This study was funded by Human Resources for Health, World Health Organization (HQHRH ), and by the Global Center for Health Economics and Policy Research, a WHO/PAHO Collaborating Center on Health Workforce Economics Research, at the University of California, Berkeley. Human Resources for Mental Health: Workforce Shortages in Lower and Middle Income Countries Richard M. Scheffler, Ph.D. University of California, Berkeley Tim Bruckner, Ph.D. University of California, Irvine

Draft – Not for Distribution Collaborators World Health Organization Shekhar Saxena, M.D. Programme Manager, Department of Mental Health and Substance Abuse Coordinator, Evidence, Research and Action on Mental and Brain Disorders Mario Dal Poz, M.D., M.Sc., Ph.D. Coordinator, Information and Governance, Department of Human Resources for Health Dan Chisholm, Ph.D. Technical Officer, Costs, Effectiveness and Expenditure and Priority Setting Unit, Department of Health Systems Financing Jodi Morris, Ph.D. Technical Officer, Mental Health: Evidence and Research Team, Department of Mental Health and Substance Abuse University of California, Berkeley Tim-Allen Bruckner, Ph.D. Assistant Professor Program in Public Health University of California, Irvine Jangho Yoon, Ph.D. Assistant Professor Health Policy and Management Jiann-Ping Hsu College of Public Health Georgia Southern University Gordon Shen, M.Sc. Graduate Student Health Services and Policy Analysis Ph.D. Program University of California, Berkeley Brent D. Fulton, Ph.D. Assistant Research Economist Global Center for Health Economics and Policy Research University of California, Berkeley 2

Draft – Not for Distribution Learning Objectives Understand the steps to estimate target workforce levels Locate appropriate data sources to arrive at (1) the population in need and (2) target service delivery models Identify the assumptions built into the models Describe the magnitude of the mental health workforce shortage

Draft – Not for Distribution 4 Presentation Outline Introduction Methods and Data Results Discussion

Draft – Not for Distribution Introduction Mental health is critical to overall health – Depression was the third leading cause of disability (based on DALYs) in 2004, ahead of heart disease and HIV/AIDS An estimated 14% of the global burden of disease involves mental, neurological, and substance use (MNS) disorders Costs – direct economic costs of mental healthcare – indirect economic costs of lost productivity, impaired functioning, and premature death 5

Draft – Not for Distribution Treatment Gap In low- and middle-income countries (LAMICs), 50-65% with mental disorders are not treated LAMICs spend only 2% of the government health budget on mental health Several reports have called on governments to scale-up the mental health workforce in LAMICs 6

Draft – Not for Distribution Workforce Research Questions What is the needed number of mental health workers required to treat mental, neurological, and substance use (MNS) disorders in low- and middle-income countries (LAMICs)? What is the supply of mental health workers in LAMICs? What is the shortage of mental health workers in LAMICs? How much are the wage bill costs to scale-up the mental health workforce in LAMICs? 7

Draft – Not for Distribution 8 Presentation Outline Introduction Methods and Data Results Discussion

Draft – Not for Distribution Method to estimate mental health workforce shortage by country Needed number of mental health workers – Based on disorder prevalence, treatment rates, and treatment modality Supply – Number of psychiatrists, nurses working in mental health settings, and psychosocial care providers Shortage = Need – Supply 9

Draft – Not for Distribution Step-by-step process to calculate persons with a mental disorder requiring treatment: epilepsy in Ethiopia Step 1: Estimate prevalence cases per 1,000 persons Source: WHO Global Burden of Disease, 2004 Step 2: Multiply prevalence by the population of adults Step 3: Multiply number of persons by target coverage rate 438,057 X 80% coverage = 350, cases per 1,000 persons X 42million = 438,057 Source: United Nations Population Reference Bureau, 2008 Revision Source: Ding D et al., Epilepsia (3): ,445 Target number of persons needing treatment

Draft – Not for Distribution Notes on Population in Need Population (not clinic) based prevalence Population age structure important – ex: dementia is 1 of the 8 disorders covered Target coverage depends on – severity of disorder – the ability to detect cases – probability cases will seek care 11

Draft – Not for Distribution Baseline workforce need for mental health: epilepsy in Ethiopia Step 4: Begin with persons needing treatment 350,445 persons Step 5: Assign treatment models Step 6: Calculate FTE needed per setting = outpatient FTEs hospital outpatient services Psychiatrists: 32 Nurses: 334 Psychosocial care providers: ,445 PHC outpatient services (11 consults / day X 225 working days / yr) 2,453,115 outpatient visits / yr 87,611 bed-days / yr = beds(365 days in yr X 1.15 rotation factor) Step 7: Assign staffing proportions based on setting needs community residential inpatient services

Draft – Not for Distribution Method to estimate needed number of mental health workers Step 1: Estimate prevalence of the 8 priority MNS disorders by country Step 2: Set treatment rate goals for each disorder – Depression (33%) – Schizophrenia, other psychotic disorders (80%) – Suicidal ideation (80%) – Epilepsy (80%) – Dementia (80%) – Disorders due to use of alcohol (25%) – Disorders due to use of illicit drugs (50%) – Mental disorders in children (20%) 13

Draft – Not for Distribution Method to estimate needed number of mental health workers (cont’d) Step 3: Estimate needed treatment: number of outpatient visits and inpatient bed days – cost-effective interventions Step 4: Estimate number of psychiatrists, nurses, and psychosocial workers needed to deliver treatment 14

Draft – Not for Distribution Example: estimate needed number of mental health workers required to treat epilepsy in Ethiopia Epilepsy cases: 438,000 – Based on prevalence of per 1,000 Epilepsy cases to treat: 350,000 – Assumes 80% treatment rate Treatment modalities – 100% use primary care outpatient services (4 visits/year) – 50% use hospital outpatient services (5 visits/year) – 5% use community residential inpatient services (5 bed-days/year) 15

Draft – Not for Distribution Example: estimate needed number of mental health workers required to treat epilepsy in Ethiopia (cont’d) Worker productivity – 2,475 outpatient visits per worker per year (11 visits per day x 225 days) – inpatient beds: various ratios by specialty and setting for example: 1 psychiatrist needed per 34.5 inpatient beds for residential care Workers needed: 1,198 – Psychiatrists/specialist: 32 – Nurses: 334 – Psychosocial care provider:

Draft – Not for Distribution Supply of Workers WHO-AIMS – Assessment tool at all levels of organization National, provincial, local, level : 58 LAMICs participated – Work closely with WHO to administer WHO-AIMS 17

Draft – Not for Distribution Ethiopia workforce results for 8 priority MNS disorders 18

Draft – Not for Distribution Data MNS Prevalence – 2004 Global Burden of Disease Project – Comparative Risk Assessment (CRA) Population – United Nations Population Database Treatment modalities and number of workers per modality – Chisholm et al., 2007; Chisholm & WHO-CHOICE, 2005 Mental health workforce supply – World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS) Version 2.2 Workforce wages – Occupational Wages around the World (OWW) Database 19

Draft – Not for Distribution Data Sources: search for Chisholm D or Lund C. Step 4: Begin with persons needing treatment Step 5: Assign treatment models Step 6: Calculate FTE needed per setting Step 7: Assign staffing proportions based on setting needs Chisholm D et al., J Stud Alcohol 65: ; Chisholm et al, 2004; Br J Psych 184: ; Chisholm et al., Bull WHO 2008 Jul;86(7):542-51; Hyman et al., Mental Disorders. In Disease Control Priorities in Developing Countries pp ; Chisholm et al., Br J Psych 2007 v191, ; (Lund et al., S African Med J 90: ; Lund and Fleisher, Soc Psychiatry and Psychiatric Epidemiology 41: Source: Rispel, Price, and Cabral, Confronting Need and Affordability: Guidelines for Primary Health Care Services in South Africa. Johannesburg: Centre for Health Policy. Source: Chisholm D, Lund C, Saxena S. Br J Psychiatry Dec;191:

Draft – Not for Distribution 21 Presentation Outline Introduction Methods and Data Results Discussion

Draft – Not for Distribution Supply represents 22% of need, resulting in a 282,000 worker shortage in 57 of 58 LAMICs 22

Draft – Not for Distribution Countries with the largest shortages 23

Draft – Not for Distribution

A few caveats Point estimates vs. confidence intervals (need for sensitivity analyses) Specified target coverage level exerts strongest influence on staffing need We assumed no transferability of staff across specialty (or across country)

Draft – Not for Distribution Sensitivity Results

Draft – Not for Distribution 282,000 worker shortage grows to 1.4 million if include all MNS disorders and LAMICs 27

Draft – Not for Distribution Annual wage bill to remove shortages approaches $700 million (USD 2005) 28

Draft – Not for Distribution Annual wage bill to remove shortages in countries with largest shortages 29

Draft – Not for Distribution Annual wage bill to remove shortages for all MNS disorders in 144 LAMICs approaches $3.5 billion (USD 2005) 30

Draft – Not for Distribution 31 Presentation Outline Introduction Methods and Data Results Discussion

Draft – Not for Distribution Discussion – Ways to Mitigate Shortage Productivity improvements Skill mix Worker incentives, both monetary and non-monetary 32