Closing the mental health treatment gap in low- and middle-income countries
Although health systems around the world are facing ever greater demands and challenges, they are particularly strained in low- and middle-income countries (LMICs). In fact, many LMICs are seeing an epidemiological transition, or double burden of disease, where decreasing levels of mortality for communicable, maternal, perinatal and nutritional conditions are being replaced by increasing rates of chronic non-communicable diseases – including mental disorders. “Health systems in LMICs are failing to meet the mental health needs of the populations they seek to serve,” says Jose L. Ayuso-Mateos, a psychiatrist from the Universidad Autonoma de Madrid in Spain that participated in the EU-funded EMERALD (Emerging mental health systems in low- and middle-income countries) project. “Starting from the premise that there can be no health without mental health, a health system cannot function properly if it is unable to protect and take care of the basic health rights and needs of the sick and the vulnerable, and this includes the mentally ill.” With this principle in mind, the EMERALD project set out to improve mental health in Ethiopia, India, Nepal, Nigeria, South Africa and Uganda. To do so, it focused on capacity building and generating evidence for enhanced health systems, thereby improving mental health care and contributing to a reduction in the mental health treatment gap. Substantial improvements Project researchers demonstrated that although it is essential to expand access to integrated mental health care in LMICs, one first needs to build the capacity of the service users and their caregivers, service managers and in-country researchers. Governments and donors can facilitate this capacity building by requiring the involvement of service users and caregivers and by providing the necessary resources. “The EMERALD project showed that, as part of effective planning, countries can benefit from undertaking an assessment of the human and financial resources needed to scale-up a package of evidence-based care and prevention strategies for priority mental disorders,” explains Ayuso-Mateos. Using a new module for estimating the costs and impact of a scale-up of mental health services, researchers found that although the costs are modest in absolute terms, they are considerably above current allocations. However, the resulting improvements in health achieved from a scale-up are substantial. “We found that the integration of mental health into primary health care (PHC) requires more than just technical training and supervision of care providers in the required clinical skills,” says Ayuso-Mateos. “This training needs to be accompanied by a systems strengthening of the basic building blocks of PHC to support integrated mental health care.” According to Ayuso-Mateos, this includes system interventions to support integrated, patient-centred and collaborative continuing care of both chronic and multi-morbid conditions at an organisational level. In addition, it requires workforce preparedness interventions that include relational leadership skills, clinical communication skills and emotional coping skills. “To assist with this process, EMERALD developed a set of indicators that can be used within the routine mental health information systems in LMICs to monitor the provision of mental health services in primary health care,” adds Ayuso-Mateos. “These indicators show that it is possible, useful and acceptable to integrate the indicators into routine monitoring of mental health care within existing health information management structures in LMICS.” Tangible results EMERALD’s work with mental health service users has produced tangible results. For example, it contributed to improved services in India and Nigeria and the establishment of the first mental health service user representative organisation in Ethiopia. In South Africa, the project played an influential role in developing and launching an integrated set of chronic care guidelines for ensuring clinical competence in the diagnosis and treatment of chronic conditions. And in Nepal, psychotropic medication has been included on the country’s Free Drug List, resulting in greater access to treatment.
Keywords
EMERALD, mental health, health care, LMICs
