Webinar: Mental Health and the World Health Assembly
Chair
Raj Mariwala, Mariwala Health Initiative
Panellists
Mark Van Ommeren, WHO
Niall Boyce, Lancet Psychiatry
Nasri Omar, Focal Point Mental Health System and Services, Mental Health Division, Ministry of Health, Government of Kenya
Taiwo Lateef Sheikh, Association of Psychiatrists in Nigeria
Raj Mariwala
The Global Mental Health Action Network is an open community of mental health professionals, and the largest network of its kind in the world. It works to accelerate support for mental health through a variety of activities, which you can learn more about here.
This month members of the World Health Assembly (WHA) will be discussing Mental Health preparedness and response in emergency settings. Clearly COVID-19 has had a devastating impact, so there has never been a more important time to discuss this.
Starting with a question for Mark, what is the World Health Assembly, and why is this year’s WHA so important for mental health and development?
Mark Van Ommeren
Thank you all for joining this session. I work for WHO, and the WHA is the governing body of the WHO. Each year it meets with 194 member states, and the delegations come from governments combining administrations of foreign affairs and health.
The Mental Health Action Plan extension was extended to 2030. Next week the WHA will make a decision on whether or not to adopt the updated plan. This is important as indicators and targets have been updated, and there is a slightly more refined look at countries’ progress on mental health. It has been strengtheneed in a number of areas, including children, public health emergiences, human rights, suicide, digital health, and workplace mental health. UHC is also central, and there is much more language on that.
Mental health will be discussed twice on this WHA agenda. Once in agenda item 13.2 on NCDs, which will give member states an opportunity to review progress made so far on the mental health action plan. Then Agenda item 18 is purely on mental health and COVID-19. This is also the item that will make the decision on whether or not to adopt the updated Mental Health Action Plan.
Raj Mariwala
Can you give us a quick overview of the current status of global mental health - why is it important to be discussing this in the context of global health?
Niall Boyce
The best starting point is that the WHA theme is ending the pandemic and building a healthier and safe world. This is a laudable sentiment, but for a long time the world has been unhealthy, unfair and unsafe for those with mental health problems.
The extent of mental health problems is huge. The most recent burden of global disease studies shows depression, self harm and anxiety in the top twenty five causes of disability adjusted life years for all ages, and these move into the top 6 when we look at the 10-24 year old age range.
It’s still too early to tell the long term impacts of the pandemic, as we move into recovery. Data from England suggests a deterioration of mental health in the population here back in April 2020, which led to some recovery later in the year, but there are still continued impacts. This is linked to other impacts, such as the financial implications of the pandemic.
Why does this all matter? The amount of money spent on research and treatment is miniscule in proportion to the challenge faced. This was outlined in the Lancet’s Commision on Sustainable Development a few years ago, and has not changed since then.
There’s a pragmatic case to be made. We won’t have a healthier, safer and fairer world, until we address mental health.
Raj Mariwala
What are the recent highlights from the Mental Health and psychosocial support (MHPSS) COVID-19 response in Kenya?
Nasri Omar
In Kenya, there was development of guidelines for mental health at the start of the pandemic which are now being finalised . Community volunteers’ mental health manuals have also been developed to help provide some basic intervention in mental health.
We are still working on improving our MHPSS services. This has involved coordination of a lot of partners; academics, NGOs and governments. We’ve partially trained all 47 counties on mental health first aid, and on Quality Rights. We’ve submitted some of the guidelines we made on MHPSS.
We’ve also been working with UNICEF and Kenya Red Cross to provide mental health first aid training to teachers and officers. We’re still working on the development of a national tele mental health centre. We’re trying to mark the resource we have in different counties, and have just finalised our Kenya Mental Health Action Plan which is soon to be launched.
Finally we’re working with WHO and UNDP on the investment case for Kenya, and we’re really looking forward to developing this national response based on cost effective interventions.
Raj Mariwala
Taiwo, you have been particularly involved in legislation change in Nigeria, can you tell us more about how you achieved change?
Taiwo Lateef Sheikh
In terms of mental health care accessibility, this relies on the legislation and policy framework of the country. That is what will determine how people can access affordable mental health care.
In Nigeria, the legislative aspects have been a huge challenge. In 1916 the British introduced the Lunacy Act, which is still being used today. It became a law in 1959. For over 35 years various groups of people have been trying to change mental health law in Nigeria, since the early 90’s. This is still not over, however we have been able to raise awareness about the law and how it doesn’t speak the modern mental health language. We’ve taken it to the executive at the national assemblies, and attention is now being paid to this law. We brought in a variety of stakeholders, including service users, to develop a draft bill to revise that law. This has gone through 3 readings at the Senate which we hope will move it on to the Presidency to make it the new law. This would be a huge change, and would completely eliminate so many human rights abuses associated with mental health.
Raj Mariwala
This year’s 74th WHA has a specific agenda item on COVID-19 and mental health (agenda item 18). What do you expect will happen in this session and what is the opportunity?
Mark Van Ommeren
This is the first time that there will be an agenda item on mental health in emergencies at the WHA. This is an advocacy network I’m speaking to now, so it’s important to understand that in the WHA Member States will be making statements on mental health. This is optional, but we expect many states would like to make a statement as it is important for them to talk about this issue now.
Many will say what they are doing, validating the need for action, some will be making requests for work to be done, and some will be making commitments. I understand many people on this webinar may work with the government or interact regularly, and there is an opportunity to make a very strong statement here.
These statements are on the record, so from an advocacy point of view this is very helpful to use within one’s own country. We are looking forward to the discussion at this session. We hope to see more energy and more commitment to mental health.
Raj Mariwala
COVID-19 has affected global health massively, and your journal has published much on this. From a Science perspective what kind of actions should countries take to address the pandemic?
Niall Boyce
We need better data. The Lancet Psychiatry recently showed the relationship between the pandemic and suicide rates. It showed that there didn’t seem to be a relation, but most data came from HICs. If we don’t have basic data, it’s hard to form any kind of response.
On the subject of global mental health in the context of the pandemic, there was a recent article in which they recommended fully integrating mental health into UHC, and accelerating changes in global mental health, such as through task sharing and leaning on digital interventions.
Beyond this we need to think about past crisis responses. Maybe global mental health needs to consider the end game more. How do we get there? There is the overarching issue in the need for a shake up in traditional power hierarchies in mental health, particularly with people with lived experience. There are mechanisms for ethical approval and so on, but not for the inclusion of people with lived experience. This is important in research and planning.
We could also increase the use of psychological science to enhance pandemic response, such as in communication of important information. This could be helpful for any future pandemics.
Raj Mariwala
In Kenya you have a strong relationship with civil society advocates, how can civil society work with and influence their health ministry?
Nasri Omar
In Kenya for every technical working group we form, for plans, guidelines, manuals, and so on, we always have representation of lived experience. This became the case in 2019 when we adopted the Quality Rights initiative. Inviting these advocates to meetings is not enough; they need to be inputting from the beginning until the end. We would also ask if they want to collaborate with the Ministry, develop an MOU, which are usually for long term projects. For short term projects they’ve been using official letters and channels. And in legislative reviews, we encourage them to attend and contribute to meetings. They submit memorandums to different collaborations and task forces, not necessarily only on mental health, but on other issues that relate to it too.
We also work together around global days, such as World Mental Health Day. In terms of research, if CSOs want to carry out research and so on they can ask for official letters from the Ministry of Health.
Raj Mariwala
What do you think are the top priorities for change or opportunities for success in Nigeria now?
Taiwo Lateef Sheikh
In general, top priorities include having a framework as encouraged by WHO, to be able to govern properly. In terms of governance, you need legislation and policy. The most impressive activity I would want to see is getting the mental health legislation done in Nigeria, and to revise the 2013 policy, and develop a strategy plan for it.
In terms of COVID-19, a lot has been done. We published a piece on national preparedness on COVID-19, and I recently spoke with officers from the Ministry of Health on how we can tackle the associated issues. The government is aware of these now, and has formed some committees relating to this.
We worked with the NCDC to develop messages addressing anxiety, fear, and common mental health issues. We formed a group of mental health professionals in Nigeria - Mental Health Professionals for COVID-19. We developed strategies for those needing support, and developed remote support for psychologists and others to help tackle these new issues.
Raj Mariwala
A question for Taiwo, what are some of the changes that would be part of the new legislation?
Taiwo Lateef Sheikh
We know that the Lunacy Act does not properly address mental health. It cannot be used for human beings in this era. What we have is not just inefficient, but unhelpful - we need a new framework all together that looks at human rights, and addressing mental health and other conditions across Nigeria. It will address the stigma that people are facing, and the traditional value system. The Lunacy Act is not useful, it cannot be applied.
Raj Mariwala
How can the assembly hold member states accountable, especially relating to mental health?
Mark Van Ommeren
It doesn’t hold people accountable. But the Mental Health Action Plan will be mandated to monitor progress relating to mental health, and we make the Atlas report every few years. This shows changes over the years, with more indicators. When member states make commitments, and then we later see that they’ve not followed up, then there is an opportunity for advocates. But the accountability will not come from the WHA, it has to come from people in the country.
Raj Mariwala
What are the main issues that have been preventing development on this legislation, and why is now the time to change it? And what language can be helpful in drafting new legislation?
Taiwo Lateef Sheikh
The challenges have been enormous. There is so much stigma around mental illness, and a lack of political will in previous governments to address issues around mental health in Nigeria. The attitude towards mental illness has been very discriminatory, even among mental health professionals. Doing advocacy, and getting resources, has been extremely difficult as a result.
Why now? Because we’ve been able to do a lot of awareness campaigning; we have social media, and we’ve taken advantage of this. We’ve been running campaigns on TV, on phones, on Twitter, on Facebook, and we’ve been running workshops and events around the country. This has helped us to catch the attention of politicians. We now have a democratic and approachable government, with some politicians who have taken interest in our work.
In terms of the language, it’s difficult for me to outline all the languages we’ve used. But there is a WHO document that has around 11 points and acts as a guide or resource for drafting this. We’ve added our own cultural aspects to this, but the WHO resource has been extremely helpful.
Raj Mariwala
How can non-state stakeholders be part of the WHA? What is the role they can play?
Mark van Ommeren
WHO has official relations with a number of NGOs - the non state actors. The ones that are in official relations make statements, such as the world federation for mental health. Save the Children, World Vision, and others also input. This is important. It’s challenging, bringing these all together to make resolutions, but only the member states vote.
Raj Mariwala
Another audience member says that if the new act places huge financial demands on governments, Members of Parliament are going to be sceptical in passing the law. Is this something you’ve faced?
Taiwo Lateef Sheikh
A law forces a government to commit. That is what the government is running away from, and this has to do with funding and certain basic human rights. But the issue of funding is most important. They’ll ask where the money will come from.
Niall Boyce
We can move away from the language of plugging a gap, and towards a language of investment. You’re investing in the future of your society.
Mark van Ommeren
Legislation and policy work best when there is a budget commitment. If it’s not realistic within the budget of the country it just won’t happen, but it should still be ambitious.
Nasri Omar
Mental health law in Kenya has been in parliament since 2018. It’s now 2021. It brought a lot of resistance. But now we’re trying to make it smarter in terms of how we frame it, and we’re asking for specific funding for mental health in the law. And we’re working on the mental health investment case - hopefully we’ll have the report by the end of the year, which we can take to Parliament and to the Senate.
Raj Mariwala
How should advocates persuade health ministers to prioritise mental health?
Mark van Ommeren
Mental health is a core value for all human beings, investing in mental health is to value human life.
Taiwo Lateef Sheikh
Advocates need to be able to break down language in a way that people who are policy makers and in governance will understand what we are talking about, and use local examples to show what mental health is all about.
Niall Boyce
There is a quote from James Joyce which is relevant - “History is a nightmare from which I am trying to awake”. Meaningful change will address historic wrongs, and be a substantial positive investment in the future.
Nasri Omar
High level advocacy is key. Getting champions in parliament and in the executive, can be difficult, but these are the best people who can be advocates. There is a lot of political will and donor commitment, but if we don’t translate this into resource allocation then we are just going around in circles.
Resources:
Resources shared by Niall Boyce: Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30925-9/fulltext
Trajectories of anxiety and depressive symptoms during enforced isolation due to COVID-19 in England: a longitudinal observational study
https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(20)30482-X/fulltext
Mental health before and during the COVID-19 pandemic: a longitudinal probability sample survey of the UK population
https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(20)30308-4/fulltext
The Lancet Commission on global mental health and sustainable development
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31612-X/fulltext
