Global Inequalities in Mental Health Care

This essay can also be found at Global Health Jobs UK.

Man in shackles // Photo highlights the dire conditions of those with mental illness in Indonesia. Photo credits: Andrea Star Reese. For more information, visit Human Rights Watch to read about the report.

According to 2001 figures, 1 in 4 people in the world will be affected by a mental disorder at some point in their lives, and approximately 450 million people in the world are currently suffering from such conditions [1]. Mental health problems not only affect an individual’s quality of life, they can also have great implications for the society and economy. For instance, between 2002 and 2003, the estimated economic and social costs incurred by mental health issues in the UK amounted to £98 billion [2]. Despite this, mental health services have often been overlooked at the expense of other areas in health care. This is especially so in low- and middle-income countries (LMICs). In these countries, the public spending for mental health is only US$2 per capita, and most of the expenditure goes towards inpatient care [3].

What are low and middle-income countries?

The World Bank classifies the countries’ economies based on the estimated annual GNI per capita [4]. As of 1 July 2014, the classifications are as follows:

Low-income countries: $1,045 or less

Middle-income countries: $1,045 to $12,746

High-income countries: $12,746 and above

What are some of the aspects of global inequalities in mental health care (MHC)?

Funding

A smaller proportion of the national budget is allocated for mental health in LMICs [5]. However, there is also a larger burden of infectious diseases (e.g., HIV/AIDS, malaria) in these countries, while unipolar depression is one of the leading causes of disability in North America, Europe and Western-Pacific regions (typically high-income countries) [6]. Additionally, LMICs do not usually have the infrastructure for prepayment financing schemes, such as social insurance and tax-based arrangements. Mental health care (MHC) is commonly financed through taxation (60%) or social insurance (19%). For many LMICs, the primary source of finance for MHC is out-of-pocket payment [5]. To add to the complexity of the issue, most of the budget in LMICs is spent on inpatient care [3]. Poor quality care has long been associated with inpatient care, and the lack of integration into society prolongs the patients’ recoveries [7]. Moreover, community-based care provides greater MHC access for the entire population (i.e., rural or deprived areas).

Mental health professionals

There are extreme variations worldwide in the number of mental health workers available (median of over 50 per 100,000 population in high-income countries vs. below 1 in low-income countries). In LMICs, there is one child psychiatrist available for approximately 1 to 4 million people [8]. Furthermore, most of the LMICs have non-Western cultures, and mental disorders are commonly treated through traditional healers instead of mental health professionals [9]. There may also be stigma associated with mental disorders. Many people are also deterred from entering the mental health profession due to poor working conditions and the lack of incentives [10]. Therefore, resources could be directed towards the training of primary care workers, so that they could be equipped with the necessary skills for diagnosing and treating patients with mental health problems.

Integration of MHC into primary care

As highlighted above, inpatient care limits MHC access to certain areas. Along with many other reasons, the World Health Organization (WHO) has been actively promoting for the integration of MHC into primary care [11]. However, there are many barriers. For example, primary health care professionals may lack the necessary training to diagnose and treat mental disorders [12]. It is also difficult to reorganise financial resources to community-based care. There are also problems with setting up community care facilities in rural areas [12]. It is easy to overlook the importance of integrating MHC into primary care. However, it is critical to note that mental health interventions are as cost-effective as other treatments (e.g., antiretroviral treatment for HIV/AIDS). The cost to run a full package of primary care interventions for some common mental disorders would only require US$0.20 per capita per annum in low-income countries.

Political will

There is a lack of political will in many countries — some LMICs place strong emphasis on addressing burden of communicable diseases such as HIV/AIDS. Other countries have been struck by natural disasters, such as tsunamis and hurricanes, or they have been involved in political instability. More often, political will is greater in countries high-income countries as they have greater financial resources to address mental health issues.

This is not an exhaustive list of barriers that LMICs face in MHC. Ultimately, it requires the co-operation of policymakers, NGOs and other stakeholders to raise awareness of these inequalities in MHC. Greater efforts are required to remove these barriers and improve access to MHC around the world.

For more information on out-of-pocket health payments, visit http://www.who.int/health_financing/catastrophic/en/

References

[1] http://www.who.int/whr/2001/en/whr01_en.pdf?ua=1

[2] Halliwell, E., Main, L., & Richardson, C. (2007). The fundamental facts: The latest facts and figures on mental health. London: Mental Health Foundation.

[3] http://apps.who.int/iris/bitstream/10665/178879/1/9789241565011_eng.pdf?ua=1&ua=1

[4] http://data.worldbank.org/news/new-country-classifications

[5] Saxena, S., Thornicroft, G., Knapp, M., & Whiteford, H. (2007). Resources for mental health: scarcity, inequity, and inefficiency. The Lancet, 370, 878–889. doi:10.1016/S0140–6736(07)61239–2

[6] http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_part4.pdf

[7] http://apps.who.int/iris/bitstream/10665/70927/3/9789241548410_eng.pdf?ua=1

[8] http://www.who.int/mental_health/resources/Child_ado_atlas.pdf

[9] Cromby, J., Harper, D., & Reavey, P. (2013). Psychology, mental health and distress. Palgrave Macmillan: London.

[10] Saraceno, B., van Ommeren, M., Batniji, R., Cohen, A., Gureje, O., Mahoney, J., …, Underhill, C. (2008). Barriers to improvement in mental health services in low-income and middle-income countries. The Lancet, 370, 1164–1174.

[11] http://www.who.int/mental_health/resources/mentalhealth_PHC_2008.pdf

[12] http://www.who.int/mental_health/resources/mentalhealth_PHC_2008.pdf

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