#MHForAll Webinar: The urgent need for mental health integration in Universal Health Coverage
On Thursday 10th December, United for Global Mental Health launched their latest Universal Health Coverage report, which fully lays out the latest evidence on why it is critical to integrate mental health into the UHC agenda, and how the world can do this.
To mark the launch of the report, United for Global Mental Health co-hosted a special webinar with the Civil Society Engagement Mechanism of UHC2030.
The report referred to in this webinar can be found here.
Chair
Niall Boyce - The Lancet Psychiatry
Panel
Shekhar Saxena - former Director of the Department of Mental Health and Substance Abuse at the WHO
Florence Temu - Country Director, Amref Health Africa Tanzania
Safi Malik - the Director General (Health) at the Ministry of National Health Services Regulations & Coordination, Pakistan
Champika Wickramasinghe - Deputy Director General, NCD, Ministry of Health, Sri Lanka
Charlene Sunkel - CEO of the Global Mental Health Peer Network
Key messages from the webinar
Niall Boyce - The message is that not just mental health should be part of UHC but UHC will not be a success without the integration of mental health.
Florence Temu - Mental health should not be looked at as supplemental but as integral [to UHC]. We need to minimise lost opportunities and emphasise prevention and health promotion.
Champika Wickramasinghe - Integrating mental health into primary care is the most important thing. That way we can ensure everybody has access to mental health services.
Safi Malik - To achieve UHC, integrating health services, including mental health interventions within that, is the best remedy to address the treatment gap.
Charlene Sunkel - We must place people with Lived Experience at the centre of policy and practice, because we can add great value as key partners within the process.
Shekhar Saxena - Working together is key. If we can work together within the health and the development sector we can make integration possible.
Introduction
Universal Health Coverage is on the agenda, but there’s always a gap between words and actions. The new report from UnitedGMH aims to bridge those gaps.
Niall Boyce - Why is a report in the context of Universal Health Coverage needed now?
Shekhar Saxena - Thank you, and I’m so pleased to be able to contribute to the report and to join this webinar. The report was developed by UnitedGMH - Maxim Polyakov, James Sale and Sarah Kline. It is a very important report and everyone must read this. Why? Because there is a large gap between commitment and action. But the reality is that in spite of commitments made, 90% or more of people that require mental health care do not receive it. That is completely unacceptable in 2020. That is why the report reminds people of the commitments made and also presents the actions they can undertake to turn these commitments into reality. The second reason for the report is that the evidence has built up at a rapid pace over the last few years, in particular as pertains to how integration can be achieved in lower resource settings. Third, there has been an additional and renewed attention to the importance of mental health for all during COVID-19, and UHC is about the whole community. Therefore this is a very good time to present the evidence and actions needed to contribute to reducing the gap.
Niall Boyce - What does the report recommend?
Shekhar Saxena - The report is a long one, but despite that people should take time to read it; or at least they should read the executive summary. It makes the case for why mental health should be integrated in UHC. There is a strong argument on health, which says there is a large need for mental health provision, not only for those with a mental disorder but for everyone. Everyone can benefit, including people with physical health conditions. The argument on health, disability and the benefits of integrating mental health is very strong. The second argument is an economic argument - mental health care should not be seen as a cost but an investment. If you invest in mental health, you will get a lot of returns. Thirdly, perhaps the most important argument, and particularly appropriate, as we are launching the report on World Human Rights Day, is that people deserve mental health care because it is a human right. People living with mental disorders have a right to receive care and a right to be treated well. So those are the three arguments as to why there is a very strong case for including mental health care in UHC. But the report actually goes much further and tells you how this could be done. It talks about policies, laws, workforce, the involvement of people with Lived Experience, and monitoring and accountability.
Niall Boyce - So we’ve got the practical, ethical and financial arguments for integrating mental health in UHC and the roadmap for how this can be achieved. So how would you like people to use this report? What impact would you like to see?
Shekhar Saxena - The report has several actions for different stakeholders. This webinar has representatives from nearly all the stakeholders, the stakeholders include international organisations, national governments, people with Lived Experience etc. The basic case for everyone is that when you plan for UHC, don’t forget to include mental health. That’s the key to this whole argument. And this report has an element of urgency - we should act now. And one of optimism - it can be done.
Niall Boyce - Turning to specifics, 2030 is approaching. So what is the progress on UHC so far and where are we with achieving UHC by 2030 globally?
Florence Temu - Thank you, and I appreciate Shekhar’s summary. I could not agree more with him that it’s important that people read and understand the report. First we should understand that UHC is really about equity in access, sufficient quality of services, and that accessing services should not impose financial burdens on service users. To measure success we use the proportion of the population able to access essential, quality services, and the proportion of the population that spends a large proportion of household income on health. On the first of these we use the UHC service coverage index: overall we know that at least 50% of the entire world still does not have full coverage of essential services. There has been an improvement in recent years but progress is slow, especially on mental health. UHC aims to leave no one behind, so everyone, everywhere can access affordable mental health services. On the second measure, at least 930 million people, 12% of the world, spend at least 10% of their household income on health - and health expenditure puts 100 million people into extreme poverty. At least 90% of countries have experienced disruption to essential health services due to COVID-19, too. So I cannot agree more that we need to maximise resources and promote integration.
Niall Boyce - And at a country level, what progress has been made on integrating mental health into the mental health system in Pakistan?
Safi Malik - Mental health contributes almost 16% of the total disease burden in Pakistan, with a huge treatment gap. 60% of the population lives in rural areas. Currently we have a very poor UHC service coverage index score, now we have reached 47. However, the new government has a very strong commitment to UHC. For example, the Presidential Initiative aims to improve mental health at a national level. The WHO Thinking Healthy Programme has been important, with a focus on perinatal depression. We have two important social protection programmes, including a health insurance programme.
Coming back to UHC, for around 2 years we have been having internal discussions and consultations, and now we finally have agreed essential health packages, including on the community and primary care level. That has to include integrated mental health initiatives, including interventions on depression, anxiety disorders, with psychological and anti-depression therapy. Currently we are engaging the World Bank and the Global Financing Facility to secure funding (US$500 million) to implement this UHC benefit package, starting in 40 districts and gradually expanding over a 5-10 year timeline. We will be starting with Islamabad in February 2021 and then the rest of the project will start from September 2021 onwards. This is a huge achievement and I agree with Shekhar that mental health has remained a key challenge for us. For example, we have a very weak workforce, and there is a lack of recognition of mental health interventions across the country - so there is a need for improving awareness too. We will also engage with general practitioners (GPs) in the private sector, including for training
Niall Boyce - So it’s not just extending coverage, but rethinking how mental health care is delivered, and moving towards these community based and preventative models.?
Safi Malik - These were a few points I wanted to highlight, and we have lessons to learn and challenges in Pakistan. For example, low support and low human resources. We need to train a lot of people. We will focus on family physicians and use technology and telemedicine. Plus public-private partnerships. 2021 will be our implementation year. We have got a lot of support from WHO, Bill and Melinda Gates Foundation, and other partners to move ahead in this direction.
Niall Boyce - And what about the experience in Sri Lanka? Which has of course been developing its mental health system for many years.
Champika Wickramasinghe - People have come to understand the importance of mental health in the last 15 years, especially since the 2004 tsunami. We have had services for several years - but we need decentralised, community based services. And we are moving towards this. We have reorganised our National Institute of Mental Health, and hundreds of patients were released from the Institute. From 2015 we have a dedicated budget line, through a World Bank project, to improve the primary health care available and to incorporate mental health into that. Under that we have improved our acute psychiatric care, equipment and training. In 2005 we had only 10 districts with acute psychiatric care, and now all 26 districts have this care, so people don’t need to travel to the central districts to get this. In primary care institutions we have trained personnel and they also do outreach clinics in addition (there are around 215 now). These universal services have been very useful during COVID-19 when movement is restricted. We also have a cadre of community psychiatric nurses. Those are the main improvements.
Niall Boyce - Are there any barriers for the future, and how do you plan to overcome them?
Champika Wickramasinghe - The main barrier is we don’t have enough trained staff, and not enough community psychiatric nurses. Also our mental health act is about 100 years old so now we are working on a new act; we cannot manage patients using this old act. Another current problem is substance abuse disorders: we have started our service but it is not well established enough to manage and rehabilitate these people, so that is one area we need to work on.
Niall Boyce - We have heard about health care services in terms of quantity, personnel and funding. But the quality of care is key too. Today is World Human Rights Day. Charlene, what is your experience of how mental health care is delivered, from a rights perspective?
Charlene Sunkel - We still see quite a lot of human rights violations, and they are still engrained in some types of service delivery and practices. We still see a lot of coercion, paternalism, substitute rather than supportive decision making, poor access to services and access to services that are not beneficial and appropriate to the person as they identify it. Those with Lived Experience (LE) need to be empowered to identify what services they need on the path to recovery. People with LE have often been excluded from development of services. But LE should be integral to every part of services - right from the design, up to implementation, monitoring and evaluation.
Another aspect is peer support, which is key especially at times of COVID-19. If peer support had been present in every country, I think it would have eased the burden a lot.
I am passionate about the environments in which services are delivered, and that’s also a human rights aspect. Especially when it comes to psychiatric facilities, which often look more like prisons, not a place where people can go for care. They are also often a place where abuse happens. They are quite focused on the medical model, and less on delivering a more person-centred service package that can include peer support. Integration is important, too, particularly with primary health care.
Niall Boyce - On integration, how can we make sure that mental health care is scaled up in these systems, including priority programming areas, such as child and maternal health?
Florence Temu - I have to agree that integrating mental health is doable, both into health programmes and into non-health programmes. We just need a mindset change and leadership. We have all the arguments for integration - economic, rights-based - and we have seen all the facts. We have seen that 10-20% of children globally have experienced mental ill health, that 15-23% of children have parents with mental health disorders. For UHC the benefits economically are clear. Integration should take place across sectors. Within the health sector we need to make sure our policies reflect the importance of mental health; but also we should embrace mental health in all policies, e.g. in our workplace policies.
But there is a supply side and a demand side. The former is policy and funding models, including workforce; and on the latter we need to improve literacy in the community on mental health. We need to address the stigma and work along the spectrum of prevention, treatment and rehabilitation, which should all integrate mental health. We also need to ensure equity of access, including financial access and for service users to be able to access good quality care without any stigma. As AMREF we support this report and we know we need to improve data to shape and influence policies with facts.
Niall Boyce - Is the current pandemic a threat to funding for mental health, or an opportunity to build back better? How do we minimise the threat and maximise the opportunity?
Safi Malik - The pandemic has definitely highlighted mental health needs; and they are under tremendous stress so the government is clear that there is a need for appropriate support and prioritisation. With the support of WHO we started the We Care programme for mental health of health workers to address anxiety and stress of frontline workers. We have also been supporting them with the necessary PPE and training needed. A lot of mitigation measures were taken to relieve the anxiety and alleviate the stress.
Niall Boyce - So we can turn the threat into an opportunity, using the increase in public attention and innovating in the way services are delivered. And what has been the experience in Sri Lanka?
Champika Wickramasinghe - We had a bad experience at the beginning as we were not ready or able to accommodate the level of need from COVID-19 patients within the mental health system. But this gave us an opportunity, and we have now improved psychiatric wards, the ability of hospitals to accommodate these patients, and also our underutilised primary care services. We stopped all the clinics in hospitals to prevent the spread of COVID-19, therefore we had to organise for the drugs to be dispensed through primary health care workers who have started task sharing - dispensing drugs and caring for patients.
Another problem was the media. The media was describing the patients, giving their details, it was all just bad publicity. So we have been working with the media and developing guidelines on how to report on mental health, including on personal and sensitive details, and avoiding amplifying negative details. Now things are much better.
There was also concern from frontline workers and their family members, so we started helplines especially for them, and on a case by case basis we take the frontline workers and their family and provide them with psychological support.
Niall Boyce - What about this principle of “Nothing About Us Without Us”? What should be the role of people with Lived Experience in the integration of mental health in UHC?
Charlene Sunkel - First of all it’s important to emphasise that we need meaningful and authentic involvement of people with Lived Experience (LE). We need to understand that people with LE have often been ‘left behind’, so to be meaningfully involved in many cases across countries we need to support and empower them. And by authentic I mean actually taking recommendations from people with LE, incorporating and putting them into practice. It should not just be a tick-box exercise.
Because people with lived experience have a special expertise on how to make mental health systems more efficient and cost effective. Peer support is one such aspect of the integration of mental health in UHC, and the evidence is out there to show the benefits, although sadly we need more research in the Global South. People with LE play an important role in research too. And they should be involved in advocacy and in policy influencing. We need to push for alignment with human rights instruments within policies and service delivery, e.g. with the Convention on the Rights of Persons with Disabilities. And there is an important role for people with LE in monitoring and evaluation. This can be very simple: for example, as a service user, I have never once been asked to complete a survey to feedback on the service I received.
Niall Byoce - Now, over to audience questions.
Peter Yaro, Executive Director of BasicNeeds Ghana - How can integration of mental health be achieved and sustained in a country such as Ghana where there are limited donor funds?
Shekhar Saxena - The basic responsibility for health care, including in UHC, lies with the government of the country. The Government has to be persuaded that this objective is worth implementing and they must gear themselves up to do this. Where governments find this difficult there could be assistance from the World Bank, the WHO under the Special Initiative, from regional banks or from bilateral donors. Those organisations could assist. Countries can also use innovation mechanisms for care that are actually inexpensive and that can deliver care that is culturally relevant, rights-based and that can be afforded. There are good examples, including from Ghana - good care does not always need to be expensive and innovations in care can make it possible for a very large percentage of the population to receive mental health care.
Niall Boyce - Why are donors not providing the impetus for integrating mental health in health? How can we get donors to buy into mental health in health care?
Champika Wickramasinghe - If mental health is part of primary care, this helps a lot! So in all our training, we are pushing to integrate mental health into primary care. We actually have sufficient funding from the WHO and the World Bank.
Safi Malik - We started integration in 2018, and initially there was not much support from donors. The WHO and Bill and Melinda Gates Foundation supported it, and then the donor community and partners saw the seriousness of the present government in inclusion and provision. It took us almost 2 years of consultation and dialogue, engaging all the partners and donors. When we integrated mental health into primary health care, that gave us a good case and traction with funders. That’s how we were able to secure $500 million, with a $300 million grant and a $200 million loan. Historically our public health expenditure was low, only $14-15 per capita, and out of pocket expenditure was high; shifting towards UHC and integrating it within primary health care has attracted partners and donors, increasing buy-in from our national government too. This is a win-win situation for us.
Niall Boyce - So what is the single most important step that can be taken right now to integrate mental health into UHC?
Florence Temu - Mental health should not be looked at as supplemental but as integral; it is not optional, and it is evident that we need to do more. We need to minimise lost opportunities and emphasise prevention and health promotion. Mainstreaming is key.
Champika Wickramasinghe - Integrating into primary care is the most important thing. That way we can ensure everybody has access to mental health services - they need not go for specialised services. We must do the integration properly so all services come together, and the primary care package includes mental health services.
Safi Malik - It’s all the aspects we’ve been talking about. To achieve UHC, integrating health services and including mental health interventions within that, would be the best remedy to address the treatment gap.
Charlene Sunkel - To place people with Lived Experience at the centre of policy and practice, because we can add great value as key partners within the process.
Shekhar Saxena - Working together. If we can work together within the health and the development sector we can make it possible.
Niall Boyce - The key message I’m taking away is that not just mental health should be part of UHC, but also that UHC will not be a success without the integration of mental health.
