IMPORTANCE OF ENGAGING GOVERNMENTS IN ADULT MENTAL HEALTH REFORM RACHEL JENKINS GASTEIN 2004

WHY GOVERNMENTS SHOULD ENGAGE WITH MENTAL HEALTH Mental illness causes a heavy burden Mental illness impedes the achievement of other health and development targets Mental illness contributes to poverty and social exclusion Mental illness differentially affects the poor Mental health has intrinsic value as does physical health

BURDEN OF MENTAL ILLNESS FOR INDIVIDUALS Suffering Disability Mortality Loss of economic productivity Poverty

BURDEN OF MENTAL ILLNESS FOR FAMILES AND COMMUNITIES Family burden Intellectual, emotional and physical consequences for children Intergenerational burden-cycles of disadvantage Reduced access to and success of health promotion, prevention and treatment programmes

Global Burden of Disease The global burden of neuropsychiatric disorders – 10.5% of total DALYs in 1990 and 15% in 2020 Neuropsychiatric disorders are 5 of the 10 leading causes of disability Neuropsychiatric disorders are 28% of Years of Life Lived with a disability Suicide is 10 th leading cause of death

Problems with DALYs No inclusion of family or social burden Estimates in many countries Comorbidity –Double counting because of comorbidity within mental disorder –Undercounting because of comorbidity with physical illness No inclusion of premature physical mortality

Summary of Rationale for action Positive mental health contributes to the social, human and economic capital of societies The burden of mental illness is high Effective interventions are available International collaboration is helpful

Elements of a comprehensive mental health mission 1 Promote mental health Reduce stigma Reduce incidence of mental disorder Reduce prevalence of mental disorder Reduce the extent and severity of associated disability Reduce mortality associated with mental illness

Elements of a comprehensive mental health mission 2 Develop intersectoral services and interventions Protect the human rights and dignity l people Promote the psychological aspects of general health and social care

Relevant Sectors Health Social Welfare Employment, Trade and Industry Education Home affairs and criminal justice Environment and Housing Finance

Culture must be taken into account Culture influences Value placed by society on mental health Presentation of symptoms Illness behaviour Access to services Way individuals and families manage illness Way community responds to illness Degree of acceptance and support Degree of stigma and discrimination

THE ISSUES FACE US ALL Each country is different, with different context, culture, type of service provision. Nonetheless,we also face some very similar issues. We need locally tailored solutions

Policy needs to be tailored to situation appraisal Otherwise it runs risk of not –meeting countries’ needs –being implementable

THE CHALLENGE IN E. E. Disintegration of general social supports and social structures Lack of support to people with mental illness and their families Overinstitutionalisation Limited NGO development in the field of mental health Isolation of psychiatry

THE CHALLENGE 2. Lack of resource Inflexible services Few community services No involvement of primary care Little social work or social work perspective Little occupational therapy

THE CHALLENGE 3. Lack of multidisciplinary team working No detailed multiaxial assessment of each person’s social, psychological and physical needs No individually tailored care plans to meet those needs No therapeutic optimism

THE CHALLENGE 4. Little experience of intersectoral working at individual, local and national level User groups non-existent Highly vertical structures All mental illness must be treated by a psychiatrist

THE CHALLENGE 5. Lack of a formal primary care structure No focus on mental heath in policlinics No CME for policlinic staff on mental heath No proper links between policlinic and specialist services about mental health

THE CHALLENGE 6. Governance and stewardship Financing Outcome oriented approach Decentralisation

STIGMA Lack of attention from ministers and public Decaying institutions Lack of leadership Lack of resource Inadequate information systems Inadequate legislation Inadequate attention in key public health committees

Systematic Steps for policy Detailed situation appraisal Consult stakeholders and sectors Prepare recommendations and action plan Form into policy and implementation plan Integrated with other sector plans Integrated rather than vertical programme Access generic budgets Re-appraise and fine tune the policy and plan

An integrated national mental health policy and strategy Integrate with overall national health policy General health sector reform strategy Package of essential health interventions Essential medicine kit Health information systems Curriculum for all health workers Country level work on global burden of disease

An integrated national mental health policy and strategy Integrate with overall government policy, linking to ministries of –Finance –Education –Social welfare –Home affairs/criminal justice –Employment –Housing

An integrated national mental health policy and strategy Be integrated with –Poverty Reduction strategy –Economic Recovery Plan

An integrated national mental health policy and strategy should link to legal framework funding streams mechanisms for governance, management and accountability human resources strategy Management and information strategy R and D strategy

An integrated national mental health strategy should include PHC, secondary care, linkages, interventions, guidelines, data collection Client participation Support for carers Intersectoral links with NGOs, social care, education, police, prisons, traditional healers Mental health promotion in schools, workplace, community Role of media

GOVERNANCE Multi-disciplinary team working and clinical accountabilty Mental health on agenda of district and regional health management commitees District and regional intersectoral steering commitees for mental health

ROLES AND RESPONSIBILITIES Clear definitions for each level in health service and for each intersectoral partner Regular review and discussion

RESEARCH AND DEVELOPMENT Sustainable R and D strategy –epidemiology –mental health economics –Health and social outcomes and quality of life –User and family involvement –access to libraries and internet

HUMAN RESOURCES Sustainable plan for production and continuing development of primary and secondary care staff Mentoring and support Occupational health

MENTAL HEALTH STATISTICS Good information is essential to ensure effective planning, budgeting and documentation of outcomes of expenditure –population need –primary care consultation rates –primary care treatment and outcomes –specialist referrals and outcomes

INVOLVEMENT OF NGOS People with mental illness, their carers and the community at large are the customers of the service they can spot gaps and problems and what is working well Pump priming NGOs is a cost-effective way of encouraging improvement of planning and delivery of services

LEGISLATION legal framework to balance need to treat people when they are unable to consent with their legal and human rights legislation on disability, anti discrimination and welfare benefits mental as well as physical needs of children in care ( a high proportion go to prison)

Some strategic policy steps 1. Need to address high level stigma surrounding mental health issues so that –integrate mental health policy with overall health policy –Deinstitutionalisation is not seen as opportunity to save money – machinery for monitoring needs, inputs, processes and outcomes is available

Some strategic policy steps 2. Need to address financing so that –No perverse incentives –Local funding is sustainable –Develop funding streams

Some strategic policy steps 3. Key into generic health reforms –Health information systems –Hospital optimisation –Quality standards –Basic training standards –Accreditation procedures

COMMON APPROACHES Capacity building Sustainability partnerships Strategic policy work Public relations

COMMON APPROACHES User representation NGO development Human rights approach Intersectoral partnerships Individual assessment of needs and individually tailored care plans Evidence for interventions

Getting mental health and mental illness into generic social policy Education Employment Prisons Police Urban issues Rural issues Transport Social Welfare

SUMMARY OF KEY STEPS IN NATIONAL MENTAL HEALTH REFORM Situation appraisal and consultation of stakeholders Prepare mental health policy and strategic framework Ensure mental health is integrated into generic policy documents and plans Implementation of strategic framework Identify and unpick specific blocks to implementation Evaluation of policy and implementation Improve policy and implementation