World Health Organization

WHO's Mental Health

Programme:
Continuing Challenges
Dr Shekhar Saxena
Director, Department of Mental
Health and Substance Abuse
World Health Organization
Geneva
1|

SWOT Analysis

Strengths

Weaknesses

Utilize the attention given to

autism and the possibility of
expanding it into a child MH
issue
Creates Interest & Awareness
Broadens the discussion to areas
outside health (education, social,
etc.)
Financial Resources within
Health
Effective interventions available
(e.g. functioning)
Multi factorial condition- a good
example of a non stigmatizing
condition
Might generate research interest
and funding within global mental
health

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Uncommon condition
Inefficient resources
It becomes a unique
condition disregarding the
broader definition of mental
disorder.
No available scientific
treatment (not curable)
Not a public health issue for
many countries &
internationally for WHO

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Opportunities

Threats

To see how the public

image can change with
advocacy and awareness
Can be used as a learning
mechanism

3|

Diverting attention into na area that

is not a priority
It can result in other psychiatric
disorders that are even more
stigmatizing
At the risk of losing credibility if you
widen the scope
Resources might be
misappropriated
Increased advocacy may lead to
overdiagnosis of the condition
Distortion of the research/public
health/services agenda
Might lead to services that are
specialized, neglecting other
common disorders
Can be temporary in nature if the
poltical route is taken

RESPONSE (Brainstorming)

Widening the dialogue/agenda (integrated within child care programs)

Share resources and information

Highlight lack of human and financial resources: opening dialogue with
ministry of finance in order to increase human resources to address
needs.

Parent Inclusion in programs (e.g. training)

Using dialogue to bring awareness to advocacy of larger impact

Using epidemiology to convince processes and health authoritites on
where to invest, using rationality and evidence in orienting decisions and
efforts.

Obtain additional information and give more informed advice

Advocate for Prevention Activities
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Disease Burden (DALYs)

Maternal conditions

Perinatal conditions
Nutritional deficiencies

Respiratory infections
Malaria
Childhood diseases

Other NCDs
Malignant neoplasms
5%
Diabetes

7%

6%
3%

3%

Diarrhoeal diseases
HIV/AIDS

4%

6%

13%

Neuropsychiatric disorders

Tuberculosis
Other CD causes

6%

3%

Sense organ disorders

10%

Cardiovascular diseases

12%

Injuries

4%
3%

Congenital abnormalities

Respiratory diseases
Digestive diseases
Diseases of the genitourinary system

Musculoskeletal diseases

Source: WHR 2002

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Leading Causes of Mortality and Burden of Disease

world, 2004
Mortality

DALYs

1.

Ischaemic heart disease

12.2

1.

Lower respiratory infections

6.2

2.

Cerebrovascular disease

9.7

2.

Diarrhoeal diseases

4.8

3.

Lower respiratory infections

7.1

3.

Depression

4.3

4.

COPD

5.1

4.

Ischaemic heart disease

4.1

5.

Diarrhoeal diseases

3.7

5.

HIV/AIDS

3.8

6.

HIV/AIDS

3.5

6.

Cerebrovascular disease

3.1

7.

Tuberculosis

2.5

7.

Prematurity, low birth weight

2.9

8.

Trachea, bronchus, lung cancers

2.3

8.

Birth asphyxia, birth trauma

2.7

9.

Road traffic accidents

2.2

9.

Road traffic accidents

2.7

10.

Prematurity, low birth weight

2.0

10.

Neonatal infections and other

2.7

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Leading causes of disease burden for women aged

1544 years, high-income countries, and lowand middle-income countries, 2004

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2030 rankings:
The leading causes of DALYs lost
World

1
2
3

HIV/AIDS
Depression
Ischaemic heart dis.

High-income countries

1
2
3

Depression
Ischaemic heart disease
Alzheimer

Middle-income countries 1
2
3

HIV/AIDS
Depression
Cerebrovascular

Low-income countries

HIV/AIDS
Perinatal
Depression

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1
2
3

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Scarcity
Human Resources
(N=157 to 183 countries)

9|

Burden versus Budget

Burden of mental
disorder
Proportion of budget
for mental health

25

21.37
19.56

20

14.50

15

11.48
10
7.88
6.88
5

4.27
2.26

3.76

2.62

10 |

Low-income

Higher-middle income
Lower-middleincome

All the countries

High-income

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Gap in treatment:
Serious cases receiving no treatment during the last 12 months
90

85%

80

76%

70
60

50

50%
40

30

35%

20

10

0
Lower range

Upper range

Lower range

Developed countries

Upper range

Developing countries

(WHO World Mental Health Consortium, JAMA, June 2nd 2004)

11 |

THE BURDEN OF MENTAL DISORDERS: Treatment

gap for Schizophrenia and Mood Disorders
100%
90%

Treatment

Treatment

80%

Gap

Gap

69%

98%

70%
60%
50%
40%
30%
20%
10%

COVERAGE
COVERAGE

0%

Schizophrenia n =50
COVERAGE

12 |

Mood disorders n=28

TREATMENT GAP

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INEFFICIENT USE OF RESOURCES:

High concentration of resources in mental hospitals
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%

17%

20%

63%
Other facilities
Mental hospitals

83%

80%

37%

Proportion of
expenditures

Proportion of
beds

Proportion of
human
resources

13 |

INEFFICIENCY: MENTAL HEALTH BUDGET, STAFF WORKING AND

USERS TREATED IN MENTAL HOSPITALS BY INCOME
(median rate per 100,000 population)
STAFF IN M.H.

BUDGET IN M.H.

% USERS IN MENTAL HOSPITALS

100%

86%

90%

80%

80%

72%

72%

70%
60%

50%

50%
40%

38%

34%
24%

30%
20%

10%
3%

10%

7%

3%

0%

LOW

14 |

MIDDLE-LOW

HIGHER MIDDLE

ALL

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MENTAL HOSPITALS - 1

83% of all psychiatric beds are in
GEOGRAPHICAL REGIONS (rates of beds)
MH, only 7% of all patients treated
are admitted in mental hospitals
AFRICA, SOUTH-EAST ASIA
LOW
BEDS AND PATIENTS IN MENTAL
HOSPITALS (rate per 100.000)
100%
80%
60%
40%
20%
0%

AL
L

D
LE

EUROPE

HIGH

-M

ID

LE

INTERME
DIATE

The beds in mental hospitals five years

before doesn't change in low and lower
middle income countries, while there is
a decrease (-23%) in upper-middle
income countries.

ER

The main decrease in European (-17%)

and American (-7%) countries

U
PP

ER
-M
ID
D

LO
W

LO
W

BEDS
PATIENTS

AMERICA, EASTERN
MEDITERRANEAN,
WESTERN PACIFIC

15 |

MENTAL HOSPITALS - 2

2/3 of patients stay less than 1 year
and only 1/10 more than five years.
PATIENTS BY LENGTH OF STAY (%)

100%

92%
LESS 1 YR.
MORE 10 YR.

80%
66%

60%

The average time spent in Mental

Hospital increases by 60% from
low income counties to uppermiddle income countries

49%
37%

40%
20%
2%

4%

0%
LOW

16 |

The level of occupancy is higher in

upper-middle income countries
than in the others.

LOWERMIDDLE

UPPERMIDDLE

in low income countries the Mental

Hospital works as an acute ward,
in the upper middle income
countries as a residential unit for
long stay patients.

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Human Rights Abuses

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Time Cover Story: November 2003

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Provide treatment in
primary care

Establish national policies,

programmes and legislation

Make psychotropic drugs

available

Develop human resources

Link with other sectors

Give care in the community

Educate the public

Involve communities,
families and consumers

Monitor community mental

health

Support more research

19 |

Impact of WHR-2001

Awareness

+++

Understanding

++

Action

20 |

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Additional yearly investment on the package that will be needed per

capita population to get from current to target coverage levels (20062015)

Incremental expenditure per capita (US$, 2005)

$6.00

Albania
Chile

$5.00

China (Hunan)
Ethiopia

$4.00

Iran, Islamic
Republic of
Morocco
$3.00

Nepal
Nigeria

$2.00

Paraguay
Thailand

$1.00

Ukraine
$2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

Viet Nam

Year

21 |

mhGAP
mental health Gap Action Programme
Scaling up care for mental, neurological and substance use disorders

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Mental Health Services (WHO, 2003)

HIGH

LOW

Specialist
Services

FREQUENCY
OF NEED

COST

Psychiatric Community
Mental
Services in
Health
General
Services
Hospitals
Mental Health Services
through PHC
INFORMAL COMMUNITY CARE

LOW

HIGH

SELF CARE

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mhGAP: Scaling Up Care

Objectives
To achieve significantly higher coverage with
key interventions for priority MNS conditions in
resource-poor countries

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mhGAP:
Setting priorities
Criteria:

High burden (mortality, morbidity, disability)

Large economic cost

Effective intervention available
Priority conditions:

Depression

Psychoses

Suicide prevention

Epilepsy

Dementia

Disorders due to use of alcohol

Disorders due to illicit drug use

Child mental disorders

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mhGAP Implementation

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mhGAP Intervention Package

The Vision

a model package

that will need adaptation to country settings before being used

based on a systematic situational analysis including human and financial costing

for use by the "District Medical Officer" or an equivalent health official

providing guidance on service delivery and training

with protocols for clinical decision-making

using a symptom and syndrome based approach

recommending interventions for selected conditions of public health priority

that are evidence based

and feasible to be delivered within LAMIC health systems

by non-specialist health personnel within community, first and second level care

under supervision and support from mental health professionals

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Guidance on Human Rights

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mhGAP Country Implementation

Active implementation by WHO

Supporting MoH

Supporting partners
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WHO QualityRights
Improving quality and human rights in
facilities and promoting a civil society movement

Assessment of facilities

Development of a change plan

Capacity building on human rights issues

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Thank You
For your attention

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