). It is the product of almost two years of activities of a Working Group chaired and directed by Arthur Kleinman (Harvard University Asia Center). The Working Group consists of Timothy Evans (World Bank Group), Patricio Marquez (World Bank Group), Shekhar Saxena (World Health Organization), Daniel Chisholm (World Health Organization), Anne Becker (Harvard Medical School), Pamela Collins (U.S. National Institute of ), Mary de Silva (Wellcome Trust), Pablo Farias (Harvard Medical School), Roberto Iunes (World Bank Group), Akiko Ito (United Nations Department of Economic and Social Affairs),Dean Jamison (University of Washington), Yoshiharu Kim (National Institute of Mental Health, Japan), Judith Klein (Open Society Foundations), Vikram Patel (London School of Hygiene and Tropical Medicine), and Benedetto Saraceno (NOVA University of Lisbon).

In addition to members of the Working Group, it includes research by Pim Cuipers (Vrije Universiteit Amsterdam), Amanda Glassman (Center for Global Development), Bruce Rasmussen (Victoria University), Peter Sheehan (Victoria University), Filip Smit (Vrije Universiteit Amsterdam), Kim Sweeny (Victoria University), Leslie B. Tarver (Massachusetts General Hospital), and Daniel Vigo (Harvard University).

The Working Group acknowledges the contributions of Mary Dethavong, Annikki Herranen-Tabibi, and members of the staffs of the World Bank Group and the World Health Organization. It also would like to thank The National Academies of Sciences, Engineering, and Medicine’s Health and Medicine Division for its support of a meeting of the Working Group on April 20, 2015.

This paper was first presented during the keynote panel of a World Bank Group/ World Health Organization high-level meeting on making mental health a global development priority. The two-day event was held on April 13 and 14, 2016, as part of the World Bank Group/International Monetary Fund spring meetings in Washington, D.C.

This meeting would not have been possible without the sponsorship of: World Health Organization, Harvard University Asia Center, National Institute of Mental Health (U.S.), Grand Challenges , Wellcome Trust, Nippon Foundation, Rockefeller Foundation, Fundação Calouste Gulbenkian, Open Society Foundations, Mental Health Innovations Network, Kennedy Forum, Jack.org, iFred, Secretariat for the UN Convention on the Rights of Persons with Disabilities, Plan International USA, International Medical Corps, Strongheart Group, African Union Commission, Council, World Economic Forum, Department of State (U.S.)/APEC Mental Health Initiative, National Institute of Mental Health (Japan), Fundación Santa Fe de Bogota, Carter Center, European Commission Directorate General for Health and Food Safety, Fundación Once, Fracarita International, Nature, and George Washington University Milken Institute School of Public Health.

The organizers of the event also express their appreciation for the support provided by the Office of the United States Executive Director for the World Bank Group.

Disclaimers The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent.

Staff members of the World Health Organization who contributed to this report are responsible for the views expressed in this publication, which do not necessarily represent the decisions, policy, or views of the World Health Organization.

2 © 2016 Seth Mnookin, World Bank Group, and World Health Organization. Making Mental Health a Global Development Priority

Executive Summary

• Mental disorders impose an enormous burden on society, accounting for almost one in three years lived with disability globally.

• In addition to their health impact, mental disorders cause a significant economic burden due to lost economic output and the link between mental disorders and costly, potentially fatal conditions including , , diabetes, HIV, and obesity.

• 80% of the people likely to experience an episode of a in their lifetime come from low- and middle-income countries.

• Two of the most common forms of mental disorders, anxiety and depression, are prevalent, disabling, and respond to a range of treatments that are safe and effective. Yet, owing to stigma and inadequate funding, these disorders are not being treated in most primary care and community settings.

• Confronting mental disorders will require new sources of funding to bridge current resource gaps. Investment from a combination of national governments and international development partners could bridge these gaps and result in cost-effective mental health interventions.

• This funding will provide a strong return on investment, with scale-up leading to good returns in restored productivity as well as improved health.

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Introduction

It is no secret that mental disorders cause untold Unfortunately, the realities of the world mean human misery: Studies estimate that at least 10% that there is not adequate funding for every of the world’s population is affected1 and that intervention that would improve our health and 20% of children and adolescents suffer from happiness. As a result, when looked at within a some type of mental disorder.2 In fact, mental framework of resource allocation, the case for disorders account for 30% of non-fatal disease robust investment in mental health treatment burden worldwide (Figure 1) and 10% of overall may initially seem tenuous. This is only true, , including death and disability.3 however, if one ignores the many ripple effects Suicide, which is frequently caused by mental created by mental disorders. This discussion disorders, also exacts an enormous toll on will show that, in addition to the moral case society: In India, it has overtaken complications for treating mental disorders, there is also a from pregnancy and childbirth as the leading strong economic argument to be made. cause of death among women aged 15 to 49.4 Indeed, careful analysis shows that treating It is also well known that anxiety and depression, anxiety and depression is an affordable and two of the most common mental disorders, cost effective way to promote well-being and respond well to a variety of treatments. If we prosperity in a given population – and that failure accept that we have an obligation to alleviate to treat them can be a significant contributor death and suffering when it is within our power to impoverishment at the household level and to do so, a strong argument can be made that to diminished economic growth and social well- adequate mental health treatment should be being at the national level. considered a fundamental human right and a moral imperative. 17% Communicable, maternal, perinatal and nutritional conditions 6% Injuries

31% Mental, neurological Figure 1 and substance use Global distribution disorders of non-fatal disease 5 10% Depression burden of disease 4% Anxiety disorders 31% (years lived with disability) 4% Alcohol use disorders Other non- 14% Other disorders communicable diseases (e.g. CVD, cancer, diabetes, respiratory diseases)

14% Musculoskeletal diseases 4 Making Mental Health a Global Development Priority

There are two main reasons for this. The first is the STORIES FROM THE FIELD: lost economic output caused by untreated mental A 52-YEAR-OLD HOUSEWIFE disorders as a result of diminished productivity FROM INDIA at work, reduced rates of labor participation, foregone tax receipts, and increased welfare Last year, I was having terrible head and body payments. Based on an investment-case analysis aches due to a cold and was also experiencing prepared for this meeting, it is projected that the heaviness in my head, which meant I couldn't global cost of this lost production amounts to sleep. I did not feel like eating food and I had more than 10 billion days of lost work annually – no interest in completing my daily household the equivalent of US$1 trillion per year.6 chores. I was worried about my daughter, and I had to help her end her marriage because her The second is the two-way relationship that exists between mental disorders and unhealthy husband was not treating her properly. This issue behaviors such as poor diet and physical inactivity. caused frequent fights and arguments with my These, in turn, are contributing factors to cancer, husband and son. I began getting disturbing cardiovascular disease, obesity and diabetes, thoughts and had no interest in doing anything. and a range of other costly and potentially I thought that my existence is of no worth and conditions.7 Mental disorders also increase the wanted to end my life. likelihood of drug and alcohol abuse, which can lead to risky sexual behaviors that increase the I went to the primary health center where a risk of HIV infections and other injuries. Finally, gentleman offered me counseling and helped and most tragically, they are a significant factor me immensely. He helped me understand in suicides. Because of these relationships, my health problem in an easy manner. improvement in a population’s mental health After following the suggestions offered by him, will lead to improvement in its physical health my disturbing thoughts have reduced. I don’t – and will help enhance overall social and have thoughts of ending my life. I have started economic welfare. It will also help achieve one doing household work again and I also go to of the targets in the Sustainable Development Goals endorsed at the United Nations General temple for worshipping and take part in the Assembly in September 2015: Promoting mental activities organized by the temple authority. health and well-being and reducing mortality As per the counselor’s suggestion, I am also from non-communicable diseases by one third interacting with my neighbors. I feel good by 2030.8 these days.

The combination of overall lack of resources devoted to mental health and budgetary constraints in the world’s poorest regions means that the countries that can least afford lost economic output and increased costs are the ones affected the most. A recent WHO survey indicates that most low- and middle-income countries spend less than US$2 – and often less than US$1 – per person on the

5 OUT OF THE SHADOWS

treatment and prevention of mental disorders,9 and social interventions, and antidepressant a figure not remotely proportionate to the public medication are all among the low-cost, cost- health and economic burden these illnesses effective forms of treatment that will lead to cause.10 On average, low-income countries assign significant economic, social, and health gains. only 0.5% of their health budget to mental health. High-income countries, on the other hand, devote The question, then, becomes: Are these sufficient 5.1% – an amount sufficient to implement a series to justify the political will and financial capital of highly cost-effective interventions, but still achieving them will require? Our investment- disproportionately small given the prevalence case analysis, which measured the costs and and impact of mental disorders.11 Indeed, the benefits associated with a scaled-up response proportion of development assistance provided to depression and anxiety over the period 2016- for poor countries for mental health is under 1%. 2030, makes abundantly clear that they are.13 This paper will explicate effective options and settings It is not hard to understand why this gap exists: for treating common mental disorders, analyze The poorer the country, the greater the urgency potential impediments to incorporating these of the competing priorities for scarce resources. treatments into new mental health initiatives, Existing policies and funding priorities, combined and identify potential sources of funding for with the stigma associated with mental disorders, implementing new mental health strategies. have the effect of calcifying the problem: It is always easier to continue upon the path one is I. The case for investing in already on, especially if changing course would mental health require addressing neglected problems or facing uncomfortable truths. But the strong correlation Health relevance and impact of mental disorders with poverty and poor Recent analyses have indicated that the physical health illustrates that interventions can burdens of mental disorders are significantly and should be viewed as an integral part of anti- underestimated.14 Even so, as mentioned above, poverty policies and programs. That is, mental conservative estimates are that at least 10% of health assistance is central to development. the world’s population is affected by one or more There is also evidence showing that refugees mental disorders.15 Through a combination of from war and terror, as well as people affected its health effects, injuries, and suicide, mental by natural disasters and epidemics, suffer from disorders are also a major killer. Even using the significantly higher rates of depression and most conservative figures available, mental anxiety than the general population.12 Because disorders are the leading cause of years lived with of this, mental health treatment should be disability globally.16 Evidence also indicates that considered a major component of resettlement they are on the rise: A 2015 Lancet study found and recovery efforts in war-torn regions and that the prevalence of anxiety disorders increased an integral component of national disaster risk by 42 percent and depressive disorders by 54 management initiatives. percent between 1990 and 2013.17 Because mental disorders greatly increase the risk of a The good news is that for a problem with such person developing another chronic disease, and wide-reaching effects, there are feasible solutions vice versa,18 it is clear that mental disorders affect currently available across sectors. For depression both a significant portion of the population and and anxiety disorders, self-care, psychological disproportionate numbers of the vulnerable and the underserved.

6 Making Mental Health a Global Development Priority

Economic impact when those receiving treatment are better able In 2010, the global cost of mental disorders was to form and maintain relationships; to study, work estimated to be approximately US$2.5 trillion; or pursue leisure interests; and to make decisions by 2030, that figure is projected to go up by in everyday life. Assessment of these benefits – 240%, to US$6.0 trillion. In 2010, 54% of that and relating them back to investment costs to burden was borne by low- and middle-income establish the rate of return – can be achieved by countries (LMICs); by 2030, that is projected to estimating current and future levels of mental reach 58%.19 The overwhelming majority — disorders, the costs associated with effective roughly two-thirds — of those costs are indirect treatment coverage, and the social and economic ones associated with the loss of productivity impacts of improved mental health outcomes. and income due to disability or death. There is Just as mental disorders generate large economic also significant evidence showing that social and social costs, treating or preventing them can conditions associated with poverty create stress generate substantial health and economic gains. and trigger mental disorders, and that the labor Earlier work has assessed the cost-effectiveness insecurity and the health care costs associated of many of the evidence-based interventions with mental disorders in turn move many into discussed below. poverty.20 This circular relationship between mental disorders and poverty creates a cycle that A 2005 paper, for instance, looked at low- and leads to ever-rising rates for both. Several recent middle-income regions around the world and studies in high-income countries have found that found that each year of healthy life gained cost the total costs associated with mental disorders less than average annual per capita income,21 total between 2.3% and 4.4% of GDP (Table 1). while a 2007 paper focused on Nigeria found that a package of selected mental health interventions Costs and benefits of investing in mental health generated an additional year of healthy life at a There is intrinsic value in increased mental health cost below that country’s average per capita treatment in the form of patients’ improved well- income.22 These studies mirror research being. There is also instrumental value that results conducted in high-income countries: In the UK,

Table 1 Direct and indirect costs of mental disorders: Results from selected studies23

Direct Costs Indirect Costs Total Costs Country Year % of GDP (Billions) (Billions) (Billions)

CANADA 2011 CAD 42.3 CAD 6.3 CAD 48.6 4.40

ENGLAND 2009/10 GBP 21.3 GBP 30.3 GBP 51.6 4.10

FRANCE 2007 EUR 22.8 EUR 21.3 EUR 44.1 2.30

GLOBAL 2010 USD 823 USD 1,670 USD 2,493 4.00

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for instance, the returns on investment in 10 out As well as the direct impact of interventions on of 15 interventions that prevent mental disorders health, effective treatment also leads to increased are greater than five-to-one.24 In short, available participation in the workforce, reduced rates of evidence strongly points to the cost-effectiveness of absenteeism, and substantially improved scaling up mental health interventions in LMICs.25 functioning while at work. Findings from a new analysis indicate a favorable economic return will follow from effortsto scale-up services for depression and anxiety (Box 1).

Box 1:

Scaling-up the care of depression While these costs are sizable, the returns on this and anxiety: returns on investment investment are also substantial. A 5% improvement in labor participation and productivity produces Using the estimated prevalence of depression an estimated global return with an NPV of more 26 and anxiety in different regions of the world, than US$399 billion, US$230 billion of which is a new analysis of treatment costs and outcomes the result of scaled-up depression treatment and over the period of 2016-2030 has been carried out US$169 billion of which comes from treatment of for 36 low-, middle-, and high-income countries anxiety disorders. The economic value of improved that between them account for 80% of the global health is also significant (an NPV of US$250 billion burden of common mental disorders. A modest for scaled up depression treatment alone). The end improvement of 5% in both the ability to work result is a favorable benefit-to-cost ratio, ranging and productivity at work was factored in as a result between 2.3-3.0 to 1 when economic benefits of treatment and was subsequently mapped to only are considered and 3.3-5.7 to 1 when social the prevailing rates of labor participation and GDP returns are also included (Figure 2).28 per worker in each of the 36 countries analyzed.27 The key outputs of the analysis were year-by-year estimates of the total costs of treatment (the investment), increased healthy life years gained as a Figure 2 result of treatment (health return), enhanced levels Ratio of (economic and social) benefit of productivity (economic return) and the intrinsic to cost for scaled-up treatment value associated with better health. The stream Depression of costs incurred and benefits obtained over the Anxiety period 2016-2030 were discounted at a rate of 3%, 5.7 to give a Net Present Value (NPV). 5.4 5.3 4.2 3.8 3.9 4.0 Results show that the investment needed to scale 3.3 up effective treatment coverage for common mental disorders is substantial: The NPV of all investments in the 36 large countries examined

over the period 2016-2030 amounts to US$141 Low-income Lower Upper High-income billion, with US$91 billion going towards treatment countries middle-income middle-income countries (N=6) countries countries (N=10) of depression and US$50 billion going toward (N=10) (N=10) treatment of anxiety disorders.

8 Making Mental Health a Global Development Priority

II. Dealing with common mental disorders

Perhaps the single most important intervention evidence demonstrating that non-specialist by a health care practitioner is encouraging workers in primary care and community patient expectation of improvement with self- settings can deliver these treatments with great care and support from family and social networks. effectiveness to a variety of populations.32 Self-care (paying careful attention to diet, exercise, sleep, etc.) enables people living with mental Drug therapies disorders to take the first step at effective There are several major groups of management of their conditions. Because of this, antidepressants in common use today, including a shift towards acknowledging depression and tricyclic antidepressants, selective serotonin anxiety as legitimate health concerns, and not the reuptake inhibitors (SSRIs), and serotonin- result of individual shortcomings, will pay almost norepinephrine reuptake inhibitors (SNRIs). immediate dividends. In the majority of cases, Studies have found strong evidence for the however, self-care will not be sufficient for a full efficacy of antidepressant pharmacotherapy and or sustained recovery. no evidence of an advantage for any specific drug over another.33 Antidepressants generally,34 Treatment of moderate to severe conditions and SSRIs in particular,35 have well-documented The primary treatments for moderate to severe efficacy in the treatment of anxiety disorders and depression and anxiety disorders are antidepressant other disorders related to depression. drugs and structured, time-limited psychological treatments. Treatment of severe and refractory conditions The combination of structured psychological Psychological treatments treatments with antidepressants enhances Numerous randomized trials support the the recovery rates in people with medication- efficacy of depression-specific psychotherapies, resistant depression. Patients with severe or especially in the form of brief treatments based treatment-resistant depression and older patients on cognitive, behavioral, and inter-personal with depression have been shown to respond mechanisms. Examples of these are cognitive to electroconvulsive therapy (ECT).36 This is, behavioral therapy, problem solving therapy, however, typically the last line of treatment, as behavioral activation, and interpersonal therapy it must be administered in specialized settings for mood and anxiety disorders.29 There appears because it requires the use of anesthesia and to be relatively small differences between these muscle relaxants. One side effect of continued types of treatment; as a group, they were shown ECT is memory loss; therefore, it is used as a to be consistently superior to unstructured maintenance therapy only for those patients psychosocial support.30 These treatments share who were unable to sustain improvements after many strategies in common; what’s more, switching from ECT to available antidepressants. ‘trans-diagnostic’ treatments (viz. those that are designed to address mood, anxiety, and some other disorders) have been shown to be scalable and effective.31 There is also a growing body of

9 OUT OF THE SHADOWS

III. Treatment settings and integration STORIES FROM THE FIELD: Mental health system A 59-YEAR-OLD PAINTER AND FARMER Effective care of depression and anxiety requires a FROM INDIA comprehensive mental health system encompassing governance, healthcare institutions, and community Recently I was bed-ridden due to kidney settings. This involves building a multi-sectorial stones. I lost almost a month’s salary due to consensus backed by strong political will to enact holistic mental health plans. Mental health planners this problem. I was not able to go to our farm; and policy makers need to develop, through public all the work in the field was piled up. The pain awareness and community engagement, care was so unbearable and I didn't feel like talking delivery systems that are sensitive to local social, to anyone. I was constantly getting disturbing economic, and cultural contexts; this will ensure thoughts about my life, my children’s future, that services are appropriately sought out and and my family situation. I had no money and felt utilized. There is published evidence that national- embarrassed to ask for money from my kids. level health system reforms, such as those in Brazil,37 38 39 40 Chile, Italy, and the UK, have transformed the After surgery to remove the kidney stones, lives of people with mental disorders, and there I met with a counselor during one of my visits to is anecdotal evidence reporting similar effects in the health center. He understood my situation places as varied as Afghanistan, Jamaica,41 India,42 and explained to me that I needed to reduce and Peru.43 worrying. He visited me four times at home and gave me a booklet about depression and Integrated care for depression in primary, explained it to me. He also suggested I talk to maternal, and pediatric care In addition to its impact on overall physical health, family members, watch television, and read depression can negatively affect management of books. These things helped me to divert my bad common co-occurring diseases, such as diabetes, thoughts. With the support of the counselor and hypertension, cardiovascular disease, and cancer. my family members, I started doing household Collaborative care—an evidence-based approach work and then started going to work on the to care for chronic illness applied in primary care farm as well. settings—guides the effective use of resources for delivery of quality mental health care. It emphasizes systematic identification of patients, working alongside primary care providers (e.g. self-care, and active care management by clinical nurses, clinical officers, doctors) in community providers, blended with other medical, mental settings, in reducing symptoms of depression.46 health, and community supports. Collaborative care emerges as an effective way to address co- Anxiety and depression also play large roles morbid conditions and commonly co-occurring in the health of expectant and new mothers risk factors while improving overall health and their progeny: A 2007 review and meta- outcomes.44 The approach has proven effective analysis found that more than one-half (54%) of in general population samples and vulnerable pregnant women suffered from symptoms of sub-populations in high-income countries, and anxiety and more than one-third (37%) suffered increasingly in LMICs.45 Evidence from low-income from symptoms of depression.47 Antenatal countries demonstrates the effectiveness of care depression has been shown to increase the delivery by community or lay health workers, likelihood of preterm birth, low birth weight, and

10 Making Mental Health a Global Development Priority

cognitive disturbances.48 In addition, 10-15% of Information and communications technology new mothers suffer from perinatal depression. (ICT)-based platforms Substantial investments in maternal and ICT offers alternative modes of mental health newborn health render maternal care settings care delivery when resources are scarce, while a viable and desirable platform for delivery also addressing long-standing obstacles in of depression care, where early and effective mental health delivery, such as transportation intervention for maternal depression can be barriers, stigma associated with visiting mental implemented. Studies in both low- and high- health clinics, clinician shortages, and high income countries have shown that antenatal costs.56 These platforms, especially mobile mental and postnatal interventions are effective in health interventions, can offer remote screening, reducing depressive symptoms and improving diagnosis, monitoring, and treatment; remote infant outcomes.49 training for non-specialist healthcare workers; and can be used to develop and deliver highly Depression and anxiety disorders also have a specific, contextualized interventions.57 Cognitive negative effect on the ability of students to learn behavioral therapy has been successfully and study. This has been shown to be true for implemented through information technology children in elementary school50 all the way up platforms, demonstrating improvement in to young adults in college.51 What’s more, 75% depressive symptoms, reduced costs, patient of lifetime mental disorders have first onset by acceptance, and enhanced primary care ages 18-24.52 Integrating mental health treatment workflow.58 In addition, patient participation into standard pediatric and adolescent health is rapidly expanding in peer-to-peer social care would not only improve students’ learning networks where patients can access around the outcomes, it would also present an opportunity clock support with demonstrable improvements to establish a treatment regimen that could allow in depression symptoms.59 children and young adults to get what could be a lifelong affliction under control. Platforms outside the health sector

HIV care services Anti-stigma campaigns The frequent co-occurrence of depression with Stigma associated with mental disorders HIV infection warrants integrated approaches can result in social isolation, low self-esteem, to management of both disorders.53 Depression and more limited chances in areas such as is associated with poor adherence to HIV care, employment, education and housing. It can also as well as greater morbidity and mortality hinder patients seeking help, thereby increasing due to HIV-related disease.54 On the flip side, the treatment gap for mental disorders.60 What’s psychological and psychotropic interventions more, stigma can result in a general reluctance for depression have shown to be effective for to invest resources in mental health care61 and people with HIV. What’s more, non-specialists discrimination among medical professionals, with adequate support can deliver effective with negative consequences on the quality of psychological interventions in low-resource mental health services delivered.62 For all of these contexts, as demonstrated in Zimbabwe reasons, anti-stigma campaigns can be powerful and Uganda.55 tools in confronting mental disorders.

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School-based interventions Interventions related to conflicts and Primary and secondary schools are well- natural disasters established platforms for community-based Conflict exposes civilian populations and health surveillance and health interventions refugees to violence and high levels of stress,70 across virtually all clinical domains, including resulting in dramatic rises in mental illness71 that infectious diseases, non-communicable diseases can continue for decades after armed conflict has and risk behaviors,63 and mental health.64 Key ceased. Cambodians, for example, continue to strengths of school-based health screening suffer widespread mental illness and poor health and care delivery include a decentralized almost four decades after the Khmer Rouge-led infrastructure that can be utilized to achieve high genocide of the late 1970s.72 coverage for school age children and adolescents. Potential benefits of school-based programs Part of the rebuilding efforts in post-conflict include broad positive impact on healthy and post-disaster societies, therefore, should development and resilience, improved academic be on building out mental health services performance, and opportunities to integrate that are well integrated into primary care and school and clinic-based services.65 School-based public health efforts. A series of catastrophic life skills programs have also been shown to earthquakes in Japan, including the 1995 improve students’ learning outcomes and help Hanshin-Awaji Earthquake, the 2006 Niigata establish effective treatment regimens.66 Chuetsu Earthquake, and the 2011 Great East Japan Earthquake, has provided evidence that Workplace interventions mental health and psychosocial support can be There is a robust body of evidence showing that effectively integrated as part of humanitarian investment in workplace wellness programs response and disaster risk management.73 is not only good for employees but also for the bottom line of companies.67 In addition At present, sectoral projects funded by the World to obesity and smoking cessation programs, Bank Group (WBG) and other organizations workplace interventions commonly focus on utilize a bottom-up, multidisciplinary approach stress management, nutrition, alcohol abuse, and to re-integrate displaced population groups after blood pressure, and on preventive care such as conflicts and natural disasters. Incorporating the administration of the flu vaccine. treatment for mental illness into these existing projects would help overcome barriers to Workplace mental health interventions focused securing employment among the poor and on individuals can be centered on either vulnerable. Further investment in education, treatment or mental health promotion such social protection, and employment training as cognitive-behavioral approaches targeting would help prevent social exclusion an build stress reduction.68 Organizational-level workplace social resilience by serving the unique needs of interventions can include policies that address vulnerable groups. prevention and early intervention. There is some evidence that an integrated approach to workplace mental health, involving harm prevention through reducing workplace risks, mental health promotion, and treatment of existing illness, provides the most comprehensive management of mental health needs.69

12 Making Mental Health a Global Development Priority

IV. Resource gaps, funding options, and proposals for the future Those figures allow us to estimate the magnitude Resource gaps of the resource gap for mental health: US$1.6 Just because a given intervention represents good billion for low-income countries and US$6.6– value does not mean that there is money available US$9.3 billion for lower-middle-income to fund it. In order to be relevant from a public countries.77 Tackling this problem will require policy perspective, an intervention has to be both ambitious and strategic financing policies, which cost-effective and affordable. will need to take into account not only how resources are mobilized and pooled but also how The annual cost of a scaled up, basic package of they are channeled, allocated, and implemented.78 cost-effective mental health care interventions is estimated at US$2 per capita for low-income Potential funding options countries; US$3–US$4 for lower-middle-income countries; and US$7-US$9 for Latin America and Create a dedicated pool of funding based on sin taxes the Caribbean.74 For low- and lower-middle- A potential source of dedicated funding may income countries, this corresponds, on average, come from the taxes raised from alcohol or other to between 10% and 14% of public expenditures addictive substances, such as tobacco, that are on health and between 4% and 6% of total health disproportionately used by the mentally ill. Data expenditures; in Latin America and the Caribbean, from the World Health Organization for the 77 it translates to between 3% and 4% of public countries from which information is available expenditures on health and roughly 2% of total indicate that the annual tax revenue from excise health expenditures. A key reason why these taxes on alcohol could be substantial. Price and costs are low is the relatively low price of essential tax measures on tobacco and alcohol can be an psychotropic medications, many of which are now effective and important means to reduce tobacco off patent. As noted previously, current public consumption, alcohol abuse and health care costs, spending on mental disorders in LMICs is well and represent a revenue stream for financing for below what would be required to fund a cost- development in many countries.79 Besides the effective package of interventions. The already potential health benefits of this fiscal measure, it discussed health and welfare consequences of could help broaden the tax base and generate mental disorders provide ample evidence as to additional revenue to support budgetary capacity why governments and government resources to finance universal health coverage (UHC) and should play a major role in the funding of mental health scale-up. mental health.75 A potentially innovative financing model could Between 2007 and 2013, less than 1% of combine the resource-pooling experience of international health aid went to mental health; as a UNITAID, which receives resources from a small result, total spending on mental health—domestic tax on airfare tickets in nine countries, with some public spending plus external aid—came to only combination of the strategies implemented by US$0.25 per person in low-income countries and Gavi: The Vaccine Alliance and The Global Fund to to $US0.61 in lower-middle-income countries.76 Fight AIDS, Tuberculosis, and Malaria. These last This means that funding for mental health would two funding sources allow for the channeling of have to increase from five to eight times its current resources to a country’s health system, and have value in order to support a basic package of cost- introduced performance-based mechanisms effective interventions in low-income countries. to generate incentives aimed at improving

13 OUT OF THE SHADOWS

implementation. Accordingly, a portion of the Scaling up mental health coverage revenues generated from specific sources, such as The challenge to financing mental health lies in alcohol taxes, could be pooled into a fund aimed the fact that interventions should not be seen at financing context-specific packages of cost- as being isolated from one another; rather, they effective mental health interventions channeled to should be incorporated into different delivery primary or community care services. This financing platforms, such as primary care and community instrument could potentially adopt multi- health.80 This means that if these platforms do not stakeholder participation for resource allocation function well, or are not appropriately structured and performance-based incentives to improve and funded, mental health interventions will service delivery. also be ineffective. In the long term, earmarking or creating funding mechanisms dedicated Resources from mineral wealth exclusively to funding mental health interventions Many developing countries are rich in mineral without also ensuring other aspects of patient resources. Unfortunately, those resources are not care and health coverage are unlikely to be typically used to promote equitable growth and successful. In the short term, however, dedicated social development. The experiences from countries sources of financing are necessary to break the like Botswana, Chile, and Malaysia demonstrate cycle of neglect that affects mental health policies that the combination of sound economic policies, and programs, alongside efforts to improve strong institutions, and a commitment to social service delivery, platforms, and quality of care. development can reduce poverty and build human The emergence in recent years of a strong Global capital. A similar approach could be used in other Mental Health movement provides a base of developing countries to finance UHC and mental evidence-based knowledge and capacity to health programs. promote and support these efforts, but funding is needed to expand its reach in LMICs where mental It should be stressed, however, that while innovative health capacities have been chronically limited.81 financing mechanisms may contribute to the promotion of mental health and interventions in Include mental health in universal health the short term, they are not a substitute for the coverage packages role of governments and development assistance. Mechanisms used to prioritize interventions for Consistent with the Financing for Development financing and payment within UHC policies, such Action Document that was adopted at the as national health benefits plans or essential Third International Conference on Financing for medicines lists, are an opportunity to focus LMICs’ Development in Addis Ababa in July 2015, and domestic public spending on cost-effective endorsed at as part of the United Nation’s recent mental health interventions, and to structure Sustainable Development Goals initiative, it development donor support in this direction. should be recognized that for all countries, public Including the treatment of common mental policies and the mobilization and effective use of disorders within primary care has been one of the domestic resources are central to the common most accessible means of achieving progress, and pursuit of sustainable development. Building on the can be reflected in UHC benefits plans. (Successful considerable achievements in many countries since efforts in Chile, Colombia, Cuba, and Ghana the adoption of the Monterrey Consensus in 2002 provide lessons on how to integrate, scale up, and the Doha Declaration in 2008, countries need and sustain service provision.) This is particularly to strengthen the mobilization and effective use of important as some countries are explicitly domestic resources.

14 Making Mental Health a Global Development Priority

excluding some mental health conditions from societies could help mainstream mental health their plans. The UHC package is the opportunity to services. Another opportunity for scaling up bring policy and funding together. global mental health in the near future could be found in social impact bonds and development Build on results-based funding initiatives impact bonds, which would provide upfront Results-based funding between donors and funding from private investors who would earn a health systems in developing countries may offer return if evidence showed that programs achieve innovative ways to fund mental health programs pre-agreed outcomes.82 and pay providers within health systems, existing as an alternative and complement to traditional development assistance for global health. There are a number of ways this could occur: For example, natural synergies exist between mental health and other non-communicable diseases, and there is a growing awareness of the importance of mental health in the fields of maternal and child health. Cooperation across sectors also provides an opportunity for funders, including multilateral finance institutions such as WBG; regional development banks such as the Inter-American Development Bank, the Asian Development Bank, and the African Development Bank; regional bodies such as the European Commission; bilateral agencies such as the Department for International Development, the Japan International Cooperation Agency, and the United States Agency for International Development; and philanthropies such as the Bill & Melinda Gates Foundation, Bloomberg Philanthropies, the Nippon Foundation, and the Rockefeller Foundation, to use existing service platforms to support the scaling up of mental health treatment and care. For example, a bilateral donor or philanthropy could contribute to the WBG’s Global Financing Facility’s support of Every Woman Every Child with funding earmarked for mental health prevention and treatment. Investment in other areas, including education, social protection, and labor and employment, could also be utilized to respond to the unique needs of vulnerable groups. Multi-sector packages of services used for the reintegration of displaced populations in post-conflict and post-disaster

15 OUT OF THE SHADOWS

Key Policy Actions

• Mental health matters: Visibly increase the attention given to mental disorders at the national and international levels (including migration and humanitarian aid; social inclusion and poverty reduction; and human rights protection and universal health coverage). Strong leadership is needed to make mental health a priority, to commit to innovative and quality services, to channel resources toward mental health systems, and to strengthen community services.

• Mental health works: Introduce or strengthen programs that promote and protect mental well-being into general health services (integrated care), school curricula (life skills), and occupational health schemes (wellness at work); and promote better coordination across these platforms and sectors.

• Mental health needs: Devote additional resources from development assistance donors and domestic health budgets towards implementing community-based mental-health programs and strengthening the overall treatment of mental disorders as part of the progressive realization of universal health coverage.

16 Making Mental Health a Global Development Priority

Endnotes

1 Patel, V. and S. Saxena (2014). “Transforming lives, 14 Vigo, D., et al. (2016). “Estimating the true burden of mental enhancing communities — innovations in global mental illness.” The Lancet Psychiatry 3, no. 2:171-178. health.” New England Journal of Medicine 370, no. 6:498-501; Helliwell, J.F., et al. (2013). World Happiness Report. Available 15 Patel, V. and S. Saxena (2014); Helliwell, J.F., et al. (2013). at http://unsdsn.org/wp-content/uploads/2014/02/ WorldHappinessReport2013_online.pdf 16 Whiteford, H.A., et al. (2015). “The global burden of mental, neurological and substance use disorders: An analysis from 2 World Health Organization (n.d.). “10 Facts on Mental Health.” the Global Burden of Disease Study 2010.” PLOS ONE 10, no. Available at http://www.who.int/features/factfiles/mental_ 2:e0116820. health/mental_health_facts/en/; De Silva, M. and J. Roland, on behalf of the Global Health and Mental Health All-Party 17 de Menil, V. and A. Glassman (2015). Missed opportunities in Parliamentary Groups (2014). Mental health for sustainable global health: Identifying new strategies to improve mental health development. London, UK. in LMICs. CGD Policy Paper 068. Washington DC: Center for Global Development. 3 World Health Organization (n.d.) “Health Statistics and Information Systems: Estimates for 2000–2012.” Available at 18 Bloom, D.E., et al. (2011). Marquez and Farrington, (2013). http://www.who.int/healthinfo/global_burden_disease/ estimates/en/index2.html. 19 Bloom, D.E., et al. (2011).

4 Patel, V., et al. (2012). “Suicide mortality in India: a nationally 20 de Menil, V. and A. Glassman (2015). Patel, V. and A. Kleinman representative survey.” Lancet 2012;379:2343-51. (2003). “Poverty and common mental disorders in developing countries.” Bulletin of the World Health Organization 81, no. 5 World Health Organization (n.d.) “Health Statistics and 8:609-615; Saraceno, B., et al. (2005). “The public mental Information Systems: Estimates for 2000–2012.” health significance of research on socio-economic factors in and major depression.” World Psychiatry 4, 6 Chisholm, D., et al. (in press). “Scaling up treatment of no.3:181-185; Lund C., et al. (2010). “Poverty and common depression and anxiety: a global return on investment analysis.” mental disorders in low and middle income countries: A The Lancet Psychiatry. systematic review.” Social Science & Medicine 71, no. 3:517-528.

7 Bloom, D.E., et al. (2011). The global economic burden 21 Chisholm, D., on behalf of WHO-Choice (2005). “Choosing of noncommunicable diseases. Geneva: World Economic cost-effective interventions in psychiatry: results from the Forum; Marquez, P. and J. Farrington (2013). “The challenge CHOICE programme of the World Health Organization.” World of non-communicable diseases and road traffic injuries in Psychiatry 4, no. 1:37-44. Sub-Saharan Africa: an overview.” Washington DC: World Bank. Available at http://documents.worldbank.org/curated/ 22 Gureje O., et al. (2007). “Cost-effectiveness of an essential en/2013/06/17997739/challenge-non-communicable- mental health intervention package in Nigeria.” World Psychiatry diseases-road-traffic-injuries-sub-saharan-a