International Consortium for Mental Health Policy and
S e r v ic e s
Supported by the Global Forum for Health Research, and the governments of
Australia, United Kingdom, United States of America
MENTAL HEALTH POLICY TEMPLATE
DOMAINS AND ELEMENTS FOR MENTAL HEALTH POLICY
FORMULATION
INTRODUCTION
“Public policy consists of a plan of action or program and a statement of objectives.”
(1) “An explicit health policy achieves several things: it defines a vision for the future
which in turn helps establish benchmarks for the short and medium term. It outlines
priorities and the expected roles of different groups. It builds consensus and informs
people, and in doing so fulfils an important role of governance.” (2)
A mental health policy is a concise statement by government intended to set clear
directions to improve the mental health of the community, for the future development
of mental health services “and other aspects of care provided by the family,
community and other relevant agencies.” (3) Some countries include within their
national mental health policy a Mission Statement or Vision that captures the thrust or
direction of the policy. “Mental health policy is concerned with a diverse agenda that
aims to improve the mental health status of populations by providing clinical services
and treatment, preventing mental illness or minimizing progression of emotional
distress to mental disorder and promoting mental health.” (4) Mental health plans,
programmes and strategies are developed from the mental health policy and outline
the way in which mental health policy objectives will be achieved. Mental health
policies “coordinate through a common vision and plan, all programmes and services
related to these objectives. Without this type of organization, programmes and
services are likely to be inefficient and fragmented.” (5) “It is widely recognized that
national policy, programme and legislation on mental health are basic requirements
for the mental health care in any country.” (6)
Despite wide recognition of the importance of national mental health policies, data
collected by the World Health Organization (WHO) reveals that of the 181 countries
of the world, covering 98.7% of the world’s population, 43% (78) have no mental
health policy and 23% (37) have no mental health legislation. (7) For example, about
half of the WHO African and Western Pacific region countries do not have a mental
health policy. (8) As a result while there are increasingly effective interventions
available to reduce the burden of mental illness, many countries do not have the
policy and planning frameworks in place to identify and deliver mental health
interventions, even when resources are available. As a result, people with serious and
chronic mental illness, such as schizophrenia, and their families, suffer extreme
1
personal, social and economic hardship and disempowerment, often on a life-long
basis.
Experience in many countries and that of organizations such as WHO and the World
Bank has shown that sector wide reform, in both health and mental health, has been
more successful when undertaken within a clear, long term policy framework,
supported by government and major stakeholders. Both WHO and the World Bank
have emphasized the need for ready access to the basic tools for mental health policy
formulation, implementation and sustained development. At present such tools are
extremely limited. (9)
The Mental Health Policy Template aims to provide the user with a basic tool or
framework upon which to base the formulation of a mental health policy. It is
intended to be generalizable across countries and regions and to include what is
common to all countries. The Template is not prescriptive in terms of measures to be
used or actions to be taken in relation to policy development or implementation.
The Template identifies the essential domains and elements that need to be considered
when formulating mental health policy. It consists of four major domains. Within
each domain are elements that form part of the overall domain. The title given to each
domain and element aims to be generic enough to be applicable for all countries. The
Template is a non-recursive as opposed to linear model. The information collected in
the Outcomes Domain serves to inform the action undertaken in the Context,
Resources and Provision Domains.
The Template uses language, concepts and terminology consistent as possible with
mainstream health sector reform and aims to be consistent with the World Health
Report 2000-Health Template. (10) While countries may wish to use terminology that
is country specific, the generic terminology, consistent with the World Health
Organization, will provide a common language that may facilitate communication
between countries, regions, and organizations associated with mental health policy
and servicing. Mental health stakeholders at meetings convened by the International
Consortium for Mental Health Policy and Services and held in Eastern Europe,
Africa, Latin America, the Eastern Mediterranean, South East Asian and Western
Pacific Regions of the world during 2000/2001 have considered all terminology.
Explanatory notes have been developed for each domain and element. The
explanatory notes define the way the term is used within the Template and the scope
that the term is meant to cover. The explanatory notes also discuss the importance of
each domain and element in relation to mental health and suggest why mental health
policy makers may wish to consider a domain or element when formulating mental
health policy.
Country specific examples are provided for a number of the elements. In addition,
extracts from existing mental health policies are provided for a number of elements.
These extracts provide examples of how countries have formulated policy for specific
domains and elements.
2
International Consortium for Mental Health Policy and
S e r v ic e s
Supported by the Global Forum for Health Research, and the governments of
Australia, United Kingdom, United States of America
MENTAL HEALTH POLICY TEMPLATE
DOMAINS AND ELEMENTS FOR MENTAL
HEALTH POLICY FORMULATION
EXPLANATORY NOTES
3
CONTEXT DOMAIN
The Context Domain focuses on the environment in which policy formulation will
occur. It includes the environmental factors in a country that influence the health of
the population and within which interventions are delivered. This includes factors
outside the health system that will influence the performance of the mental health
elements and determine some outcomes.
“Although the links between social forces and ill health are complex and
varied, close inspection suggests that mental health concerns almost always
relate to more general concerns that have to do with economic welfare of a
family or community, the environment in which a person lives and the kinds
of resources that he or she can draw upon. In general–enduring political and
economic structures-both within and between societies-contribute to the
perpetuation of poverty, hunger, and despair. Demographic and environmental
pressures, spark regional and intrastate conflicts which in turn lead to personal
trauma, social demoralization, and dislocation.” (11,12)
The Context Domain consists of four elements:
1. Societal Organization and Culture
2. Public Policy
3. Governance
4. Population Need and Demand
1. Societal Organization & Culture
 Demography
Demography is the study of human population statistics. (13)
Demographic characteristics include: population, age, gender, rates of divorce and
homelessness, parenting patterns, household composition, ethnic composition,
education and literacy, urbanization, refugee populations, migration and
unemployment rates.
Demographic characteristics assist the policy maker to better understand the
prevailing conditions within which a policy is to be implemented and to identify areas
of need. For example, an understanding of population density levels may assist in
informing mental health financing policy issues. “Higher population densities are
indicative of a more developed private sector because large numbers of even very
poor people can provide a sufficient market for certain types of private sector
providers.” (14)
Example 1.
The significance of demographics for mental health policy can be seen in the
examples of Africa, Asia, and Latin America where there are increasing
numbers of elderly people within country populations. “These demographic
changes influence mental health in several ways. The growth in the elderly
population means an inevitable increase in age-related diseases, such as the
dementias. In addition, changes in social patterns will alter the role of the
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elderly and the ways they are valued. These changes can lead to poor mental
health outcomes, such as depression, anxiety, suicide and serious constraints
on the quality of life among elderly individuals. In addition, the high prevalence
of multiple co-existing physical conditions, such as incontinence, hip fracture,
and sensory loss influence mental health through the loss of self-esteem and
independence. Finally, families will also be affected by the increased demand
for care-giving.” (15)
 The economic environment
The economic environment is that part of society pertaining to systems of production,
consumption and management of resources. Elements within these systems include
financial systems operating within a country, money, industry, goods and services,
employment and the various stakeholders associated with these elements. Policy
makers will need to consider the economic environment in which mental health policy
is to be designed and implemented and the effect of this environment on mental health
and well-being. This is seen as significant in countries where new economic models
are emerging in countries with new democratic governments. (First Meeting of the
Latin America and Caribbean Region, Consortium for Mental Health Policy and
Services, Chile 8-10, Nov, 2000)
“Economic issues acting at the country level influence clinical practice. In terms of
public expenditure on mental health services, the overall level of economic
development (along with the relative importance attached to mental health in relation
to other medical specialties) has a profound effect upon the extent and quality of the
clinical services available.……Economic cycles of growth and recession which may
affect different subgroups of the population in different ways, influence the direct
funding of state mental health services (both capital and revenue), the provision of
welfare benefits, expenditure on mental health research and such cycles have indirect
effects mediated by levels of employment.” (16)
“Economic perspectives contribute to policy at a macro-or system level, in terms of
analysis of the overall organization and financing of mental health services, as well as
consideration of the effects of mental ill-health on the economy as a whole (such as
lost productivity and unemployment). At a more micro-level of service providers and
users, key concerns include need assessment, the cost-effectiveness of different
treatment strategies and elicitation of user preferences.” (17)
 The political environment
The political environment is the state, government and its institutions and legislations
and the public and private stakeholders who operate and interact with or influence that
system. The stability of the political environment and government will impact on the
prioritisation of mental health policy in relation to other policies, the funding
available to mental health and the time frames in which policies and programmes can
be realized.
Political environment also includes the political culture i.e. “widely held views,
beliefs and attitudes concerning what governments should try to do and how they
should operate and the relationship between the citizen and the government.” (18)
Political culture includes population participation and involvement in the electoral
process and the level of government acceptance by the population. This is of
5
particular importance in countries where democratic processes are emerging. (First
Meeting of the Latin America and Caribbean Region, Consortium for Mental Health
Policy and Services, Chile Santiago, 8-10, Nov, 2000; First Meeting of the Eastern
European Region, Consortium for Mental Health Policy and Services, Prague, Czech
Republic, 1-4, Nov, 2000)
The political process is extremely important in policy development, implementation
and reform. “Policy reform is a profoundly political process. Politics affects the
origins, the formulation and the implementation of public policy, especially when
significant changes are involved…Policy reform is inevitably political because it
seeks to change who gets valued goods in society.” (19,20) While policy makers may
not formally address the political environment in a mental health policy it is important
that the political environment in which a mental health policy is to be formulated and
implemented is carefully considered if policy implementation and reform are to be
successful.

Social structures and systems (organization), including the role of religion,
family, cultural perspectives, beliefs and values etc
Social structures and systems together form a society. They include nuclear, extended
families and kinship networks, community, neighbourhood and social networks,
leadership patterns, religion, caste and class systems. Social structures and systems
also include cultural perspectives on illness attribution and management. This
includes the formal and informal belief systems that influence the understanding of
mental health and mental illness in a culture and the culturally accepted methods by
which help is sought. It has been argued, “every country must formulate a mental
health policy based on its own social and cultural realities” (21)
Example 1.
Ito et al (1999) argue that true reform of mental health services has not yet
occurred in Japan, despite a series of governmental, legal and financial
initiatives.(22) Limited change is attributed to the impact of Japanese values
and traditions on mental health reform. Ito et.al. argue that the success of
policy and service reform is dependent on policies being “structured to
respect the cultural differences between Japan and the West e.g. emphasis on
the group over the individual, stress on social control and community safety
and involvement of families.” (23)

Two important features of social structure and systems that have been highlighted
as critical determinants of mental health are stigmatisation and gender disparity
and discrimination. (24)
i) Stigma: The stigma associated with mental illness and disability constitutes
a significant burden for the sufferer and those around him or her.
Stigmatization often promotes under or non-reporting of mental illness by the
sufferer (25) and underlies rejection by friends, relatives, neighbours and
employers. It constitutes a barrier to reintegration into the community,
adversely affecting family relationships, employment opportunities, access to
quality treatment and leads to discrimination and human rights violations. (26)
6
Example 1
A contemporary example of the impact of stigma can be seen in Japan where
mental illness evokes significant stigmatisation of entire families. High rates of
long-term psychiatric hospitalisation are thought to be the result of this social
stigma with hospitalisation a desirable solution for many families of the
mentally ill. A 1989 survey undertaken by the Japanese Association of
Neurology and Psychiatry found that 33% of persons who were hospitalised for
more than 2 years were inpatients for social, not medical reasons. (27)
Example 2.
In many Eastern European countries mental health is not regarded as an
important issue. Patients and psychiatrists are stigmatised. Psychiatrists are
not perceived as expert professionals and there is a negative attitude to
medical science generally and to psychiatrists in particular. Researchers in
Eastern Europe have also found that psychiatrists and other mental health
professionals are stigmatising of people with a mental illness, including those
they treat. (ANAP 5th Working Conference, Vilnius, Lithuania, March 30 - April 3, 2001)
“Gender roles are critical determinants of mental
health that need to be considered in policies and programmes…..They
affect the control men and women have over socio-economic
determinants of their mental health, their social position, status and
treatment in society. They also determine the susceptibility and
exposure of men and women to specific mental health risks.” (28)
Gender differences can be seen in the prevalence of mental disorders
and there are gender specific risk factors for mental illness. Gender
bias is also seen in the diagnosis and treatment of psychological
disorders.
ii) Gender Disparities:
In response to these issues mental health policy makers may wish to consider whether
their mental health policy addresses stigma and destigmatization e.g. through
legislation, public information campaigns, support to nongovernmental organizations
and education for professionals across a range of service sectors; and whether it is
sensitive to gender issues and addresses gender specific risk factors necessary for
(mental illness) prevention. (29)
 Social pathology:
Social pathology includes: substance abuse, violence, abuses of women and children,
crime, terrorism, corruption, criminality, discrimination, isolation, stigmatisation and
human rights violations. “Many contemporary social problems are global in nature
and are shared by many countries.” (30)
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Example 1.
“Violence against women is a public health concern in all countries. An
estimated 20% to 50% of women have suffered domestic violence. Surveys in
many countries reveal that 10% to 15% of women report that they are forced to
have sex with their intimate partner. The high prevalence of sexual violence to
which women of all ages are exposed, with the consequent high rate of posttraumatic stress disorder, explains why women are most affected by this
disorder.”(31)
Social pathologies “often lead to a flood of social, economic and psychological
problems that undermine well-being.”(32) and therefore need to be considered in
developing a mental health policy that promotes population mental health well-being
and addresses issues that contribute to mental illness.
 Other environmental influences
Other environmental influences include: natural disasters, nutrition levels, and
endemic disease. Environmental influences, whether constant, regularly occurring or
singular in nature may have direct impact on the well-being of a population and may
have implications for mental health policy formulation, financing and service
provision.
Example 1.
Prevalence of mental health problems can rise significantly after natural
disasters and conflict. Sharon et al (33) assessed survivors in 23
households in three villages in India affected by an earthquake, and found
59% to have a psychiatric diagnosis. In a study of Bosnian refugees, 45%
reported psychiatric symptoms and 25% disability associated with these
symptoms (34). A study of 854 Rwandans and Burundese in 23
refugee camps found a 50% prevalence for serious mental health problems (35).
The amount of violence to which refugees are exposed
tends to predict the level of functioning associated with mental disorder
(36). Other factors can also affect prevalence. For example,
rates of service utilization for substance abuse in the USA increased
following the aggressive introduction of cocaine and the associated increase
in the prevalence of disorders resulting from its use (37).
Example 2
Of the 3 billion people affected by disasters from 1967 to 1991, about 85% lived
in Asia. Roughly 11% lived in Africa and 4% in the Americas. Only 0.4% lived in
Europe. (38) “Much of Bangladesh’s population, for instance, lives in areas of
repeated flooding: they therefore must contend with recurring natural
calamities as an expected (and highly feared) part of the annual cycle of life,
which is already constrained by poverty.” Suffering associated with disasters
includes psychological distress. “Mental health care, along with basic
humanitarian care, is essential in the wake of disasters.” De Girolamo and
McFarlane , quoted in Desjarlis (1995) estimate that “Roughly 36% of those
affected by disasters suffer some form of mental distress” with few receiving
needed mental health treatment. (39)
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Example 3
The psychosocial impact of communicable diseases, e.g. the HIV/AIDS
pandemic, must be taken into account in mental health policy. This is
particularly important in African countries where the number of people
currently affected by HIV/ AIDS is of overwhelming proportions e.g. 50% of
women aged between 25-35 are HIV positive. This situation has huge
implications for mental health and well-being of whole communities over the
next ten years. (First Meeting of the African Region, Consortium for Mental Health Policy and
Services, Lusaka, Zambia 27-29, Nov, 2000)
2.
Public Policy
Public policy defines the government’s actions in a certain area. For health this is
usually found in the national health policy.
A national health policy framework:
 Identifies objectives and addresses major policy issues;
 Defines respective roles of the public and private sectors in financing and
provision;
 Identifies policy instruments and organizational arrangements required in both
the public and private sectors to meet system objectives;
 Sets the agenda for capacity building and organizational development;
 Provides guidance for prioritising expenditure, thus linking analysis of
problems to decisions about resource allocation; (40)
There are other enactments of government that impact on mental health policy
including, employment, housing and education.
3.
Governance
Governance is the role of the state in the health sector. It involves the “regulatory and
supervisory dimensions of public policy.”(41) The manner in which governments
undertake the role of governance will vary and policy makers may wish to consider
existing and alternative methods of governance and the implications for policy
formulation.
Many observers agree “governments should be the ‘stewards’ of their national
resources, maintaining and improving them for the benefit of their populations. “ (42)
In health this means:
 Government takes ultimate responsibility for careful management of the well
being of the population;
 Government establishes the best and fairest health systems;
 Government makes health a national priority;
This form of governance has been termed ‘stewardship’. It combines ethics,
legitimacy and trust with accountability, efficiency and substantive outcomes.
“Outside of government, stewardship is also a responsibility for purchasers and
providers of health services who must ensure that as much health as possible results
9
from their spending. In addition, stewardship in health has an international dimension,
relating to external assistance.”(43) This “approach, is substantially more
interventionist than the economically driven agency approach to state regulation
which some health economists have proposed.” (44) While stewardship may be
considered an ‘ideal’ approach to governance by many observers it is not necessarily
the mission or ethos of all governments. In addition, the term “Stewardship” does not
translate well for many languages and a more appropriate, alternative term may be
necessary. (First Meeting of the Latin America and Caribbean Region, Consortium for
Mental Health Policy and Services, Chile 8-10, Nov, 2000; First Meeting of the
Eastern Mediterranean Region, Pakistan, January 20-31 January, 2001, Consortium
for Mental Health Policy and Services; First Meeting of the Western Pacific Region,
India, 2-3 March, 2001 Consortium for Mental Health Policy and Services)
Stewardship has been divided into six sub functions in the World Health Report 2000
that are useful for the policy maker to consider in relation to the role of government
and governance in mental health policy formulation. We have added a seventh subfunction, Research, based on feedback from Regional Meetings convened by the
Consortium for Mental Health Policy and Services during 2000/2001.
i.
Overall system design
Overall system design is “Policy formation at the broadest level. It involves the way
in which all other health system functions are put together” …and…“the organization
of all the other functions of a health system.”(45) It also includes governmental
organization.
ii.
Regulation
Regulation involves the setting of rules/standards.
Regulation “covers both the framing of the rules to govern the behaviour of actors in
the health system and ensuring compliance with them.” (46) This includes the
public/governmental sector and private provision and financing. The setting of
consistent rules and standards across regions and jurisdictions and the public and
private sectors ensure that people with mental illness have similar rights and
expectations about the mental health treatment they will receive and protection from
fraudulent or harmful practices. There are significant opportunity costs associated
with the enactment of regulation by government.
Strategies to achieve regulation may include:
 Regulatory oversight;
 Contractual strategies;
 The use of measures to ensure desired standards of care;
 Protocols for clinical treatment;
 Accreditation;
 Consistency with the UN Resolution on the Protection of the Rights of People
with a Mental Illness;
 Reporting procedures at all levels;
10
Example 1.
In many African countries, the proportion of finance and provision that is
private is rising. “Central issues for health policy and health systems reform
over the coming decade include the proper roles of governments to improve
the accessibility to and quality of services offered by the private sector.” (47)
iii.
Consumer Rights/Consumer Protection
Consumer rights and consumer protection could be regarded as a subset of ii.
Regulation. They have particular importance because “persons with mental illness are
especially vulnerable and require particular protection as their rights are often
restricted.”(48) In many countries e.g. in Eastern Europe patient/consumer movements
are extremely embryonic and there is little community or self- perception of
consumers or carers as partners in the mental health policy development process. (5th
ANAP Working Conference, Vilnius, Lithuania, March 30 - April 3, 2001.) As a
result stewardship involves government leadership in “Achieving equality between
consumers and producers and other stakeholders within the mental health system.” (49)
Consumer rights/legislation can define and protect the rights of those with mental
disorders alongside the community’s legitimate expectation that it be protected from
harm.
Examples
Consumer rights/legislation that may be incorporated into a mental health
policy include:
 Adherence to international human rights including the United Nations
Resolution 46/119 on the Rights of People With Mental Illness and the
Improvement of Mental Health Care Dec 1991.
 UN Standard Rules on Equalization of Opportunities for Persons with
Disabilities
 Status on mental health legislation for the involuntary treatment of
persons with mental illness.
 The way in which other legislation (e.g. anti-discrimination; disability)
encompasses people with a mental illness or disability.
 National Human Rights Commissions.
 Involvement of consumers and carers, in policy design and in the
design and implementation of consumer protection mechanisms.
iv.
Performance assessment
An essential ingredient for providing strategic direction and assuring a level
playing field is to assess the performance of institutions involved in revenue
collection, provision and resource development within the mental health system.” (50)
in terms of what could have been achieved with the available mental health resources.
Systems for performance assessment and accountability may be prescribed in policy.
For example, policy may prescribe agreed performance indicators in relation to policy
goals and objectives or the operation of licensing agencies that grant treatment
licenses to traditional and clinical care providers.
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v.
Priority setting
“Choosing criteria for setting priorities and building a consensus around them” (51) is
an important role of governance. Policy makers are confronted with the fact that
mental health systems cannot meet all existing and projected health needs in a
population. Due to the limited resources available for health and mental health,
rationing will always occur. “So either there must be conscious choices of what
services should have priority, or the services actually may bear little relation to any
reasonable criterion of what is most important.” (52) As a result they may become
determined by powerful interest groups and partisan interests. (53) “Determining the
priorities for a health system is an exercise that draws on a variety of technical, ethical
and political criteria and is always subject to modification as a result of experience in
implementation, the reaction of the public and the inertia of financing and
investment.” (54)
In setting priorities policy makers may prioritise particular consumer groups e.g.
people with the most severe mental health problems, young people, public health
interventions or clinical interventions and services within these categories.
Example 1.
“The perceived impact of mental health on societies suggests that some
form of public attention is warranted. Public attention (regulation,
mandates, information, service provision, financing, etc) is, however also
solicited with the same urgency for a wide and competing variety of health
issues. It is essential, in particular in resource- strapped economies, that
public policy priorities be determined by a decision-making process that is
rational and that resists partisan motivation from the many stakeholders in
the health sector”. (55)
iv.
Intersectoral advocacy
“Specialized mental health services can meet only some of the varied needs of people
with severe mental health problems and mental disorders. Access to housing,
accommodation support, social support, community and domiciliary care, income
security and employment and training opportunities have a significant impact on the
capacity of a person with a severe mental health problem or disorder to manage in the
community.” (56). One role of stewardship is to ensure that there is “promotion of
mental health policies in other social systems that will advance mental health
goals”(57) thereby significantly impacting on the overall well-being of people with a
mental illness.
vii. Research
Mental health research is an activity that will not necessarily be privately funded or
promoted by private enterprise agendas. As a result, government has an important role
in ensuring that ethical research is fostered and adequately maintained. Governance,
in relation to health research, is important from a clinical perspective. Good
governance will ensure that ‘state of the art’ treatments and understanding of mental
12
illness and mental health at individual and population levels is available and
deliverable to consumers.
In turn “research should have an important role in the policy process, providing
evidence for identifying issues and prioritising them, laying out the options for
addressing policy problems, and feeding back the appropriateness of those
directions.”(58). In addition, anticipated breakthroughs in science and technology, and
their potential impact on prevention and treatment of disease, need to be incorporated
into thinking about health policy. (59)
Good governance can ensure that appropriate research is funded and undertaken to
facilitate decision-making that is made “on the basis of fact and less on the basis of
political expediency and ideology”. (60). In summary, to ensure that valid research data
is available to inform and substantiate policy, good governance will not only use
research but will ensure that research is promoted and monitored. (61)
4.
Population Need and Demand
Population need is informed by epidemiological information on mortality, prevalence,
severity, impairment, risk factors (e.g. gender and social class) burden associated with
mental illness within general populations and service utilization of people with mental
illness. While prevalence statistics are of limited value to mental health in terms of
causal inquiry they do provide the descriptive statistics that are highly informative as
indicators of population need and can assist in developing accurate needs-based
policy and planning. (62).
Population demand is informed by epidemiological information on the level of
intervention that is sought by members of the population to assist with an identified
mental health need. Population demand is influenced by factors such as mental health
literacy, social and cultural attitudes to mental illness, gender and stigma. (63)
Kessler (64) cautions that contemporary psychiatric epidemiology has focused on the
description of mental disorders and prevalence rates and has not addressed issues of
risk, prevention and cross-country comparisons. Within psychiatric epidemiology
there exists “uncertainty regarding diagnostic categories and criteria and
underreporting due to respondent reluctance to admit symptoms …and….additional
problems exist in studies of special populations.” As a result population need and
demand data has been limited in its scope. Weiss et. al.2001 emphasize “The need for
additional frameworks to clarify cultural features of illness in a cultural epidemiology
of illness experience, meaning and behaviour” that can contribute to the shaping of
“policy and practice in diverse settings or among diverse populations “ (65)
The World Mental Health 2000 (WMH200) Initiative, a project of the Assessment,
Classification and Epidemiology (ACE) Group of WHO and the Consortium for
Psychiatric Epidemiology stress the need for a move from epidemiological estimates
and projections “based largely on literature reviews and limited and isolated studies
rather than on cross-national epidemiological surveys” to “general population surveys
that estimate the prevalences of mental disorders, evaluate risk factors for purposes of
13
targeting interventions , study patterns of and barriers to service use, and validate
estimates of burden world-wide.”(66,67)
Existing epidemiological data and future work will contribute to the policy maker’s
understanding of the severity, chronicity, morbidity and mortality associated with
mental illness. It will contribute to the understanding of the impact of mental illness
on the population. It will also highlight risk factors, and provide data regarding the
type and quantity of treatment needs, patterns of demand and help seeking behaviour.
Such data can assist in the formulation of policy in areas of population mental health,
promotion and prevention, service resourcing, and provision that is evidence-based
and assists in the development of realistic policy goals and objectives at varying
degrees of geographical aggregation. (68)
Examples 1, 2, 3 & 4 highlight the importance of epidemiological data for policy
makers in understanding population need and demand at national and crossnational levels and in formulating evidence based policy. They highlight some
of the ongoing challenges associated with the compiling and use of this data.
Example 1.
“The increase in psychiatric morbidity in the 21st century will have important
repercussions for the social development of Latin American countries and in
the planning and provision of health services. The complexity of psychosocial
factors in the causation and triggering of mental health disorders calls for the
establishment of clear policies for prevention, education and rehabilitation.
Broadening of services may be based not only on demographic growth but
also on the increase of prevalence rates.” (69)
Example 2.
Studies of the determinants of help-seeking in the USA show that “financial
barriers are important impediments to treatment and that treatment rates
increase substantially when these barriers are removed”. (70) At the same time,
“a recent comparative study of help-seeking in the USA and Canada found that
the same low proportion of people with mental disorders seek treatment in the
two countries even though Canadians enjoy free access to mental health
treatment while people in the USA do not.” (71) An investigation of the reasons
for not seeking treatment carried out in this comparative study found that the
typical mentally ill person not in treatment reported a number of reasons for
not seeking help, including perceived lack of efficacy of treatment believing
that the problem will eventually go away by itself, and the feeling that he/she
wants to handle the problem himself/herself without outside help.
“These and related findings in other epidemiological studies of the helpseeking process strongly suggest that misunderstandings about the nature of
mental illness and perceived stigma continue to interfere with the help-seeking
process. Public education campaigns have been launched in some countries
to address these problems.” (72)
Example 3.
“Use of alcohol and other drugs has significant consequences for morbidity
and mortality but does not necessarily lead to dependence. Ambivalent
attitudes toward abuse and the abuser, the stigma associated with substance
abuse and the criminal nature of the drug trade have led to a serious and
14
pervasive lack of systematic, objective, comparable, and precise datagathering among countries.” (73) In addition, “the results obtained from many
country epidemiological surveys cannot be compared because of the
differences in sampling and research methods, and the lack of a standard
nomenclature such as ICD-10. Consequently pure distinctions between varying
levels of use and dependence are not clear.” (74)
Example 4.
In many Eastern European countries need and demand data are either not
collected or difficult to access and highly sensitive. What data is available is
frequently invalid and there are “official” and “real” versions of the same data.
No country in Eastern Europe has national incidence data and statistical data
regarding registered patients often pertains to patients who have not been
treated for long periods, sometimes many years. (5th ANAP Working Conference,
Vilnius, Lithuania, March 30 - April 3, 2001)
15
RESOURCES DOMAIN
Resources are those elements that are injected into the total mental health system, and
which need to be distinguished from the activities that take place within that system in
providing mental health care. (75)
The Resources Domain consists of 5 elements:
1. Financing
a)
b) i.
ii.
iii.
c)
2.
3.
4.
5.
Public financing of services (direct & indirect
taxation, government owned insurance schemes)
Private financing of services (insurance-for
profit/not-for-profit)
Private financing (for-profit companies e.g.
pharmaceuticals)
Private financing (not for profit e.g. charity, donors)
Personal purchasing
Human Resources
Physical Capital
Consumables
Social Capital
1. Financing
The financing of health and mental health services is derived from a combination of
sources within the public and private sector. Public financing is derived from taxation,
from government owned insurance schemes and from profit and non-profit donors
and grants. Private financing is derived from privately owned for- profit and nonprofit health insurance schemes, private financiers and charity and donors. In addition,
financing is derived, particularly in developing countries, from out-of-pocket
spending by consumers and their families and carers. “Much of what is included in
the financing function occurs outside what is usually considered to be the health
system.”(76) It is argued that the financial arrangements for mental health should be
incorporated into the general health financing arrangements but that mental health
resources should remain identifiable and be allocated through a mental health
programme, regardless of where the services are located. (77)
Those developing mental health policy may look at how mental health is presently
being financed in a country, how this impacts on the equity and efficiency of the
existing mental health delivery system and on the distribution of the economic
burden. Policy makers may wish to determine in what direction a country should
proceed in relation to its financing of mental health services, in part, to meet the goals
within the mental health policy.
“Health system financing is the process by which revenues are collected from primary
and secondary sources, accumulated in fund pools and allocated to provider activities.
For the purposes of analysis it is useful to divide health system financing into three
sub functions: revenue collection, fund pooling and purchasing.” (78) and to consider
these sub-functions within public and private domains.
16
a)
Public Financing
 Revenue collection
“Revenue for public health funding is generally collected through direct and indirect
taxation and from secondary sources (governments and donor agencies)”(79) Taxes can
be levied on individuals, households and firms (known as direct taxes) or on
transactions and commodities (known as indirect taxes).The design of revenue
collection mechanisms has a potentially profound effect on health system
performance. (80) Once revenue is collected it is used to purchase physical capital or to
fund pool.
Fund pooling (recurrent)
Pooling is the accumulation and management of revenues in such a way as to ensure
that the risk of having to pay for health care is borne by all members of the pool and
not by each contributor individually. (81) “Important issues include: the size and
number of fund pools, mechanisms for transferring funds among pools; choice and
competition among fund pools for enrolment and governance of institutions
maintaining fund pools.”(82) An issue of importance in relation to mental health is
whether there is comprehensive health coverage or mental health is excluded. In
some countries mental health may not be covered or covered to a lesser degree than
for other illnesses. “Policy makers must decide, in the context of existing systems,
whether medical insurance can be expanded to cover mental illness. If no health
insurance exists, it is unlikely that a mental health insurance plan can be
sustained.”(83)
Example 1.
In the Philippines, government health insurance does not cover mental illness.
Families pool their resources to pay for private care, which is very expensive
(pers. comm. Conde, B., February 2001)
Example 2.
In Kenya, hospital insurance excludes mental illness and the psychiatrists of
that country have reportedly stated that “failure by hospitals to provide cover
for mental illness allowed patients to develop worse conditions from otherwise
simple diseases.” (84)
Example 3.
In Singapore the government insurance scheme Medisaid enables contributors
to use funds to pay for health services including mental health however the
amount available for mental illness is 50% less than for other illnesses.
(Presentation: Meeting of the Western Pacific Region, Consortium for Mental Health Policy and
Services, Beijing, February, 2001)
Purchasing
Purchasing is the “Process through which revenues that have been collected in fund
pools are allocated to institutional or individual providers to deliver a set of
interventions…Purchasing can range from simple budgeting exercises in highly
integrated public systems…to more complicated strategies where specified units of
inputs, outputs or outcomes are purchased.” (85)
17
b) Private Financing has been divided into three groups
i.
Private financing of services (insurance: for profit/not-for-profit)
Hospital and out-of-hospital services may be funded through private health insurance
or other sources of funding such as work insurance schemes or individual copayments. As with public provision, private provision can be divided into three sub
functions: revenue collection from members of the insurance scheme or health
benefits fund, fund pooling and purchasing through the fund. It has been found
however that “Health insurance companies discriminate between mental and physical
disorders and provide inadequate coverage for mental health care.” (86) In addition,
“many people influenced by the stigma that society attaches to mental illness and the
perception that “one cannot contract mental illness”, do not believe they are at risk.
As a result they are unlikely to pay for others who might require treatment. Recent
developments have been made in high-income countries to circumvent this problem
by incorporating mental health conditions into existing plans and producing payment
parity.” (87)
ii.
Private financing (for-profit companies e.g. pharmaceuticals)
In some countries for-profit organizations play an important role in providing
financial input for mental health and service provision.
iii.
Private financing (not for profit e.g. charity, donors)
This arrangement for financing is usually through formal organizations independent
of government including religious groupings. Although they may earn surpluses they
do not distribute this surplus to shareholders or owners. Historically, these groups
dominated mental health care provision in developing countries and they continue to
provide a variety of services.
Example 1.
“Donor contributions as a source of revenue for the health system, are of key
importance for some developing countries….Several countries in Africa
depend on donors for a large share of total expenditure on health…..Most aid
comes in the form of projects, which are separately developed and negotiated
between each donor and the national authorities.” (88) Past donor aid
programmes in poor countries have involved accumulation of physical capital
that the countries have been unable to maintain or operate. “There are often
incentives in less developed countries for decision makers to accept donor
support irrespective of the long-term consequences on the balance among
existing resources or between investments and recurrent costs…. Competing
agendas among donors have led to further fragmentation in responsibility and
short-term thinking.” (89)
18
c)
Personal Purchasing of services
 Out of Pocket expenditure
In many countries of the world there is minimal or no well-organized or private
insurance for provision of services. “Private financing, particularly in developing
countries, is largely synonymous with out-of-pocket spending or with contributions to
small, voluntary and often highly fragmented pools.” (90) Lower income countries
have health systems that are more private – in finance and provision-than higherincome countries. In Asia and especially India, health care is mainly purchased “out
of pocket” from private doctors and clinics. (91) Services must be bought by the
individual through various methods (e.g. personal payment, bartering). Initial research
into public-private mix for health care in Less Developed Countries (LDC) indicated
that, “In countries with very low levels of private sector provision, individuals’ outof-pocket payment for health services often exceeded one-third of the national health
expenditure.”(92)
Within this ‘out-of-pocket’ expenditure for health services, payments for mental
health is likely to be overly represented because, as discussed in the previous page,
insurance schemes often do not cover mental health to the same degree as for other
conditions. The absence of public provision and the need for personal purchasing of
mental health care can lead to individual and family poverty. Without a firm funding
base countries may have to consider what mental health policy initiatives are realistic
and whether this must be a major focus of policy formulation.
Example 1.
In Uganda the “total per capita health expenditure is in the range of US$7 to
US$12, with only US$3.95 attributed to government and donor spending, the
balance coming from individual out-of-pocket payments”(93)
Example 2.
In Ghana payment for traditional and ‘western type’ mental health care is
increasingly borne by the individual. “Changes in the cost of living coupled
with the introduction of licence fees (has) meant that traditional practitioners
are increasingly demanding monetary payments for their services-though
significantly, capacity to pay remains an important element in the fee
structure” The government is responsible for hospital infrastructure and the
costs of medical and nursing services whilst the patient pays for drugs, food
and other consumables. As a result “only a few people in Ghana can afford
Western-type health care.” (94)

Time spent by individuals and families negotiating the service system and
providing care.
Cost of illness estimates indicate that, in quantitative terms, individuals and families
are generally the largest provider group of hours of support in all countries of the
world. (95) In addition to providing care and support families, particularly in LDC’s,
report significant time is spent negotiating service systems to secure care for their
family members. This includes locating services, obtaining appointments for family
members, providing transport and accessing inaccessible services.
19
2. Human Resources
Human resources includes:
Mental Health Care Personnel:
 Clinical staff
 Non-clinical staff
 Complimentary
 Religious/ traditional healers
Non-Governmental Organizations
Families and carers
Clinical staff & Non-clinical staff
Human resources are the most important of the health system’s inputs. “The
performance of the health care system depends ultimately on the knowledge, skills
and motivation of the people responsible for delivering services.’ (96) In most
countries regardless of GDP, (the exceptions being countries such as Russia and the
USA where there is an undeveloped General Practitioner system) the majority of
health care is delivered at the primary health care level by General Practitioners.
“Psychiatrists and psychiatric nurses as well as allied health professionals (including
social workers, clinical psychologists and occupational therapists) are a key
component of specialized mental health services”. (97) There are also professional
groupings specific to different countries. For example, Clinical Officer, Medical
Licentiate /Assistant Medical Officer (Africa) have been created to address clinical
human resource needs. Administrators and managers in government and nongovernment sectors also form an important part of human resources. In most parts of
the world however there are severe shortages in trained personnel, including those
specialising in areas such as youth, child and refugee mental health. This shortage has
been compounded by ‘brain drain’ of professionals from developing to developed
countries. (98)
Complimentary &Religious/ traditional healers
There are an increasing variety of lay trained mental health care providers who
compliment and/or substitute for conventionally trained mental health professionals.
(99) In many countries traditional and faith healers provide much of the care provided
to people with a mental illness. “There is a lack of adequate information on the
practice of faith and traditional healers and few programmes articulate collaborative
linkages between traditional and modern medicine systems.” (100)
Example 1.
In 1990, it was estimated that in Uganda up to 80% of patients were attending
traditional healers before reporting to the allopathic health system. (Pers.
Comm. Baingana, F. 2000)
Example 2.
In Ethiopia about 85% of emotionally disturbed people were estimated to seek
help from traditional healers partly in response to the lack of formally trained
mental health care providers e.g. 10 psychiatrists for the population of 61
20
million. This situation has been reflected in policy. (101) Gureje & Alem (2000)
argue however that although “many policies makers in Africa talk about the
need to integrate traditional health care into orthodox service delivery little
success has been achieved because the policy for integration has not been
well articulated...Policies have commonly failed to specify the service needs
which can be met by the traditional approach or show how specific traditional
interventions are to be assessed for efficiency or to give some idea of how
good standards in service delivery can be achieved and maintained.”(102)
“Clearly the future of traditional medicine in mental health is a question that
must be addressed by policy makers in Africa.” (103)
Example 3.
“In Nepali folk medicine, symptoms of distress are both somatic and
psychological and are explained as attacks or possession by demons, ghosts
or spirits. The origin of these attacks or possession may be the random
malevolence of ghosts etc. or may result from conflicts within the community
which cause an aggrieved party to direct a demon to bring misery to a member
of the responsible family. Regardless of the specific cause, a family may hire a
Jhankri or Dhami to expunge the demon and cure the patient. It is generally the
case that patients who utilize the modern forms of health treatment in Nepal
have visited indigenous healers prior to seeking modern forms (Subedi,
1989,1992; Subedi and Subedi, 1995). The modern trained psychiatrists in
Katmandu report no conflicts with folk healers and indeed have found them to
be cooperative in that Jhankries/Dhamis sometimes refer patients to the
modern mental health system.”(104)
Example 4.
A report from the Assistant of the General Director of Mental Health and Social
Services, MOH, Saudi Arabia outlined plans for cooperative action in that
country between government services and traditional healers to minimize
stigma toward mental illness among the population and to encourage people to
seek mental health treatment. (First Meeting of the Eastern Mediterranean
Region, Consortium for Mental Health Policy and Services, Rawalpindi,
Pakistan, 29-31,Jan, 2001)
Non-government organizations
NGO’s are non-government organizations that provide services including treatment,
rehabilitation and advocacy. NGOs can be formal registered bodies or unregistered
groups. “The presence of NGOs in a majority of countries is reassuring, since they
serve an important function, especially where the governmental sector response has
been slow and inadequate.” (105) However, the participation of the nongovernmental
sector still needs further expansion in many parts of the world. (106)
Example 1.
“In a large country like India, with its population at the one billion mark,
national policy has begun to recognize the value of the commitment and
activities of NGOs. In some cases, where their work is closely linked to
community development, they may be especially well placed to formulate
strategies not only for treating but also preventing mental disorders and
promoting mental health, contributing to a comprehensive mental health
21
agenda beyond curative services. Less encumbered by the constraints of a
clinically orientated health service system and without direct responsibility in
the organizational structure of the government health and other ministries,
many NGOs operate effectively. Cross-cutting programmes of NGO’s are better
able to deal with the social aspects of many issues related to mental health,
such as gender, alcohol and other substance abuse, and mental retardation.”
(107)
Families
Families are also important human resources in mental health provision, particularly
in developing countries (108,109,110) where family involvement has been identified by
researchers as contributing to improved mental health outcomes that equal or are
superior to more developed countries. (111,112)
Example 1.
“The magnitude of unpaid caring is enormous. The United Nations
Development Programme estimated that US$ 16 trillion of unpaid caring work
was missing from the 1995 global GDP of US$ 24 trillion (United Nations
Development Programme, 1995). This emphasises the broader social costs of
illness and disability.” (113)
Policy directions that policy makers may pursue in relation to Human Resources
include:
 Policies that seek to make more efficient use of available personnel
through geographic redistribution, the use of multi-skilled personnel and
close matching of skills to functions. (114)
 Policies that seek to ensure that there is consistency between the mental
health needs of the country and the number of health personnel that are
trained and their skills and functions. (115) e.g. “about 71% of all people in
the world have access to less than one psychiatrist per 100,000 people.
Access to psychiatric nurses is also poor; 46% have access to less than one
nurse per 100,000. (116)
 Policies that optimise/establish the role of traditional and complimentary
mental health personnel in the mental health system
 Optimal use and support of NGOs, carers and families.
3.
Physical Capital
Physical capital includes:
 Health facilities such as hospital beds and equipment, day treatment and
rehabilitation facilities and community clinics;
 Non-health infrastructure (e.g. roads, schools, prisons) that meets the *primary
intent criterion of improving mental health;.
 Information Technology e.g. electronic recording systems, graphical
representation of clinical data, telemedicine, teleconsulting; (117)
 Other technology e.g. EEG & ECT;
22
(*Primary intent criterion: inclusion of an element within the mental health system is
determined by whether the primary intent of the element is to improve or maintain
mental health)
4.
Consumables
 Medical Equipment
 Pharmaceuticals
The availability, effectiveness and control of consumables such as pharmaceuticals
can be an important issue for policy makers in developing and developed countries to
consider. Advances made in psychopharmacology during the last 2 decades of the 20th
century radically altered the treatability and treatment of most mental illness. (118) The
newer classes of medications (e.g. atypical antipsychotics) however are “much more
expensive than the older agents and many health plans (in developed countries) have
chosen to severely limit their use”(119) due to this increased cost.
In developing countries access to effective, affordable pharmaceuticals is a major
challenge. “Pharmaceutical expenditures in poor countries typically account for
between 10 and 30% of total recurrent costs of public sector health expenditures,
ranking second after salaries. (120) These high expenditures and the involvement of the
public and private sector at national and international levels, make drugs a high
priority for policy makers.
Policy makers in all countries may need to consider whether medication is available,
effective and affordable and the political implications of policy development and
reform in this area. (121)
Example 1.
In Africa access to modern psychotropic medication is extremely limited due to
cost and patents on these compounds prohibit local production of the drugs in
cheaper forms for local use. (122)
Example 2.
In Ghana “attempts to control the quality of herbal preparations through
clinical trials and other biomedical research has meant that the costs of the
final products have risen well beyond the means of many ordinary people,
thereby undermining ease of access normally associated with traditional
medicine.” (123)
Example 3.
In parts of Africa anti-depressants are extremely limited or unavailable.
Cheaper medications are often more available but less effective. Policy makers
need to consider not only the availability of medication but also the quality of
the drugs that are available. (First Meeting of the African Region, Consortium
for Mental Health Policy and Services, Lusaka, Zambia, 27-29 November, 2000)
Example 4.
“An estimated 39 million people in the world suffer from epilepsy, but some 30
million of them-almost three out of every four-get almost no help for the
condition…In developing countries 60-90% of people with epilepsy are
excluded from treatment” (124) despite the availability of low cost and effective
treatments such as Phenobarbital. Inadequate supplies of anti-epileptic drugs
23
has been identified as one of the obstacles to people in poor countries
receiving this needed treatment.
5.
Social Capital
Although there is not a definitive definition of social capital it is generally
conceptualized as “the features of social organization such as civic participation,
norms of reciprocity and trust in others that facilitate cooperation for mutual benefit”.
(125) Social capital emerges from social interactions and shared norms that are external
to the individual. It includes the nature and extent of relationships and networks
within communities and between communities and also between communities and
formal institutions. Social capital resides in relations rather than individuals and is a
resource that can generate a stream of benefits for society over time. (126) Social
capital is greater than the sum of the individual contributions to it, it is shared by a
group and as a consequence it is a public (as opposed to private or individual) good
that in turn enables the supply of other important public goods and the enhancement
and amplification of other capital. Social capital is thought to have the capacity to
bond or ‘glue’ like groups, create bridges between different groups in society and to
create vertical links between groups of people and government and formal
institutions. Social capital when combined with a “well-functioning state,
compliments the state’s abilities and produces the fertile soil necessary for social and
economic development.” (127)
Correlations between social capital and health outcomes have been researched. There
is good evidence that more socially cohesive societies are healthier with lower
mortality. (128,129,130) The mechanisms by which this social capital is beneficial to
health are not clearly delineated, but social networks are believed to promote better
health education, better access to health services, informal caring and enforcing or
changing societal norms that impact on public health.
“In terms of mental health, little work has been done to specifically explore how it
may interface independently with social capital, although this body of knowledge is
growing” (131) The relationship between mental health and social structure, social
isolation, poverty, life events and psychological stress has been demonstrated.
(132,133,134)
It is argued that social capital affects the mental health of individuals and groups.
Social capital is thought to mediate against the downward social drift caused by
mental illness and to reduce the impact of psychosocial stressors experienced by
vulnerable people in socially disadvantaged situations, that trigger mental illness.
Whether reduction and prevention of mental illness in turn generates benefits for the
wider social group by increasing the store of social capital available within the
community has yet to be investigated. (135) “In the context of mental health, adding the
dimension of social capital integrates the biopsychosocial determinants of mental
disorder (genetics, neurobiology, psychological factors, social environment etc) in a
way which brings an understanding of population mental health beyond the
aggregation of individual health characteristics or risk factors.” (136)
Social capital mechanisms for improvement of mental health may occur at different
levels of society. At the national level social mechanisms can address inequalities in
24
political participation that lead to a lack of political commitment to improving
services for vulnerable groups. At a community level, community cohesion can
facilitate the organization of groups and movements that agitate for increased access
to services and amenities that can address the immediate and long-term needs of the
mentally ill. (137) Bridging social capital can also unite marginalized groups with the
mainstream and promote a more inclusive approach to the provision of mainstream
services and resources to people with a mental illness. Social capital also promotes
rapid diffusion of health information and therefore may affect mental health well
being and may address issues of stigma and discrimination of the mentally ill. (138) At
the individual level bridging social capital facilitates social integration that contributes
to better health for the individual.
Social capital is important for mental health policy makers to consider because it is a
potential mechanism for preventing mental illness within the community. It is also
thought to influence the health of individuals via psychosocial processes providing
effective support and acting as a source of self-esteem and mutual respect (139) Social
capital is also important to consider as a prerequisite for effective policy and
successful policy implementation. Well-formed policy will, in turn, increase the store
of social capital that will impact on individual and community well-being including
mental health.
Policy makers may therefore wish to consider the importance of social capital in the
following areas:
a) Its contribution to the overall mental health and well being of the population;
b) Preventing social decline in individuals with mental illness
c) Improving access to mental health services
d) Improvement of mental health status and its impact on the building of social capital
(eg in post–conflict populations).
e) How the concept of social capital may inform social policy in general, including
mental health policy and it’s implementation, including:
 Policies that strengthen social networks;
 Policies that build social organizations;
 Policies that strengthen community ties;
 Policies that strengthen civil society;
 Policies that address inequalities in political participation;
 Policies that increase community access to services;
 Policies that focus on individual social integration and reduction in exclusion;
 Policies that facilitate bridging social capital and thereby facilitate inclusion of
minorities e.g. people with mental illness;
25
PROVISION DOMAIN
“Providing services is something the system does: it is not what the system is.”(140)
Health services aim to protect or improve health, whether they do so depends on
which services are provided and how they are organized. At the centre of service
delivery is the patient, in the case of clinical interventions, or a population in the case
of population-based health services. (141) Within an environment of limited resources,
mental health policy will be concerned with effective mental health service and
programme provision at individual and population levels and to special needs groups
e.g. women, children, indigenous people, both from within the health sector and
intersectorially.
The Provision Domain consists of 3 elements:
1. Personal Mental Health Services:
2. Population-based Mental Health Services
3. Intersectoral Linkages
1.
Personal Mental Health Services:
Personal mental health services are those “Services that are consumed directly by an
individual, whether they are promotional, preventative, diagnostic, therapeutic or
rehabilitative, and whether they generate externalities or not.”(142) These services
include assessment, crisis intervention, acute inpatient services, specific psychological
and social interventions, community outpatient clinics, mobile treatment teams,
domiciliary services and living skills programmes, rehabilitation and vocational
services. (143)
2.
Population-based Mental Health Services
Population-based mental health services are “actions that are applied either to
collectivities (e.g. mass health education, promotion) or to the non-human
components of the environment” (144) Examples of non-human components of the
environment include; structures erected to prevent suicide from public buildings or
bridges; blister packs on pharmaceuticals.
3. Intersectoral Linkages
Intersectora1 linkages address the relationship between mental health services and
those services that are not primarily mental health services but do impact on a
person’s overall mental health outcome and general well being. “Mental health
policies need to recognize and stress the importance of other areas of the social
services which have strong implications for mental health.”(145) These services may
fall outside the responsibility of health departments. A comprehensive mental policy
will explicitly encourage the development and maintenance of links and cooperation
between mental health services and those services that meet the health and non-health
needs of people with mental health problems or that play a part in maintaining
individual and population well-being. Currently, in many countries service providers
do not communicate sufficiently and intersectoral linkages are not well established.
(First Meeting of the African Region, Consortium for Mental Health Policy and
Services, Lusaka, Zambia, 27-29 November, 2000) “Policies aimed at improving
26
these social factors will inevitably have a bearing on the mental health status of the
community. (146)
Intersectoral linkages may be prescribed in mental health policy at national
government levels between health sector and other public services (e.g. education and
finance) and at service levels.
Areas in which intersectoral linkages should exist include:
 Welfare, religious, education, rehabilitation, vocational and employment,
accommodation, correctional, police and other social services required by
people with mental illness and disability or with which they are likely to come
into contact;
 Services within the workplace such as Human Resource Management,
Training and Occupational Health and Safety that impact on mental health
well being;
27
OUTCOMES DOMAIN
Outcomes are used as indicators of the impact of the mental health system, services
and mental health policy at individual and population levels. “Meaningful,
comparable information on health system performance, and on key factors that
explain performance variation, can strengthen the scientific foundations of health
policy at international and national levels.” (147) “Appropriate indicators and
frameworks for evaluating the structure and performance of mental health systems are
badly needed to inform policy in low- and middle-income countries.” (148)
Policy makers may wish to build into mental health policy, mechanisms to collect
information that assess the impact of the policy and services. These data can help
inform which policy elements need to be refined to enhance mental health and wellbeing.
The Outcomes domain consists of four elements
1. Health
a) Population
b) Individual
2. Economic Outcomes
3. Service Outcomes
4. Social Outcomes
1.
Health
Mental health outcomes are generally considered to be changes in functioning, in
morbidity and mortality, that are attributable to the treatment and care received. (149)
Mental Health outcomes can be considered at the individual level or for whole
populations.
a) Population outcomes
Population mental health outcomes are concerned with changes in the mental health
status of the whole population that may be considered to be attributable, at least in
part, to the range, quality and type of mental health services available to the
community. Policy makers may wish to incorporate into policy a commitment to
measure and review changes in the incidence and prevalence of mental health
indicators and changes in mortality during the policy cycle and the relationship of
these rates to policy actions.
Population outcomes include general health and welfare of populations that can be
attributed to good mental health. General population mental health indicators exist for
some countries from local or nationally representative samples. Few routinely
collected indicators are generally available. One such measure is suicide rates. “Until
quite recently counting deaths was the only way to determine whether public health
programmes were succeeding.” (150) A recent development in this area (although they
need refinement) are the types of methods used in the Global Burden of Disease
study. These methods combine mortality and morbidity measures making it possible
to measure the impact of mental treatments on population health and the reduction in
the burden of mental illness on the general population. (151)
28
b)
Individual outcomes
Individual outcomes are the changes in an individual, who has accessed a mental
health intervention, that can be attributed wholly or partly to the intervention.
“There is a large body of literature on the dimensions that should be included in the
assessment of outcomes at the individual level (152) “ Ultimately the choice of what to
measure will depend on the decisions that are to be made on the basis of the
information obtained from the measure.” At the individual or “micro-level of
decision-making the measures will be specific to the goals of treatment as designed in
accordance with the needs of the consumer.” (153) It is generally accepted that all
major stakeholders should be involved in the outcome measurement process and that
accepted qualitative and quantitative measures be used e.g. Health of the Nation
Outcomes Scales, Health of the Nation Outcomes Scales for Children and
Adolescents, The Medical Outcomes Study Short Form; The Mental Health
Inventory.
Few countries currently collect individual outcome measures on a routine basis
although there is broad agreement that this is a desirable step. Recent developments in
Australia and the United Kingdom are moving in this direction. Similarly, initiatives
have been taken in several United States jurisdictions to comprehensively collect
individual outcome data on a regular basis.
Individual outcome domains may include:
 Mental health status;
 Functional status (including: Social and vocational functioning)
 Quality of life;
 Satisfaction with access and interventions;
Measuring individual outcomes has the potential to provide policy makers with
reliable data about the efficiency and effectiveness of mental health services and
interventions. These data can be used as an evidence base for decisions regarding
resource allocation and service provision and overall policy direction and reform.(154)
2.
Economic Outcomes
Economic outcomes are the economic consequences of mental health intervention, or
lack of intervention, to the community as a whole and include consideration of the
overall cost to society of mental disorders. Economic outcomes also include the
economic consequences of mental health intervention to the individual and their
family and other carers. “The economic impact of mental disorders is wide-ranging,
long-lasting and large. Measurable causes of economic burden include health and
social services needs, impact on families and caregivers (indirect costs) lost
employment and lost productivity, crime and public safety, and premature death.”
(155) In the context of perennial pressures on resources, which is now perhaps also
more widely acknowledged, more stakeholders in mental health care systems want
economic evidence to guide their arguments, decisions and behaviours. “Costeffectiveness data can be compared to interventions for other physical conditions, in
order to provide a firmer basis for new investment” of resources and greater parity
between mental and physical health conditions. (156) However, “few economic
29
evaluations have been conducted outside Western Europe, North America or
Australia.” (157)
We have identified four key sub-elements that should be considered in assessing the
economic outcomes resulting from the implementation of a mental health policy and
service system.
 Direct Costs and Indirect Costs
 Productive Role
 Externalities
 Poverty levels at individual and population levels
 Direct and Indirect Costs
Direct costs to the individual include the contributions made by service users, their
families, employers and taxpayers or insurers towards the costs of treatment and care,
and the productivity losses resulting from work disability, impaired work performance
and mortality. At the individual level “The choice to seek treatment can result in
catastrophic costs for individuals which may lead to poverty” (158) while successful
treatments may reduce costs and improve the economic well-being of individuals and
their families.
At a community level studies from countries with established economies have shown
that mental disorders consume more than 20% of all health service expenditure. Even
in countries where the direct treatment costs are low it is likely that the indirect costs
due to “productivity” loss account for a large proportion of overall costs. (159,160, 161)
Indirect costs are less quantifiable costs such as the economic consequences of quality
of life losses and informal care giving by family members and friends. (162)
To understand the economic outcomes that result from mental health policy and
service implementation, policy makers will consider the quantity of resources that are
used for treatment of illness by individuals and the community and their cost during
the policy cycle and whether these have been reduced and redirected as a result of
mental health interventions. They will also consider changes in indirect costs as a
result of mental health policy implementation.
It is important to note that direct costs are rarely considered on their own as they
provide only a small part of the picture of economic costs and benefits of mental
health. “Cost of illness studies are not sufficient for policy making; whether
treatments are effective and available to a population should also determine public
investment.” (163)

Productive Role
In considering the effectiveness of the mental health policy and the service system,
policy makers will also consider changes in levels of individual human capital and the
consequent changes in the productive role of people who have used the mental health
system and their families and carers. They may also wish to examine whether these
changes impact on the economic status of individuals, households and the community.
Human capital resides in individuals. The concept of human capital embodies “skills
and other attributes of individuals which confer a range of personal, economic and
30
social benefits.” (164) Human capital includes acquired skills and competencies as well
as innate capacities or attributes. Mental health and well-being contributes to the
individual’s store of human capital which in turn contributes to an individual’s
capacity to undertake a productive role in the community either in a renumerated or
non-renumerated role. Effective mental health interventions will also contribute to the
individual’s store of human capital. While difficulty still exists in “identifying the
complex interactions through which human capital plays a role in the growth process”
recent research indicates “human capital does have a substantial and positive impact
on growth in GDP or income per capita”(165)
Example 1:
“Data from the US National Comorbidity Survey has shown that work
impairment is one of the major adverse consequences of psychiatric disorder
with approximately one billion lost days of productivity per year in the civilian
workforce.” (166) In addition, the ability of an individual to contribute
productively to a non-renumerated social role is as important as for those in a
renumerated role. “Less ‘days out of role’ for individuals who do not have paid
employment- non-wage production-has considerable social cost savings and
also promotes economic development.” (167)
The change in the level of productivity attributable to optimal or improved mental
well being, and its impact on individual economic well-being and on the national
economy as a whole is an important factor that policy makers may wish to consider
within a policy formulation. Policy makers may wish to consider the number of
people disabled by mental illness who have been returned to an increased productive
role including non-remunerated roles (eg less ‘days out of role’) due to mental health
interventions and to consider the economic implications of this data both at the level
of individual households and at a more macro level.
 Externalities
An externality is a significant effect of an intervention, on a non-purchaser or a person
or group that is not the specific target of that intervention. Externalities can be
positive or negative in terms of their effect on these players. (168,169) In terms of mental
health policy, externalities are those outcomes experienced by part or all of the
community due to mental health interventions that were not the direct aim of the
intervention e.g. reduced crime rates. Some externalities generated by mental health
interventions will contribute to economic outcomes or will result in direct economic
outcomes for the community. The economic outcomes of a reduced rate of
homelessness, for example, that was generated by mental health policy interventions
could include reduced costs to the community in law enforcement and involvement of
the judicial system in relation to vagrancy and squatting.
 Poverty
“Poverty remains a reality for much of the world, and mostly affects women." (170)
Poverty from an epidemiological perspective can be defined as:
 Low socio-economic status (SES)
 Unemployment
 Low levels of scholarship
 Low family standing.
31
Mental disabilities result in substantial burdens for individuals and societies. They
constitute a significant drain on the economies of poor countries. Understanding the
interrelationship between mental health and poverty is important for policy makers to
consider in evaluating the effectiveness of existing policy and how to formulate future
policy directions. (171)
The relative risk for schizophrenia is estimated to be eight times higher for people
from lowest socioeco status (SES) than those of the highest SES. Over past decades
the relationship between poverty and mental illness has generated considerable
epidemiological research. The literature posits a positive link between poverty and
mental illness. (172,173) The classic studies of Faris and Dunham (174), Hollingshead and
Redlick (175) Leighton (176) and Brown and Harris (177) demonstrated relationships
between mental health and social structure, social isolation, poverty, life events and
psychological stress. (178)
Traditionally, two explanations have been put forward to explain the association
between mental disorders and poor social circumstances. One explanation is that
mental disorder impairs psychological and social functioning and this leads to
downward “social drift”. (179,180) Thus individuals with mental disorder and psychiatric
disability end up in more socially disadvantaged groupings. Some mental disorders,
such as schizophrenia, can result in dramatic social decline as a result of impaired
psychological and social functioning.
The second explanation for the association between mental disorders and poor social
circumstances is that individuals in socially disadvantaged situations are exposed to
more psychosocial stressors (adverse life events) than those in more advantaged
environments. These stressors act as triggers for the onset of symptoms and the loss of
the individual psychological abilities necessary for social functioning (181). The
psychosocial pathways to the development of mental disorders include higher levels
of life events, anomie, learned helplessness, thwarted aspirations, low self-esteem,
and less security (182)
Research suggests that most of people with mental illnesses share the consequences
of the environment of poverty including homelessness, mortality and substance abuse,
(loss of employment and productivity), time lost and opportunity costs. (183) “Serious
disability caused by mental disorders is often not considered for state disability
benefits. Of the 74 countries where information about disability benefits is available,
more than a quarter do not provide state or public disability benefits for mental
illness. A large number of countries where benefits are available only provide limited
assistance in the form of a small monetary allowance or pension benefits for
government employees.” (184)
With mental disorder, the burden of lost employment and days out of role for family
members caring for a relative with mental health problems is well documented (185).
Mental illness can cause poverty for families, particularly those families that have to:
a) pay for out of pocket care and treatments;
b) devote time and economic resources to negotiating the service system;
c) who have to devote time that would be devoted to income generation
in caring for their family member;
32
The material poverty of the individual associated with mental health has implications
for the national economy, including the resources that must be devoted to service and
treatment provision, financial support through social security payments and the loss of
real or potential productivity contributed to the economy by the sufferer and family.
Early identification of, and intervention to remove, target symptoms associated with
the social and vocational decline in mental disorders is now possible (186). Good
mental health policy can seek to address poverty in mental illness through provision
of appropriate, accessible services, programs and intersectoral linkages, at individual
and population levels that will:
 Reduce the economic burden or drain on individual sufferers and their families
created by the need for out of pocket purchasing of services and treatments
 Reduce the economic burden on society through reduction of service need
 Facilitate the capacity for individual sufferers and families to return to
renumerated and non-renumerated roles that will enhance the economic well being
of individual and the family and the overall economy.
Poverty is a correlate with mental illness in many countries. As a result policy makers
may wish to incorporate into mental health policy consideration of changes in poverty
levels amongst those people with a mental illness during the policy cycle as well as
changes in the levels of economic burden on the overall community and whether this
cab be attributed to the mental health policy.
3. Service Outcomes:
Service outcomes are concerned with overall health system performance and the
impact of service provision on the users of services. The focus here is on the
efficiency and effectiveness of service provision in responding to the needs of people
for whom mental health services are funded to serve, measured at the aggregate level
rather than the individual consumer.
Service outcomes are the typical province of performance indicators developed to
assess the performance of health systems and whether value for money has been
achieved in relation to the funds allocated. Service outcome measures include
quantitative and qualitative aspects of service provision and are designed to address
the question of ‘who receives what services from whom at what cost and with what
effect’. (187)
Indicators of service outcome include the following sub-elements:

Efficiency, which concerns how well health systems use their resources to
produce units of services. Typical measures used to include average bed day costs,
cost per treatment episode and other unit cost indices.

Access and Equity, which concern the extent to which people who need services
actually receive those services. Indicators used to measure access and equity may
include service timeliness, population treatment rates, and comparative service
utilisation by particular subgroups within the population.

Appropriateness, which concerns the extent to which services are delivered in a
manner that conforms to pre-defined standards of good or acceptable care. As
33
such, measures of the health care quality are usually concerned with the inputs and
processes of the health system. They typically involve qualitative measures
targeted at specific aspects of clinical practice such as use of specific drug
treatments, extent of use of involuntary treatment, compliance with clinical
protocols and so forth.

Quality, which in contrast to appropriateness, can be defined as those elements of
treatment or services that have been empirically shown to affect individual
outcomes. While appropriateness may be based on consensus or normative beliefs,
quality requires a higher level of evidence. It is important to distinguish between
quality and appropriateness because resources invested in improving the
appropriateness of services may not result in better consumer outcomes. Given
this higher standard of evidence there are fewer indicators of the quality of mental
health services. Specific evidence based treatment of drug protocols are examples
of quality standards as well as therapeutic alliance in psychotherapy. (Pers.Comm.
Bickman, L., 2001)

Effectiveness, which concerns how well the health system achieves its objectives
in relation to the clinical populations targeted for treatment. Indicators of service
effectiveness are usually derived as aggregate measures of individual consumer
outcomes and may focus on the extent of improvement in clinical symptoms,
consumer satisfaction with services or broader social outcomes such as
employment and housing tenure.
Developing measures of service outcomes provides critical information to policy
makers to assist in making decisions about resource allocation and how to develop
services in the future.
4. Social Outcomes
Social outcomes are concerned with overall changes in the social environment,
changes in relationships between individuals, and changes in the relationship between
the individual and the environment that result from improved mental health and wellbeing.
The positive and negative symptoms of schizophrenia can interfere with the person’s
capacity to cope with the usual demands of interpersonal interaction and the decoding
of social communication (188). Adverse effects on socialization can also arise from the
more common mental disorders, such as depression and anxiety.
These mental disorders have adverse consequences that include a breakdown in
marital stability (189) increased teenage parenthood (190), more distant social
relationships (191) and other factors associated with social deterioration.
Enhanced mental health increases the capacity of the individual to access and interact
with people and resources within their local communities. This includes, for example,
the individual’s capacity to access to housing, vocational and recreational
opportunities as well as socially supportive relationships. A number of standardised
measures of social outcomes at the individual level have been developed for
monitoring progress in these areas. These include improved relationships between
individuals and groups, improvement in the quality of family relationships and
community relationships and increased constructive participation in civil society.
34
These improved relationships contribute to enhanced social capital with benefits
accruing to the wider social group. Other measures of social outcome at the
population level may include indicators of family violence, stigma and discrimination,
mental health literacy, housing availability. However, more research is needed to
establish the relationship between improved mental health and social outcomes.
Harvey Whiteford & Clare Townsend
International Consortium for Mental Health Policy and Services
July 2001
35
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