Mental Health Policy and Service Guidance Package THE MENTAL HEALTH CONTEXT “Efforts to improve mental health must take into account recent developments in the understanding, treatment and care of people with mental disorders, current health reforms and government policies in other sectors.” World Health Organization, 2003 Mental Health Policy and Service Guidance Package THE MENTAL HEALTH CONTEXT World Health Organization, 2003 WHO Library Cataloguing-in-Publication Data Mental health context (Mental health policy and service guidance package) Mental health services - organization and administration Mental health services - standards Mental disorders - therapy Public policy Cost of illness Guidelines I World Health Organization II Series ISBN 92 154594 (NLM classification: WM 30) Technical information concerning this publication can be obtained from: Dr Michelle Funk Mental Health Policy and Service Development Team Department of Mental Health and Substance Dependence Noncommunicable Diseases and Mental Health Cluster World Health Organization CH-1211, Geneva 27 Switzerland Tel: +41 22 791 3855 Fax: +41 22 791 4160 E-mail: funkm@who.int © World Health Organization 2003 All rights reserved Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: bookorders@who.int) Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to Publications, at the above address (fax: +41 22 791 4806; email: permissions@who.int) The designations employed and the presentation of the material in this publication not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries Dotted lines on maps represent approximate border lines for which there may not yet be full agreement The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use Printed in Singapore ii Acknowledgements The Mental Health Policy and Service Guidance Package was produced under the direction of Dr Michelle Funk, Coordinator, Mental Health Policy and Service Development, and supervised by Dr Benedetto Saraceno, Director, Department of Mental Health and Substance Dependence, World Health Organization The World Health Organization gratefully thanks Dr Soumitra Pathare, Ruby Hall Clinic, Pune, India who prepared this module, and Professor Alan Flisher, University of Cape Town, Observatory, Republic of South Africa who drafted a document that was used in the preparation of this module Editorial and technical coordination group: Dr Michelle Funk, World Health Organization, Headquarters (WHO/HQ), Ms Natalie Drew, (WHO/HQ), Dr JoAnne Epping-Jordan, (WHO/HQ), Professor Alan J Flisher, University of Cape Town, Observatory, Republic of South Africa, Professor Melvyn Freeman, Department of Health, Pretoria, South Africa, Dr Howard Goldman, National Association of State Mental Health Program Directors Research Institute and University of Maryland School of Medicine, USA, Dr Itzhak Levav, Mental Health Services, Ministry of Health, Jerusalem, Israel and Dr Benedetto Saraceno, (WHO/HQ) Dr Crick Lund, University of Cape Town, Observatory, Republic of South Africa finalized the technical editing of this module Technical assistance: Dr Jose Bertolote, World Health Organization, Headquarters (WHO/HQ), Dr Thomas Bornemann (WHO/HQ), Dr José Miguel Caldas de Almeida, WHO Regional Office for the Americas (AMRO), Dr Vijay Chandra, WHO Regional Office for South-East Asia (SEARO), Dr Custodia Mandlhate, WHO Regional Office for Africa (AFRO), Dr Claudio Miranda (AMRO), Dr Ahmed Mohit, WHO Regional Office for the Eastern Mediterranean, Dr Wolfgang Rutz, WHO Regional Office for Europe (EURO), Dr Erica Wheeler (WHO/HQ), Dr Derek Yach (WHO/HQ), and staff of the WHO Evidence and Information for Policy Cluster (WHO/HQ) Administrative and secretarial support: Ms Adeline Loo (WHO/HQ), Mrs Anne Yamada (WHO/HQ) and Mrs Razia Yaseen (WHO/HQ) Layout and graphic design: 2S ) graphicdesign Editor: Walter Ryder iii WHO also gratefully thanks the following people for their expert opinion and technical input to this module: Dr Adel Hamid Afana Director, Training and Education Department Gaza Community Mental Health Programme Dr Bassam Al Ashhab Ministry of Health, Palestinian Authority, West Bank Mrs Ella Amir Ami Québec, Canada Dr Julio Arboleda-Florez Department of Psychiatry, Queen's University, Kingston, Ontario, Canada Ms Jeannine Auger Ministry of Health and Social Services, Québec, Canada Dr Florence Baingana World Bank, Washington DC, USA Mrs Louise Blanchette University of Montreal Certificate Programme in Mental Health, Montreal, Canada Dr Susan Blyth University of Cape Town, Cape Town, South Africa Ms Nancy Breitenbach Inclusion International, Ferney-Voltaire, France Dr Anh Thu Bui Ministry of Health, Koror, Republic of Palau Dr Sylvia Caras People Who Organization, Santa Cruz, California, USA Dr Claudina Cayetano Ministry of Health, Belmopan, Belize Dr Chueh Chang Taipei, Taiwan Professor Yan Fang Chen Shandong Mental Health Centre, Jinan People’s Republic of China Dr Chantharavdy Choulamany Mahosot General Hospital, Vientiane, Lao People’s Democratic Republic Dr Ellen Corin Douglas Hospital Research Centre, Quebec, Canada Dr Jim Crowe President, World Fellowship for Schizophrenia and Allied Disorders, Dunedin, New Zealand Dr Araba Sefa Dedeh University of Ghana Medical School, Accra, Ghana Dr Nimesh Desai Professor of Psychiatry and Medical Superintendent, Institute of Human Behaviour and Allied Sciences, India Dr M Parameshvara Deva Department of Psychiatry, Perak College of Medicine, Ipoh, Perak, Malaysia Professor Saida Douki President, Société Tunisienne de Psychiatrie, Tunis, Tunisia Professor Ahmed Abou El-Azayem Past President, World Federation for Mental Health, Cairo, Egypt Dr Abra Fransch WONCA, Harare, Zimbabwe Dr Gregory Fricchione Carter Center, Atlanta, USA Dr Michael Friedman Nathan S Kline Institute for Psychiatric Research, Orangeburg, NY, USA Mrs Diane Froggatt Executive Director, World Fellowship for Schizophrenia and Allied Disorders, Toronto, Ontario, Canada Mr Gary Furlong Metro Local Community Health Centre, Montreal, Canada Dr Vijay Ganju National Association of State Mental Health Program Directors Research Institute, Alexandria, VA, USA Mrs Reine Gobeil Douglas Hospital, Quebec, Canada Dr Nacanieli Goneyali Ministry of Health, Suva, Fiji Dr Gaston Harnois Douglas Hospital Research Centre, WHO Collaborating Centre, Quebec, Canada Mr Gary Haugland Nathan S Kline Institute for Psychiatric Research, Orangeburg, NY, USA Dr Yanling He Consultant, Ministry of Health, Beijing, People’s Republic of China Professor Helen Herrman Department of Psychiatry, University of Melbourne, Australia iv Mrs Karen Hetherington Professor Frederick Hickling WHO/PAHO Collaborating Centre, Canada Section of Psychiatry, University of West Indies, Kingston, Jamaica Dr Kim Hopper Nathan S Kline Institute for Psychiatric Research, Orangeburg, NY, USA Dr Tae-Yeon Hwang Director, Department of Psychiatric Rehabilitation and Community Psychiatry, Yongin City, Republic of Korea Dr A Janca University of Western Australia, Perth, Australia Dr Dale L Johnson World Fellowship for Schizophrenia and Allied Disorders, Taos, NM, USA Dr Kristine Jones Nathan S Kline Institute for Psychiatric Research, Orangeburg, NY, USA Dr David Musau Kiima Director, Department of Mental Health, Ministry of Health, Nairobi, Kenya Mr Todd Krieble Ministry of Health, Wellington, New Zealand Mr John P Kummer Equilibrium, Unteraegeri, Switzerland Professor Lourdes Ladrido-Ignacio Department of Psychiatry and Behavioural Medicine, College of Medicine and Philippine General Hospital, Manila, Philippines Dr Pirkko Lahti Secretary-General/Chief Executive Officer, World Federation for Mental Health, and Executive Director, Finnish Association for Mental Health, Helsinki, Finland Mr Eero Lahtinen Ministry of Social Affairs and Health, Helsinki, Finland Dr Eugene M Laska Nathan S Kline Institute for Psychiatric Research, Orangeburg, NY, USA Dr Eric Latimer Douglas Hospital Research Centre, Quebec, Canada Dr Ian Lockhart University of Cape Town, Observatory, Republic of South Africa Dr Marcelino López Research and Evaluation, Andalusian Foundation for Social Integration of the Mentally Ill, Seville, Spain Ms Annabel Lyman Behavioural Health Division, Ministry of Health, Koror, Republic of Palau Dr Ma Hong Consultant, Ministry of Health, Beijing, People’s Republic of China Dr George Mahy University of the West Indies, St Michael, Barbados Dr Joseph Mbatia Ministry of Health, Dar-es-Salaam, Tanzania Dr Céline Mercier Douglas Hospital Research Centre, Quebec, Canada Dr Leen Meulenbergs Belgian Inter-University Centre for Research and Action, Health and Psychobiological and Psychosocial Factors, Brussels, Belgium Dr Harry I Minas Centre for International Mental Health and Transcultural Psychiatry, St Vincent’s Hospital, Fitzroy, Victoria, Australia Dr Alberto Minoletti Ministry of Health, Santiago de Chile, Chile Dr P Mogne Ministry of Health, Mozambique Dr Paul Morgan SANE, South Melbourne, Victoria, Australia Dr Driss Moussaoui Université psychiatrique, Casablanca, Morocco Dr Matt Muijen The Sainsbury Centre for Mental Health, London, United Kingdom Dr Carmine Munizza Centro Studi e Ricerca in Psichiatria, Turin, Italy Dr Shisram Narayan St Giles Hospital, Suva, Fiji Dr Sheila Ndyanabangi Ministry of Health, Kampala, Uganda Dr Grayson Norquist National Institute of Mental Health, Bethesda, MD, USA Dr Frank Njenga Chairman of Kenya Psychiatrists’ Association, Nairobi, Kenya v Dr Angela Ofori-Atta Professor Mehdi Paes Dr Rampersad Parasram Dr Vikram Patel Dr Dixianne Penney Dr Dr Dr Dr Dr Yogan Pillay M Pohanka Laura L Post Prema Ramachandran Helmut Remschmidt Professor Brian Robertson Dr Julieta Rodriguez Rojas Dr Agnes E Rupp Dr Dr Dr Dr Ayesh M Sammour Aive Sarjas Radha Shankar Carole Siegel Professor Michele Tansella Ms Mrinali Thalgodapitiya Dr Graham Thornicroft Dr Giuseppe Tibaldi Ms Clare Townsend Dr Gombodorjiin Tsetsegdary Dr Bogdana Tudorache Ms Judy Turner-Crowson Mrs Pascale Van den Heede Ms Marianna Várfalvi-Bognarne Dr Uldis Veits Mr Luc Vigneault Dr Liwei Wang Dr Xiangdong Wang Professor Harvey Whiteford Dr Ray G Xerri Dr Xie Bin Dr Xin Yu Professor Shen Yucun vi Clinical Psychology Unit, University of Ghana Medical School, Korle-Bu, Ghana Arrazi University Psychiatric Hospital, Sale, Morocco Ministry of Health, Port of Spain, Trinidad and Tobago Sangath Centre, Goa, India Nathan S Kline Institute for Psychiatric Research, Orangeburg, NY, USA Equity Project, Pretoria, Republic of South Africa Ministry of Health, Czech Republic Mariana Psychiatric Services, Saipan, USA Planning Commission, New Delhi, India Department of Child and Adolescent Psychiatry, Marburg, Germany Department of Psychiatry, University of Cape Town, Republic of South Africa Integrar a la Adolescencia, Costa Rica Chief, Mental Health Economics Research Program, NIMH/NIH, USA Ministry of Health, Palestinian Authority, Gaza Department of Social Welfare, Tallinn, Estonia AASHA (Hope), Chennai, India Nathan S Kline Institute for Psychiatric Research, Orangeburg, NY, USA Department of Medicine and Public Health, University of Verona, Italy Executive Director, NEST, Hendala, Watala, Gampaha District, Sri Lanka Director, PRISM, The Maudsley Institute of Psychiatry, London, United Kingdom Centro Studi e Ricerca in Psichiatria, Turin, Italy Department of Psychiatry, University of Queensland, Toowing Qld, Australia Ministry of Health and Social Welfare, Mongolia President, Romanian League for Mental Health, Bucharest, Romania Former Chair, World Association for Psychosocial Rehabilitation, WAPR Advocacy Committee, Hamburg, Germany Mental Health Europe, Brussels, Belgium Ministry of Health, Hungary Riga Municipal Health Commission, Riga, Latvia Association des Groupes de Défense des Droits en Santé Mentale du Québec, Canada Consultant, Ministry of Health, Beijing, People’s Republic of China Acting Regional Adviser for Mental Health, WHO Regional Office for the Western Pacific, Manila, Philippines Department of Psychiatry, University of Queensland, Toowing Qld, Australia Department of Health, Floriana, Malta Consultant, Ministry of Health, Beijing, People’s Republic of China Consultant, Ministry of Health, Beijing, People’s Republic of China Institute of Mental Health, Beijing Medical University, People’s Republic of China Dr Taintor Zebulon President, WAPR, Department of Psychiatry, New York University Medical Center, New York, USA WHO also wishes to acknowledge the generous financial support of the Governments of Australia, Finland, Italy, the Netherlands, New Zealand, and Norway, as well as the Eli Lilly and Company Foundation and the Johnson and Johnson Corporate Social Responsibility, Europe vii “Efforts to improve mental health must take into account recent developments in the understanding, treatment and care of people with mental disorders, current health reforms and government policies in other sectors.” viii Table of Contents Preface Executive summary Aims and target audience x Introduction 10 2.1 2.2 2.3 2.4 The burden of mental disorders The global burden of mental disorders Economic and social costs of mental disorders Vulnerable groups Resources and funding for mental health 12 12 14 15 16 Historical perspective 17 Recent developments in the understanding, treatment and care of persons with mental disorders 4.1 Interface between physical and mental disorders 4.2 Effective treatments for mental disorders 20 20 21 5.1 5.2 5.3 Global health reform trends and implications for mental health Decentralization Health finance reforms Implications of reforms for mental health: opportunities and risks 23 23 23 25 Government policies outside the health sector which influence mental health 27 Mental Health Policy and Service Guidance Package: purpose and summary of the modules Mental Health Policy, Plans and Programmes Mental Health Financing Mental Health Legislation and Human Rights Advocacy for Mental Health Quality Improvement for Mental Health Organization of Services for Mental Health Planning and Budgeting to Deliver Services for Mental Health 30 30 32 32 34 35 37 39 7.1 7.2 7.3 7.4 7.5 7.6 7.7 References 41 ix Mental Health Policy and Service Guidance Package: purpose and summary of the modules This document has so far highlighted the current global burden of mental disorders, the inadequate resources and funding for mental health, and the opportunities for remedying this situation provided by recent developments in the treatment of mental disorders Furthermore, the implications of recent health sector reforms and the effects of macroeconomic and political issues on mental health have been outlined Governments have a crucial role to play in ensuring the mental health of their populations Recent advances in the knowledge and treatment of mental disorders mean that the goal of improving the mental health of populations is attainable There is now a need for action The current situation demands urgent action The Mental Health Policy and Service Guidance Package is intended to help countries to address these issues The package provides practical information to assist countries in developing policy, planning for services, financing those services, improving the quality of existing services, facilitating advocacy for mental health and developing appropriate legislation The guidance package provides practical information to assist countries in developing policy, planning for services, financing those services, improving the quality of existing services, facilitating advocacy for mental health and developing appropriate legislation The package has been developed by experts in the field of mental health policy and service development, in consultation with a wide range of policy-makers and service planners from around the world The package has been reviewed by ministries of health, nongovernmental organizations, and organizations representing national and international consumers, families, professionals and governments The purpose, target group for the modules and their format and use have been described in the preamble to this module The content of the modules in the Policy and Service Guidance Package is summarized below 7.1 Mental Health Policy, Plans and Programmes Introduction An explicit mental health policy is an essential and powerful tool for a mental health section in a ministry of health When properly formulated and implemented through plans and programmes, such a policy can have a significant impact on the mental health of a population Developing a policy A mental health policy is an organized set of values, principles and objectives for improving the mental health and reducing the burden of mental disorders in a population It defines a vision for the future and helps to establish a model of how action should be taken 30 The essential steps for developing a policy include the following - Step Step Step Step Step Step Step Step 1: 2: 3: 4: 5: 6: 7: 8: Assess the population’s mental health needs Gather evidence for effective policy Consult and negotiate Exchange information with other countries Set out the vision, values, principles and objectives of the policy Determine areas for action Identify the major roles and responsibilities of the different sectors Conduct pilot projects Developing a mental health plan The strategies of a mental health plan should correspond with the areas for action defined by the policy They involve activities that have to be carried out in order to ensure the implementation of these areas for action The development of a mental health plan requires the following activities to be undertaken - Step 1: Set priorities for the major strategies - Step 2: Establish the time frame and resources Developing a mental health programme A programme defines the concrete mental health interventions that the population will receive This means organizing a number of interrelated technical activities in effective schemes so as to address a mental health issue, using the best available evidence The formulation of a programme should involve the following steps - Step Step Step Step Step Step Step Step 1: 2: 3: 4: 5: 6: 7: 8: Identify the issue or problem to be addressed Set out the objectives of the programme Choose appropriate programme interventions Describe programme activities Identify responsible agents Set out a time frame Draw up a budget Evaluate the programme Implementation issues for policy, plans and programmes A mental health policy can be implemented through the priority strategies identified by the plan and the priority interventions identified by the programme Several actions are necessary for the implementation of these strategies and interventions - Step Step Step Step Step Step Step 1: 2: 3: 4: 5: 6: 7: Disseminate the policy Generate political support and funding Develop supportive organization Set up a demonstration area Empower mental health providers Reinforce intersectoral coordination Promote interaction among stakeholders Specific examples from countries are used to illustrate the process of developing policy, plans and programmes throughout the module 31 7.2 Mental Health Financing Financing is a critical factor in the realization of a viable mental health system It is the mechanism by which plans and policies are translated into action through the allocation of resources Policy-makers and mental health planners should address the following key questions - How can sufficient funds be mobilized to finance mental health services and the required infrastructure? - How can those funds be allocated and how can the delivery of mental health care be organized so that defined needs and priorities are addressed? - How can the cost of care be controlled? It is important to note that the financing of mental health care is not an isolated activity but occurs in widely disparate political and economic contexts In many countries it is subsumed under more general health financing and is often not distinct It is often shaped, if not determined, by the objectives of such financing The steps in mental health financing are as follows - Step 1: Understand the broad health care financing context - Step 2: Map the mental health system in order to understand the level of current resources and how they are used - Step 3: Develop the resource base for mental health services - Step 4: Allocate funds to address planning priorities - Step 5: Build budgets for management and accountability - Step 6: Purchase mental health services so as to optimize effectiveness and efficiency - Step 7: Develop the infrastructure for the financing of mental health - Step 8: Use financing as a tool to change the delivery of mental health services 7.3 Mental Health Legislation and Human Rights Context of mental health legislation Mental health legislation is necessary for protecting the rights of persons with mental disorders, who comprise a vulnerable section of society They face stigma, discrimination and marginalization in most societies This implies a heightened probability of violation of their human rights Legislation should strike a fine balance between the individual’s rights to liberty and dignity on the one hand and society’s need for protection on the other There is no national mental health legislation in 25% of the world’s countries, accounting for nearly 31% of the global population, although countries with a federal system of governance may have state mental health laws It should be noted that the existence of mental health legislation does not necessarily guarantee the protection of the human rights of persons with mental disorders In some countries, indeed, mental health legislation contains provisions that lead to the violation of human rights Activities preceding the formulation of legislation A country that has decided to draft and enact new mental health legislation should conduct certain preliminary activities that can inform this process, among them the following - Identify the principal mental health problems and barriers to the implementation of mental health policies and plans 32 - Critically review existing legislation in order to identify gaps and difficulties - Study international human rights conventions and standards - Critically review existing mental health legislation in other countries, especially ones with similar social and cultural backgrounds - Engage all stakeholders in consultation and negotiation about possible components of mental health legislation Content of mental health legislation Some of the more important issues to be addressed in legislation are indicated below (I) Substantive provisions for mental health legislation These include: - the principle of the least restrictive alternative; confidentiality; informed consent; voluntary and involuntary admission; voluntary and involuntary treatment; independent review body; competency and guardianship (II) Substantive provisions for other legislation impacting on mental health These include legislative provisions for protecting the rights of persons with mental disorders in the following sectors: - housing; - employment; - social security Legislation can also be used in order to promote mental health and prevent mental disorders It should contain specific provisions for protecting the rights of vulnerable groups such as women, children, the elderly and indigenous ethnic populations Other examples include measures to promote mother-and-child bonding through the provision of maternal leave, legislation for the early detection and prevention of child abuse, laws restricting access to alcohol and drugs, and legislative provisions for setting up school mental health programmes Process issues in mental health legislation The task of drafting legislation should be delegated to a specially constituted committee A draft of proposed legislation should be presented for consultation to all the key stakeholders in the mental health field Consultation plays a key part in identifying weaknesses in proposed legislation, potential conflicts with existing laws, vital issues inadvertently omitted from the draft legislation, and possible practical difficulties in implementation Difficulties in implementation can be anticipated as from the drafting stage and corrective measures can adopted Such difficulties may arise because of a lack of finances, a shortage of human resources, a lack of awareness among professionals, carers, families and the general public about mental health legislation, a lack of coordinated action, and, occasionally, procedural problems 33 Funding is required for the activities connected with the implementation of new mental health legislation Adequate budgetary provision should be made for this purpose A coordinating agency can help with the time-bound implementation of various sections of mental health legislation Implementation is also helped by wide dissemination of the provisions of new mental health legislation to mental health professionals and users, carers, families and advocacy organizations A sustained programme of public education and of increasing public awareness can also play an important role in implementation 7.4 Advocacy for Mental Health Concept of mental health advocacy Mental health advocacy is a relatively new concept It was developed with a view to reducing stigma and discrimination and promoting the human rights of people with mental disorders It consists of a variety of actions aimed at changing the major structural and attitudinal barriers in the way of achieving positive mental health outcomes in populations Importance of mental health advocacy The emergence of mental health advocacy movements in several countries has helped to change the way in which people with mental disorders are perceived Consumers have begun to articulate their own vision of the services they need and want, and are increasingly making informed decisions on treatment and other matters of their daily lives In itself the participation of consumers and families in advocacy organizations may have several positive impacts The roles of different groups in advocacy (I) Roles of consumers and families The roles of consumer groups in advocacy have ranged from influencing policies and legislation to providing concrete help for persons with mental disorders These groups have helped to sensitize the general public to their cause and have helped to educate and support people with mental disorders They have denounced some forms of treatments believed to be negative, poor service delivery, inaccessible care and involuntary treatment Families have a distinctive key role in caring for persons with mental disorders, particularly in developing countries In many places they are the primary care providers and their organizations are fundamental as support networks In addition to providing mutual support and services, many family groups have become advocates, educating the community, increasing support from policy-makers, denouncing stigma and discrimination, and fighting for improved services (II) Roles of nongovernmental organizations These organizations may be professional, i.e including only mental health professionals, or interdisciplinary, i.e with members from diverse areas Nongovernmental organizations may carry out many of the advocacy roles described for consumers and families Their main contribution to the advocacy movement involves supporting and empowering people with mental disorders and their families 34 (III) Roles of general health workers and mental health workers Mental health workers can play an important part in protecting consumer rights and raising awareness of the need for better services However, there may be conflicts of interest between health workers and consumers (IV) Roles of policy-makers and planners Ministries of health, and specifically their mental health sections, can and should play an important part in advocacy They may implement advocacy actions directly, in order to have an impact on the level of mental health in populations and on consumers’ civil and health rights Ministries of health may achieve similar or complementary impacts on populations indirectly by supporting advocacy organizations (consumers, families, nongovernmental organizations, mental health workers) It is necessary for each ministry of health to convince other policy-makers, including the executive branch of government, the ministry of finance and other ministries, the judiciary, the legislature and political parties, to focus on and invest in mental health Furthermore, ministries of health can develop many advocacy activities by working with the media There may be some contradictions in the advocacy activities of ministries of health Some of the issues that can be advocated may also be responsibilities, at least partially, of health ministries If ministries of health are service providers and also advocate for accessibility and for services of satisfactory quality, for example, they can become vulnerable to criticism from political oppositions How ministries of health can support advocacy Ministries of health can support advocacy activities with: - consumer groups, family groups and nongovernmental organizations; general health workers and mental health workers; policy-makers and planners; the general population 7.5 Quality Improvement for Mental Health There should be access to basic mental health care for everyone who needs it This means that mental health care should be affordable, equitable, geographically accessible, available on a voluntary basis and of adequate quality In many countries, services for people with mental disorders remain minimal and not measure up to these principles In a context where resources are inadequate and mental health is emerging as a new priority, concern for quality may seem premature Quality may seem more of an issue for well-established, well-resourced systems than for ones that are just becoming established Why is quality important for mental health care? Quality is important in all mental health systems for various reasons From the perspective of persons with mental disorders, good quality means that they receive the care they require and that their symptoms and quality of life improve From the perspective of family members it means that support is provided and that help is given for the preservation of family integrity From the perspective of service providers or programme managers it means that effectiveness and efficiency are ensured From the perspective of policy-makers it is the key to improving the mental health of populations and ensuring accountability and value for money 35 What is quality? In mental health care, quality is a measure of whether services increase the likelihood of desired mental health outcomes and whether they are consistent with current evidence-based practice For people with mental disorders, their families and populations as a whole, this definition emphasizes that services should produce positive outcomes For practitioners, service planners and policy-makers, it emphasizes the best use of current knowledge and technology Steps for quality improvement The steps for improving quality are cyclical Once policy, standards and accreditation procedures are established the continual improvement of the quality of care requires the ongoing monitoring of services, the integration of quality improvement strategies into management and the improvement of services Step 1: Align policy for quality improvement Policy-makers have a key role in the quest for quality They are in a position to establish the broad parameters of quality through consultation, partnerships, legislation, funding and planning Consultation is necessary with all mental health stakeholders, in both the development of policy and all subsequent steps of quality improvement Active steps should be taken by policy-makers to develop partnerships with professional groups, academic institutions, advocacy groups and other health and social service sectors Such partnerships form the backbone of the quality improvement process and make it possible to achieve long-term sustainability They build consensus and consistency in messages related to the need for quality, and can also be a mobilizing force for obtaining the resources and other necessary supports Policy-makers should promote legislation that reflects concern for and emphasizes quality Financial systems for mental health care should be aligned so that they maximize quality and not hinder quality improvement Improved efficiency is an essential goal in relation to both quality improvement and cost containment Step 2: Design a standards document in consultation with all mental health stakeholders An essential step towards improving the quality of mental health services involves developing a set of standards against which services can be measured This requires planners and managers to establish a working group, consult with relevant stakeholders and draft a standards document covering all aspects of the mental health service identified as belonging in particular domains Step 3: Establish accreditation procedures in accordance with the criteria of the standards document Accreditation provides the opportunity to assess the quality of care delivered by mental health services and to provide them with appropriate legal recognition It is essential because it makes quality a cornerstone of the official licensing of mental health services or facilities Step 4: Monitor the mental health service by means of the standards document and accreditation procedures It is necessary to monitor mental health services in order to assess the quality of care This monitoring can take several forms: the use of standards for assessing services 36 annually; the use of accreditation procedures to assess and accredit new service developments and to review the functioning of services; routine information-gathering through existing information systems; and consultation with independent organizations of people with mental disorders, carers and advocacy groups Step 5: Integrate quality improvement into service management and delivery Apart from the use of standards and accreditation procedures for the monitoring of services it is essential that services continue to improve the quality of care Continuous quality improvement is a perpetual process of striving for optimal quality This can be achieved by: - conducting annual reviews of service quality; - including quality checks in service planning targets; - building quality improvement into clinical practice through evidence-based practice, clinical practice guidelines, teamwork and continuing professional development; - improving quality when services are commissioned; - auditing Step 6: Reform or improve services where appropriate Assessment of the quality of mental health services may highlight requirements for their systematic reform or improvement This step may require concerted planning and coordination involving various sectors Step 7: Review quality mechanisms Once quality mechanisms are in place they should be reviewed at the same time as reviews of service targets at the local level, i.e approximately every to years This is necessary so that the mechanisms can be updated on the basis of evidence relating to the most effective methods of quality improvement 7.6 Organization of Services for Mental Health Mental health services are the means by which interventions for mental health are delivered The way in which these services are organized has an important bearing on their effectiveness and on whether the objectives of national mental health policies are ultimately met Description and analysis of mental health services Different components of mental health services can be identified The following classification is not a recommendation as to how services should be organized but an attempt to broadly map the variety of services found across the world (I) Mental health services integrated into general health systems can be broadly grouped as being in primary care or in general hospitals (II) Community mental health services can be categorized as formal or informal (III) Mental hospital institutional services include specialist institutional mental health services and dedicated mental hospitals 37 Current status of service organization From the standpoint of proportionality very few countries have an optimal mixture of services In this connection two main conclusions can be drawn from experiences across the world Firstly, mental health services pose a challenge for both developing and developed countries, although the nature of the challenges differs Secondly, more expensive specialist services are not the answer to these problems Even within the resource constraints of health services in nearly all countries, significant improvements in the delivery of mental health services can be achieved by redirecting resources towards services that are less expensive, have reasonably good outcomes and benefit larger proportions of populations Recommendations for organizing services A key issue for service planners is to determine the exact mixture of different types of mental health services and the levels of provision of particular service delivery channels The absolute requirements for various services differ greatly between countries but the relative needs for different services is probably the same in all countries It is clear that the most numerous services should be informal community mental health services and mental health services provided by primary care staff, followed by psychiatric services based in general hospitals, formal community mental health services and, lastly, specialist mental health services The main recommendations are as follows, (I) Integrate mental health services into the general health system (II) Develop formal and informal community mental health services (III) Promote and implement deinstitutionalization Key issues in organizing mental health services The above principles for organizing mental health services should take into account the evidence base for mental health interventions, the unique needs of persons with mental disorders, the ways in which communities and patients have access to services, and other important structural issues, e.g the need for intersectoral collaboration Health care systems should also be oriented towards the needs of many persons with severe and long-term mental disorders These people are poorly served by a throughput model of care which emphasizes the importance of vigorous treatment of acute episodes in the expectation that most patients will make a reasonably complete recovery without requiring further care until the next such episode occurs, if there is one A continuing care approach is more appropriate, emphasizing the need to address the totality of people’s needs, including their social, occupational and psychological requirements The pathways to care are the routes whereby people with mental disorders access mental health service providers These pathways are different in developed and developing countries with different levels of health system development They can occasionally hinder access to mental health services, resulting in delays in seeking help and thus in an increased likelihood of poor long-term outcomes Service planners should also pay attention to eliminating geographical disparities between rural and urban settings in the provision of mental health services A service-led approach, as opposed to a needs-led approach, is characteristic of many mental health services and imposes significant barriers to access, especially for people 38 with severe mental disorders whose needs go beyond purely medical and therapeutic interventions There is a move towards needs-led models of service provision involving, for example, case management, assertive treatment programmes and the creation of psychiatric rehabilitation villages in rural areas These models represent an acknowledgement that the needs of patients should be placed centrally and that the organization of services should be adapted to meet these needs The complex needs of many people with mental disorders cannot be met by the health sector alone Intersectoral collaboration is therefore essential Collaboration is needed both within the health sector (intra-sectoral) and between the health sector and other sectors (inter-sectoral) 7.7 Planning and Budgeting to Deliver Services for Mental Health The purpose of this module is to present a model for assessing the mental health care requirements of local populations and for planning services accordingly The intention is to provide countries with a set of planning and budgeting tools that can assist with the delivery of mental health services in local areas The steps in planning and budgeting, which are presented in cyclical form, include the following Step A: Situation analysis This includes identifying the population to be served, reviewing the local context of mental health care, consulting with all relevant stakeholders, identifying who is responsible for mental health budgeting and planning, and reviewing current mental health resources and service utilization Step B: Needs assessment The needs of the local population for mental health care are established This includes establishing the prevalence, incidence and severity of priority conditions, estimating the service resources for the identified needs, and costing the resources for the estimated services Step C: Target-setting The above information is collated and targets are set for future planning Target-setting includes identifying and setting priorities for local mental health services, appraising options for the most urgent service priorities and setting medium-term targets for service delivery Step D: Implementation The budgeting and financial management systems should now fall into place The services have to be monitored and evaluated in order to establish whether the targets are being achieved This leads to the completion of the cycle of planning and budgeting as new service information becomes applicable to the next situation analysis 39 40 Further reading Bertolote JM (1992) Planificación y administración de acciones en salud mental en la comunidad In: Levav L, ed Temas de salud mental en la comunidad (serie PALTEX No 19) Washington DC: OPS Bertolote JM (1998) WHO guidelines for the primary prevention of mental, neurological and psychosocial disorders In: Jenkins R, Ustun TB, eds Preventing mental illness: Mental health promotion in primary care New York: John Wiley and 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Guidance Package THE MENTAL HEALTH CONTEXT World Health Organization, 2003 WHO Library Cataloguing-in-Publication Data Mental health context (Mental health policy. .. in the series comprising the Mental Health Policy and Service Guidance Package It describes the context in which mental health is being addressed and the purpose and contents of the package The