#MHForAll Webinar: The state of mental health financing
Chair
Raj Mariwala, Mariwala Health Initiative
Panellists
Dan Chisholm, World Health Organization
Ben Dossen, The Carter Center, Liberia
Douglas Otieno, TINADA Youth Organization
Valentina Iemmi, London School of Economics
Raj Mariwala
Welcome to everyone joining us, and thank you to our panellists for being here today. This session has been organised by The Global Mental Health Action Network, which has over 1200 members from over 90 countries, coming together as an open community of mental health advocates. We currently convene Financing and Youth & Child working groups, and will be launching communications, research and suicide decriminalisation groups shortly.
There has been a historic neglect in funding for mental health. Less than 2% of health budgets is spent on mental health globally, and this is less than 1% in low-middle income countries. COVID-19 has had a devastating impact around the world, and has made this issue more critical than ever.
Starting with Dan from the World Health Organization, can you give us a quick overview of the current financing situation for global mental health?
Dan Chisholm
There are three key issues concerning mental health financing: sufficiency of funding, efficiency of spending, and fairness in financing.
The adequacy and distribution of funding for mental health is still very low, and inadequate compared to the needs of the population. There are huge variations between countries, but globally speaking around 2% of government spending goes to mental health as an aggregate estimate, which is far short of what many would consider a minimum. It is recommended that in LMICs governments should spend 5% of their health budget, which increases to 10& in HIC.
The majority of the money currently goes to mental health hospitals or asylums, with just a fraction being spent in the community or on quality mental health promotion and protection activities, although the amount of expenditure can be difficult to measure.
The fairness of finance and the equity of spending is also important. According to the WHO many countries do include conditions like psychosis in national health schemes, but on closer inspection there are many countries where households and individuals are expected to pay a significant amount towards the cost of care. All of this has been exacerbated in the last year by COVID-19.
Raj Mariwala
On a more national level, what is the state of mental health financing in Liberia?
Ben Dossen
Financing in Liberia is largely donor driven and out of pocket. The government has demonstrated a remarkable effort to prioritise health, and that has led health to be one of the sectors that receives the lion’s share of the budget. But the financial challenge, due to donor dependency, is that donors have their own priorities and their funds can fluctuate. Mental health is often not the priority of the major donors in the country. This combined with a lack of political will negatively affects the level of mental health financing in the country. This in turn impacts the quality of care, services, and access across the country. This means many people with mental health problems relapse or end up in the streets.
While we have policy, legislation and a dedicated budget, the overall expenditure has been under 1% for many years. A significant chunk of the aims in the current policy will have to be passed on to the next policy when it is renewed. The government set up a technical coordinating committee to share information and consolidate efforts, but members of the committee, including the Ministry of Health, struggle to implement their basic functions due to lack of financing. The latest budget for the unit was less than US $10,000, meaning there was not adequate compensation.
But to look on the bright side, it’s fair to say that attention to mental health has really improved. We’ve seen more partners show interest in mental health and a desire to support services. That in itself is an accomplishment.
Raj Mariwala
What does TINADA do to increase affordable access to mental health services?
Douglas Otieno
We work in 5 counties in Kenya. One thing is that not all the counties budget for mental health. We invest in research so we can present these figures to governments and partners, who will only act on data. Taking an evidence-based approach is important.
We work with CSOs in every county to ensure that we push for mental health financing. We go through the national assembly, the county assembly and other systems. When we work together we see a lot of progress. Every year there is some financing for mental health. But we are pushing for an increase in the funding, and improved tracking how it is spent. It needs to be heading in the right direction.
In Kisumu county they have already increased spending. We are working to ensure there are increased and better results. If you ask people where they can go for support, they simply don’t know, or say that there isn’t anywhere. That’s why we are also working to ensure that mental health is integrated into funding for other programmes.
With evidence based advocacy we are working to improve financing, because every individual has a right to health. We need to advocate both at a county and at a national level, because when the money is received at a county level we need to provide support at a community level. We must have evidence, because when the policy makers allocate money for mental health, this is what they look for.
Raj Mariwala
What are the upcoming trends and opportunities for mental health financing?
Valentina Iemmi
There are two main trends and one big opportunity.
Proliferation is the first trend. There is an increased number of stakeholders investing in mental health, and plenty more that could be investing in mental health. This is not only a proliferation in number but also in the type of organisation involved in mental health. Previously it was pharmaceutical companies, international organisations and governments. Now it is much more varied, with organisations across multi-sector partnerships investing.
Integration is the second key trend. We have seen an increased use in integrated strategy when designing investment. This means mental health is included in investment for other conditions such as HIV, and other sectors, such as employment. This is a huge advantage both for mental health and for the other areas being addressed.
The big opportunity is COVID-19. This has been a terrible experience for everyone, but now we are starting to talk about recovery. In terms of financing, we are talking about recovery investment and recovery funds. We can build on the existing trends, including all actors and integrating mental health across other areas.
Raj Mariwala
What has been learnt from the national mental health investment cases undertaken through the UN Inter-Agency Task Force on NCDs, and what are the next steps for this work?
Dan Chisholm
These mental health investment cases are being supported by the UN Inter-Agency Task Force on NCDs using a standardized approach. To date there have been several investment case analyses, starting in the Philippines. These include a context analysis, and an economic analysis of the costs and return on investment.
These investment cases can garner a lot of new policy interest and traction. That’s because mental health is being discussed in terms of numbers and data rather than epidemiology. But right now they are largely just technical reports. Until analyses are acted upon they don’t mean that much. The real test is whether these lead to greater investment. It’s early days for that now, but the next step will be following up on the investment case analyses and ensuring that people are reading them and taking them seriously.
Overall they are a useful new tool and approach. We shouldn’t just think in financial and economics terms, but also use human rights, public health and equity frameworks to make the case for investing in mental health.
Raj Mariwala
What work has The Carter Center done on financing and mental health in Liberia?
Ben Dossen
In Liberia the Carter Center mental health programme started in around 2010 to address the needs of the population and help integrate mental health across services. There were originally 3 main pillars in consultation with the Minister of Health.
First was workforce development and sustainability. The Carter Center has been working to build the work force and ensure training of professionals who are licensed by the Board to practise, continuing to support their education. This has been a flagship programme of the Center.
The second pillar is law and policy. This is related to supporting the development of mental health policy and legislation, and supporting the implementation of those instruments. The Carter Center continues to work to increase capacity and training for mental health professionals, training them with mental health workers on WHO mhGAP guidelines, for example. This also relates to increasing the treatment centres. This is helping to increase access to support while reducing the burden on the one central hospital.
On human rights and inclusion, the Center has had strong support to help establish this movement, which was crucial in the passage of mental health legislation and the first mental health budget. We’ve seen the force and power of advocacy as a result.
Finally the Carter Center has been working with United for Global Mental Health to conduct a financing study on the landscape in Liberia, to help increase financing and get government support.
Raj Mariwala
If there was more financing available for mental health in Kenya, what would be your priority investment?
Douglas Otieno
Prevention is key. Based on the research we’ve done, there is a lot to be done in the community. We feel that investment needs to be taken to the community itself, and that we invest in community based mental health care. We should use a lot of money on resources to improve community support. And we should invest in primary health care. But this all relies on a strong policy framework to support this, as well as monitoring and evaluation. We work with supporter groups, and I feel that this is a very good model that should be replicated.
Raj Mariwala
You recently published a paper on the motivations and methods of external organisations investing in mental health in LMICS - can you give us an overview of your findings?
Valentina Iemmi
My paper focused on how the funders have invested, why, and what the opportunities are for the future, on an organisational, national and global level.
We can see they have invested in such a broad variety of activities. For example mental health awareness programmes, standalone mental health programmes, integration of mental health into existing programmes.
When we consider why these funders have invested, there are so many different reasons across different levels. But actors were a key factor across the board. Leaders and champions, political leaders, and global advocates all played a critical role.
Concerning the opportunities for the future, strong leadership, strong understanding of mental health, increased political support, and strong government structure for mental health would all be crucial for increasing investment in the future.
Raj Mariwala
What should go into qualitative case studies that will help shift investment toward financing for upstream intervention (e.g. community-based services and primary care) and away from hospitals/beds?
Dan Chisholm
The investment case work helps to sort out some of these things. For example, evidence can show a clear return on investment. When it comes to prevention and promotion, social and emotional learning programmes can provide strong evidence.
The next question is where the money comes from. COVID-19 does provide an opportunity. Working hard and ensuring mental health and psychosocial support are integrated into response plans is critical. Everyone is trying to claim some kind of share in the funding available, so the more evidence you have available, the stronger your claim will be.
We have the data, but sometimes we don’t have the strong links or partnerships that are needed.
Raj Mariwala
Let’s now take a question from the audience. What about the burden of care on caregivers, who are often women? Has there been a measurement on that burden?
Douglas Otieno
We need to strengthen community based health care, with a focus on data. The data being collected at a community level is not taking into account enough factors. A number of institutions and governments should ensure we are investing enough in evidence and monitoring. We cannot support what we don’t know.
Ben Dossen
On maternal mental health, at the Carter Center we work with the Minister of Health on an evidence based budget for managing postpartum depression. Seeing the number of pregnant women who suffer from depression score high on the PHQ. We see that they would benefit from the 16 sessions of the Carter Center programme, and that we should monitor them to see how they are progressing afterwards. Making mental health and overall part of the maternal and child care health is key to this, and allows us to put forward the case for integration to the government
Valentina Iemmi
There is a lot of cross-sectional thinking. Thinking about other areas, and other opportunities is key. Thinking diagonally is important. We should start building a big economic case, and so many people are now doing this. There is a big discussion around the care economy, which is relevant not only for mental health, but part of a bigger debate too.
The possibilities and opportunities are multiple, it’s about us being able to grab them.
Raj Mariwala
What is your top priority to increase investment in mental health?
Dan Chisholm
To ensure that mental health and psychosocial support are incorporated within country recovery and resilience plans. That is an opportunity that should not be missed.
Douglas Otieno
We must ensure that we work closely with the government, and we work in equal partnership. This work cannot be done alone. The key is to ensure that there is a mental health court in every government, and mental health is included in every budget.
Valentina Iemmi
People have the power as citizens, users and consumers. United voices from the bottom will change the top.
Ben Dossen
We must integrate mental health across all levels and sectors. This can help reduce stigma, and help us to maximise the low resources that we have.
Raj Mariwala
Thank you to everyone for joining us. Next session we will focus on the World Health Assembly, so please register your place and submit your questions in advance.
