Mental Health in the Global Health Architecture
Matching the Scale of Illness and Disability to GHA Design
Everyone has the right to good physical and mental health.
The Global Health Architecture (GHA) cannot be optimised for the future if it remains based on the functions, mandates, accountability structures and financing that ignore the current and future patterns of illness and disability.
The comorbidities between physical and mental health conditions are increasingly well documented. Prevention, diagnosis and treatment require close collaboration across the health system. This has already begun to happen in areas such as HIV and TB, but there is much more to be done across communicable and non-communicable health conditions. Vulnerable groups, particularly the young and the elderly, report rising mental ill health alongside physical health needs. In health emergencies, including pandemics, mental health is a key concern for affected populations and the health workers supporting them. Our environment is changing with mental and physical health impacts. Technology is both accelerating access to health support and arguably causing mental and physical ill health as lives become more sedentary and exposure to harmful content increases. Health systems - and GHA organisations - have significantly underinvested in mental health and in addressing comorbidities with physical health.
A World Health Organisation-hosted Joint Task Force on Global Health Architecture Reform (GHA Task Force) is now in place. This briefing calls on the GHA Task Force to include recommendations for a future GHA with an integrated health systems, not disease-specific silos, approach that delivers good physical and mental health for all.
The Global Mental Health Action Network has over 11,000 members in more than 170 countries. Its members report they want a locally led GHA, with knowledge sharing and skills development that continue past the timelines donors set, and for sustainability to be intentionally designed into every programme, in line with the Lusaka Agenda.
The GHA Task Force should recommend: a future GHA with an integrated health systems, not disease-specific silos, approach that delivers good physical and mental health for all.This will require investment in local leadership and ownership for health programmes and, in particular, health emergency response and recovery.
Read our background Member's Brief: The Future of Global Health Architecture
1.Aligning Functions and Mandates
The GHA process is rightly moving away from disease-specific silos to an integrated, health systems approach. This means that a more holistic and effective approach to addressing health needs can be achieved. However, leaving health conditions to sit implicitly within general Primary Healthcare (PHC) or Universal Health Coverage (UHC) terminology risks confusion, dilution or neglect in global, regional, and/or country-level implementation. Explicit acknowledgement of physical and health needs (and comorbidities) is essential. Moreover, future health care requires investment in training and education for health workers. For example, mental health care is frequently delivered in expensive, outdated or even harmful ways due to outdated mental health policies and budget planning, and limited numbers of trained mental health professionals.
Aligning functions and mandates is not sufficient on its own; updating policies, norms and standards, and tackling stigma within the health sector is essential.
To align functions and mandates, the Task Force should:
Identify and address existing functional gaps. For mental health, this would include child and adolescent mental health, prevention and promotion strategies, spanning the humanitarian-development nexus, procurement and distribution of essential mental health medications, and community-based support structures.
Explicitly assign institutional responsibilities for each health condition. For mental health, this would include setting mental health norms and standards; supporting legislative reform; securing access to medicines; ensuring implementation; and addressing health workforce welfare.
Recommend incentives to expand health workforce numbers (particularly in underserved areas) and additional training and support for health workers to ensure an updated approach to the design and delivery of health services, including mental health services.
Mental health advocates want the GHA process to identify gaps and assign institutional responsibilities.
GMHAN members in Jamaica reported almost everything delivered for mental health in the country has come from the agencies whose roles the GHA process is reconsidering. PAHO and the WHO supported training for community-level care. They coordinate the National MHPSS Working Group, which exists largely to strengthen psychosocial care after disasters. UNICEF mapped child and adolescent services, named the gaps in national policy, and set up a crisis chatline with the Ministry of Health and Wellness. None of these functions sits with one organisation. All of these functions are at risk if the GHA process does not reconfirm the roles of each international organisation.
In identifying and addressing existing functional gaps, the GHA Task Force should support international organisations to clarify their roles at a country level and commit to sustaining support, particularly in areas for which the government relies heavily on external support.
2. Improving Governance and Accountability
Robust global health governance requires multi-sectoral coherence and authentic social participation. Current governance structures view civil society, youth, and people with lived experience at best as information sources rather than experts to be engaged as architects of the new GHA.
Health policies and services are stronger when they are designed, delivered and evaluated with people who use them. In particular, people with lived experience have an intimate expertise in what is required for recovery and what needs to change, and the perspectives of young people can help proactively inform the future health system.
To improve governance and accountability, the Task Force should:
Proposethatfuture health governance and accountability mechanisms integrate multi-sectoral needs linking health, education, child protection, and social protection systems.
Propose structured, transparent consultations of people with lived experience (PWLE), young people and civil society in both the GHA process and the ongoing work to develop and implement effective health services.
Mental health advocates want consistent data to underpin policy and financial decisions.
GMHAN members in Mexico report that a lack of complementary legislation defining how global recommendations are implemented into local laws means neither legislative bodies nor financing agencies can identify monitoring indicators. Moreover, data programmes across the WHO, UNICEF, the World Bank and the OECD lack continuity in their information sources. Without indicators, nobody can size or defend their budget transparently. Hospitals, medical centres and psychological units meanwhile operate without the funding to meet their objectives, and often without adequate equipment or infrastructure.
The WHO has argued for years for a shift from individual-focused care towards community-based care. Governments have not changed the paradigms and protocols that govern how they allocate financial and human resources, leading to a paradigm endorsed internationally but not translated into a planning method that a Ministry of Finance recognises.
In integrating multi-sectoral needs into future governance and accountability mechanisms, the GHA Task Force should support international agreements on consistent data and information systems at national level, and should ask international bodies to work more often in joint initiatives with national specialised professional associations.
Mental health advocates want engagement of people with lived experience of mental and physical health conditions.
The WHO's framework for meaningful engagement of people living with noncommunicable diseases, and mental health and neurological conditions, sets out what participation requires in practice: involvement across the whole policy cycle rather than at consultation moments chosen late; a role in setting the agenda and not only in responding to one already set; resourcing and remuneration for the people who take part; and safeguarding arrangements that make participation safe for people who may be disclosing their own experience of distress or of coercive care.
Member States have gone further at the 77th World Health Assembly, unanimously adopting a resolution on social participation for universal health coverage which commits governments to institutionalise the participation of communities, civil society and people with lived experience in health decision-making.
The GHA process now has the chance to recommend structured, transparent consultations, carrying forward the commitments that Member States have already made, and to build on these commitments so that all organisations in the GHA process prioritise engagement of people with lived experience and social participation.
3. Financing Future Health Needs
The global transition toward “one national plan and one budget” risks replication of the historic focus on areas of health that are no longer the greatest current or future population share of illness and disability. Safeguards should be built to ensure the future GHA adjusts to current and future health needs. Moreover, reforms in health financing should incentivise efforts that improve health outcomes. For example, today 66% of government mental health spending is restricted to stand-alone psychiatric facilities, starving community-level infrastructure and denying millions of people access to mental health care. Future health funding needs to focus on community-based care and - for mental health - incentivise the deinstitutionalisation of mental health care (in accordance with WHO guidelines).
To ensure financing addresses future health needs, the Task Force should recommend:
GHA financing reforms create clear financial incentives and investment packages within domestic budgets and development bank portfolios for integrated, community-level mental health services.
Specific accountability metrics for what is actually allocated, delivered, and spent on mental health within integrated PHC systems.
A global and/or regional process to increase access to affordable medicines for health conditions not already covered by such efforts e.g. mental health psychotropics.
Mental health advocates want international funding maximised for impact.
Members in Nigeria report international funding for mental health (via the GHA) is provided for emergencies and withdrawn shortly afterwards. Mental health and psychosocial support (MHPSS) arrives as a surge deployment on short grant cycles, and it is pulled out once the acute phase of an outbreak or a displacement crisis has passed. In countries facing repeated health emergencies, a response rebuilt by external partners after each event costs more and sustains less. The GHA Task Force should recommend that every emergency response finances local capacity strengthening and government handover from the first day, with clear financial incentives and investment packages to build integrated, community-level services,
Money and training often only reach organisations not based in the field, and training reaches participants who hold no direct clinical or community service role. The GHA Task Force should recommend formal partnership mechanisms with the local organisations that will deliver long-term care, with specific accountability metrics for what is allocated, delivered and spent.
Essential psychotropics are frequently unavailable in Nigeria (and in many LMICs). A global and/or regional process to increase access to affordable medicines would help ensure essential psychotropics are listed nationally and stocked at primary care level.
Conclusion
Today, mental health advocates report that functions are unassigned, governance rarely links people to decision-making, and financing still flows to institutions rather than to communities. The GHA Task Force has the opportunity to make recommendations that could build a GHA that can truly address future patterns of illness and disability. This briefing calls on the GHA Task Force to include recommendations for a future GHA with an integrated health systems, not disease-specific silos, approach that delivers good physical and mental health for all.
