Sustainable development for global mental health: a typology and systematic evidence mapping of external actors in low-income and middle-income countries

INTRODUCTION

Mental disorders account for a substantial burden of disease and costs in low-income and middle-income countries (LMICs), but attract few resources. With LMIC governments often under economic pressure, an understanding of the external funding landscape is urgently needed. This study develops a new typology of external actors in global health adapted for the sustainable development goals (SDGs) era and uses it to systematically map available evidence on external actors in global mental health.

METHODS

The new typology was developed in line with conceptualisation in the literature and the SDGs to include 11 types of external actors for health in LMICs. Five databases (EconLit, Embase, Global Health, MEDLINE, PsycINFO) were searched for manuscripts published in peer-reviewed journals in English, French, Italian, Portuguese or Spanish between 1 January 2000 and 31 July 2018 and reporting information on external actors for mental disorders in LMICs. Records were screened by abstract, then full-text against inclusion criteria. Data were extracted and synthesised using narrative analysis.

RESULTS

79 studies were included in the final review. Five were quantitative studies analysing the resource flow of development assistance for mental health globally over the last two decades. The remainder were qualitative studies providing a description of external actors: the majority of them were published in the last decade, focused on Africa, and on public sector (bilateral and multilateral governmental organisations) and third sector organisations (non-governmental organisations). Evidence was particularly scarce for for-profit organisations and individual households.

CONCLUSION

This study reveals opportunities for unlocking additional funding for global mental health in the SDG-era from an ecosystem of external actors, and highlights the need to coordinate efforts and to use sustainable, ethical approaches to disbursements. Further research is needed to understand all external actors and the allocation of their contributions in different settings.

Mental Health System Reform in Contexts of Humanitarian Emergencies: Toward a Theory of "Practice-Based Evidence"

Humanitarian emergencies such as armed conflicts are increasingly perceived as opportunities to improve mental health systems in fragile states. Research has been conducted into what building blocks are required to reform mental health systems in states emerging from wars and into the barriers to reform. What is less well known is what work and activities are actually performed when mental health systems in war-affected resource-poor countries are reformed. Questions that remain unanswered are: What is it that international humanitarian aid workers and local experts do on the ground? What are the actual activities they perform in order to enable and sustain system reform? This article begins to answer these questions through ethnographic case studies of mental health system reform in Kosovo and Palestine. Based on the findings, a theory of "practice-based evidence" is developed. Practice-based evidence assumes that knowledge is derived from practice, rather than the other way around where practice is believed to be informed by systematic evidence. It is argued that a focus on practice rather than evidence can improving system reform processes as well as the provision of mental health care in a way that is sensitive to local contexts, structural realities, culture, and history.

Evaluating treatment of Axis I mental health disorders in Aceh, Indonesia

Aims and method

To share evaluation findings of a new decentralised mental healthcare system addressing Axis I disorders, developed in four subdistricts of Aceh Besar in Indonesia following the 2004 Asian tsunami. Two complementary methodologies were employed: an adequacy survey that assessed whether agreed programme implementation tasks were completed, and an outcome study that utilised patient, caregiver and staff assessment of the programme to determine what changes, if any, resulted from participation in the programme.

Results

The system is functional in 3 of 4 subdistricts, and 47 of 53 subdistrict clinics (puskesmas) have trained mental healthcare nurses. Both patients and caregivers reported statistically significant differences when ranking patient wellbeing and were able to qualitatively describe specific changes in patient symptomatology and social functioning.

Clinical implications

Results indicate that (a) the creation of a decentralised system with outreach at multiple levels, (b) emphasis on staff capacity building within a wider household-to-hospital continuum of care, and (c) incorporation of community volunteers working with trained medical personnel led to effective treatment options for people with Axis I disorders in a resource-poor setting.

Mental health in Aceh--Indonesia: A decade after the devastating tsunami 2004

The province of Aceh has suffered enormously from the perennial armed conflict and the devastating Tsunami in 2004. Despite the waves of external aid and national concern geared toward improving healthcare services as part of the reconstruction and rehabilitation efforts after the Tsunami, mental health services still require much attention. This paper aims to understand the mental healthcare system in Aceh Province, Indonesia; its main focus is on the burden, on the healthcare system, its development, service delivery and cultural issues from the devastating Tsunami in 2004 until the present. We reviewed those published and unpublished reports from the local and national government, from international instances (UN bodies, NGOs) and from the academic literature pertaining to mental health related programs conducted in Aceh. To some extent, mental health services in Aceh have been improved compared to their condition before the Tsunami. The development programs have focused on procurement of policy, improvement of human resources, and enhancing service delivery. Culture and religious beliefs shape the pathways by which people seek mental health treatment. The political system also determines the development of the mental health service in the province. The case of Aceh is a unique example where conflict and disaster serve as the catalysts toward the development of a mental healthcare system. Several factors contribute to the improvement of the mental health system, but security is a must. Whilst the Acehnese enjoy the improvements, some issues such as stigma, access to care and political fluctuations remain challenging.

Beyond the crisis: building back better mental health care in 10 emergency-affected areas using a longer-term perspective

BACKGROUND

Major gaps remain - especially in low- and middle-income countries - in the realization of comprehensive, community-based mental health care. One potentially important yet overlooked opportunity for accelerating mental health reform lies within emergency situations, such as armed conflicts or natural disasters. Despite their adverse impacts on affected populations' mental health and well being, emergencies also draw attention and resources to these issues and provide openings for mental health service development.

CASE DESCRIPTION

Cases were considered if they represented a low- or middle-income country or territory affected by an emergency, were initiated between 2000 and 2010, succeeded in making changes to the mental health system, and were able to be documented by an expert involved directly with the case. Based on these criteria, 10 case examples from diverse emergency-affected settings were included: Afghanistan, Burundi, Indonesia (Aceh Province), Iraq, Jordan, Kosovo, occupied Palestinian territory, Somalia, Sri Lanka, and Timor-Leste.

DISCUSSION AND EVALUATION

These cases demonstrate generally that emergency contexts can be tapped to make substantial and sustainable improvements in mental health systems. From these experiences, 10 common lessons learnt were identified on how to make this happen. These lessons include the importance of adopting a longer-term perspective for mental health reform from the outset, and focusing on system-wide reform that addresses both new-onset and pre-existing mental disorders.

CONCLUSIONS

Global progress in mental health care would happen more quickly if, in every crisis, strategic efforts were made to convert short-term interest in mental health problems into momentum for mental health reform.

Integration of mental health into primary healthcare in low-income countries: avoiding medicalization

Since 2008 the World Health Organization (WHO), through its mental health Gap Action Programme, has attempted to revitalize efforts to integrate mental health into non-specialized (e.g. primary) healthcare. While this has led to renewed interest in this potential method of mental health service delivery, it has also prompted criticism. Some concerns raised are that it would contribute to the medicalization of social and psychological problems, and narrowly focus on primary care without sufficient attention given to strengthening other levels of the healthcare system, notably community-based care and care on district levels. This paper discusses seven elements that may be critical to preventing inadvertently contributing to increasing a narrow biomedical approach to mental healthcare when integrating mental health into non-specialized healthcare: (1) using task shifting approaches within a system of stepped care, (2) ensuring primary mental healthcare also includes brief psychotherapeutic interventions, (3) promote community-based recovery-oriented interventions for people with disabling chronic mental disorders, (4) conceptualizing training as a continuous process of strengthening clinical competencies through supervision, (5) engaging communities as partners in psychosocial interventions, (6) embedding shifts to primary mental healthcare within wider health policy reforms, and (7) promoting inter-sectoral approaches to address social determinants of mental health.

Indonesian experts' perspectives on a curriculum for psychologists working in primary health care in Indonesia

Mental health is a critical issue in Indonesia, since its population ranks among the top five in the world and the prevalence of common mental disorders is 11.6% of the adult population. However, the need to build an effective mental health-care system that is accessible to the whole population has only been recently addressed. The Aceh tsunami in 2004 brought to the forefront an unexpected window of opportunity to build a mental health-care system. Integration of mental health care into primary health care is a key strategy to close the treatment gap for people with mental disorders. Existing integration of psychologists into primary health care is a big step to meet the shortage of mental health-care specialists. As primary mental health care is an emerging field, the perspectives of Indonesian experts on Indonesian mental health care are needed to develop a curriculum for training psychologists to work in primary health care. In this study, data have been collected through semi-structured interviews with 24 Indonesian mental health experts, and three focus group discussions with 26 psychologists. Overall, experts agreed that to be able to work in primary health-care psychologists should have roles and training ranging from clinical to advocacy skills. Participants also agreed that psychologists should work in the community and contribute to primary health care as service providers and that strong collaborations between psychologists and other primary health-care providers are the key; these can be developed partly through referral and by respecting each other's unique strengths.

The 2010 Haiti earthquake response

This article presents an overview of the mental health response to the 2010 Haiti earthquake. Discussion includes consideration of complexities that relate to emergency response, mental health and psychosocial response in disasters, long-term planning of systems of care, and the development of safe, effective, and culturally sound mental health services in the Haitian context. This information will be of value to mental health professionals and policy specialists interested in mental health in Haiti, and in the delivery of mental health services in particularly resource-limited contexts in the setting of disasters.

Transitioning mental health & psychosocial support: from short-term emergency to sustainable post-disaster development. Humanitarian Action Summit 2011

INTRODUCTION

The Working Group (WG) on Mental Health and Psychosocial Support participated in its second Humanitarian Action Summit in 2011. This year, the WG chose to focus on a new goal: reviewing practice related to transitioning mental health and psychosocial support programs from the emergency phase to long-term development. The Working Group's findings draw on a review of relevant literature as well as case examples.

OBJECTIVES

The objective of the Working Group was to identify factors that promote or hinder the long term sustainability of emergency mental health and psychosocial interventions in crisis and conflict, and to provide recommendations for transitioning such programs from relief to development.

METHODS

The Working Group (WG) conducted a review of relevant literature and collected case examples based on experiences and observations of working group members in implementing mental and psychosocial programming in the field. The WG focused on reviewing literature on mental health and psychosocial programs and interventions that were established in conflict, disaster, protracted crisis settings, or transition from acute phase to development phase. The WG utilized case examples from programs in Lebanon, the Gaza Strip, Sierra Leone, Aceh (Indonesia), Sri Lanka, and New Orleans (United States).

RESULTS

The WG identified five key thematic areas that should be addressed in order to successfully transition lasting and effective mental health and psychosocial programs from emergency settings to the development phase. The five areas identified were as follows: Government and Policy, Human Resources and Training, Programming and Services, Research and Monitoring, and Finance.

CONCLUSIONS

The group identified several recommendations for each thematic area, which were generated from key lessons learned by working group members through implementing mental health and psychosocial support programs in a variety of settings, some successfully sustained and some that were not.

Aceh Free Pasung: Releasing the mentally ill from physical restraint

Background

Physical restraint and confinement of the mentally ill (called pasung in Indonesia) is common in Aceh. In early 2010, the local government initiated a program called Aceh Free Pasung 2010. The main goal of the program is to release the mentally ill in the province from restraint and to provide appropriate medical treatment and care. The aim of the paper is to report the findings of a preliminary investigation of the demographic and clinical characteristics of patients who have been admitted to the Banda Aceh Mental Hospital as part of the Aceh Free Pasung program.

Methods

This is a cross-sectional descriptive study conducted at the Banda Aceh Mental Hospital, where people who had been restrained or confined in the community are being admitted for psychiatric treatment and, where necessary, physical rehabilitation, as part of the Aceh Free Pasung program.

Results

Fifty-nine of former ex-pasung patients were examined. The majority (88.1%) of the patients were male, aged 18 to 68 years. The duration of pasung varied from a few days to 20 years, with a mean duration of 4.0 years. The reasons for applying pasung are many, with concerns about dangerousness being most common. The great majority (89.8%) had a diagnosis of schizophrenia.

Discussion

The development of a community mental health system and the introduction of a health insurance system in Aceh (together with the national health insurance scheme for the poor) has enabled access to free hospital treatment for people with severe mental disorders, including those who have been in pasung. The demographic and clinical characteristics of this group of ex-pasung patients are broadly similar to those reported in previous studies.

Conclusions

The Aceh Free Pasung program is an important mental health and human rights initiative that can serve to inform similar efforts in other parts of Indonesia and other low and middle-income countries where restraint and confinement of the mentally ill is receiving insufficient attention.

Evaluating mental health after the 2010 Haitian earthquake

Mental health is an important aspect of public health after a disaster. This article describes what is known and what remains to be learned regarding the mental health impact of the January 12, 2010, earthquake in Haiti. Public health surveillance efforts in Haiti and the United States in the first 2 months after the earthquake are described. Challenges in clinical assessment and public health surveillance are explored. Potential implications for survivors and public health officials are considered.

Severe mental disorders in complex emergencies

People with severe mental disorders are a neglected and vulnerable group in complex emergencies. Here, we describe field experiences in establishing mental health services in five humanitarian settings. We show data to quantify the issue, and suggest reasons for this neglect. We then outline the actions needed to establish services in these settings, including the provision of practical training, medication, psychosocial supports, and, when appropriate, work with traditional healers. We have identified some persisting problems locally, nationally, and internationally, and suggest some solutions. Protection and care of people with severe mental disorders in complex emergencies is a humanitarian responsibility.

Emergency telepsychiatry

Telepsychiatry can be used in two kinds of psychiatric emergencies: one-time clinical events and public health situations associated with mass disaster. Emergency telepsychiatry delivered by videoconferencing has the potential to improve patient care in many settings. Although experience is limited, it has been found to be safe and effective, as well as satisfactory to both emergency department staff and the psychiatric patients treated. The development of comprehensive and standardized guidelines is necessary. There has been little use of acute telemedicine in disaster situations to date. However, telemedicine is becoming part of routine emergency medical response planning in many jurisdictions. Emergency telepsychiatry has the potential to reduce emergency department overcrowding, provide much needed care in rural areas and improve access to psychiatric care in the event of a natural or man-made disaster.