1. Markets versus mental health services John Lister Coventry University and London Health Emergency IAHPE Conference Thessaloniki 2005

2. The missing element in health system reforms Extensive debate about reforming health care systems, market-style policies and privatisation – but not on mental health Low profile, low status, low priority for resources and policy initiatives 1998: US private mental health benefits less generous than for physical health care

3. Modern psychiatry Modern age of psychiatry goes back to anti-psychotic drug Chlorpromazine (1950s): reduced need for inpatient treatment – but severe side effects More modern drugs fewer side effects – but higher costs per treatment. Trade off short-term cheapness versus long term problems of non-compliance

4. Community care In Britain pressure to replace large mental hospitals, asylums, with community-based care goes back to 1959: keynote ministerial speech in UK 1961 But little progress along these lines in UK until late 1980s: lead in Europe given by Italian government, which closed psychiatric hospitals

5. Poverty and mental health Patients in most need of mental health services are least likely to be able to pay for it: 10-30% of most severe cases use 80% of services. Close correlation between mental health and poverty “Community care” reforms in Britain 1988 concentrated on elderly with savings, largely ignoring low income mental health patients

6. A need for resources and reform Mental health problems blight the lives of tens of millions of people around the world High cost of intensive care: no fixed term for treatment – condition may last many years This makes mental health unattractive for most for-profit private providers Private sector tends to focus on those with least /most manageable problems

7. USA: “deinstitutionalisation” US reduction in psychistric beds: 558,000 in 1955, 71,600 in 1994, whole US population increased 50%. Up to 750,000 people with severe mental illness now living in the community who previously would have been in hospital Only around 60% of severely mentally ill adults received treatment in 1990s, leaving 2.2 million with no treatment at all

8. Baling out By 1994 62% of US mental health care financed by Medicare and Medicaid “The most expensive and least coordinated system of psychiatric services in the Western world” $2 billion industry giving margins of 15% and more, largely by cream skimming easiest cases and dumping those seen as higher risks

9. Mental health and markets Planned and properly resourced care n the community can be beneficial for most patients But market-style systems may reward excessive hospitalisation on the one hand, or give incentives to discharge patients prematurely and without adequate support Problem can rebound on unpaid, untrained family or other carers

10. Mental health in UK Promised improvements set out in 2000 National Service Framework still not achieved Resources for mental health squeezed by pressures on more high profile “targets” for Trusts and PCTs Mental health Trusts caught up in PFI schemes which inflate costs and offer inferior facilities (Manchester)

11. Mental health in developing countries World Bank: 14,000 documents, only 19 on “mental health”, none offering any detailed policy USAID and funded projects little or nothing to say on mental health WHO report 2001: –“Globally mental health resources in countries present a dismal picture of severe shortage and neglect. Often services are only one tenth to one hundredth of what is needed.”

12. Global burden WHO: mental health disorders account for 12% of global DALYs and almost a third of years lived with a disability 6 of the top 20 causes of disease for those aged 15-44 5/10 leading causes of disability 1.5 billion suffering from some form of mental illness. Link to ageing

13. Inverse care law Chances of having to pay out of pocket for mental health care greatest in world’s poorest countries: most ommon means to finance care in 40% of low income countries, compared with 2.9% in wealthiest countries Median psychiatrists/100,000 world- wide is 1: but wealthiest countries have 9, many African countries one per 2 million.

14. No policy: no pressure to reform WHO 2001 found 40% of countries had no explicit mental health policy 33% no mental health programme 38% no community mental health care 33% no mental health budget 33% spend less than 1% of health budget on mental health: most spend less than 5% A health problem that does not easily fit with the market model is one of the big issues that the reform agenda has not bothered to tackle.