Comment
I am a co-investigator of a grant, Control of Epidemic Inuenza, from 6 Wood JM, Oxford JS, Dunleavy U, Newman RW, Major D, Robertson JS.
MedImmune Vaccines, and I have received honoraria from AstraZeneca
(MedImmune) for scientic presentations.
1 Barrett PN, Berezuk G, Fritsch S, et al. Ecacy, safety, and
immunogenicity of a Vero-cell-culture-derived trivalent inuenza
vaccine: a multicentre, double blind, randomised, placebo-controlled
study. Lancet 2011; published online Feb 16. DOI:10.1016/S0140-
6736(10)62228-3.
2 Jeerson T, Di PC, Rivetti A, et al. Vaccines for preventing inuenza
in healthy adults. Cochrane Database Syst Rev 2010; 7: CD001269.
3 Wright PF. Vaccine preparednessare we ready for the next pandemic?
N Engl J Med 2008; 358: 254043.
4 Rocha EP, Xu X, Hall HE, Allen JR, Regnery HL, Cox NJ. Comparison of
10 inuenza A (H1N1 and H3N2) haemagglutinin sequences obtained
directly from clinical specimens to those of MDCK cell- and egg-grown
viruses. J Gen Virol 1993; 74: 251318.
5 Katz JM, Webster RG. Ecacy of inactivated inuenza A virus (H3N2)
vaccines grown in mammalian cells or embryonated eggs. J Infect Dis 1989;
160: 19198.
Mental health in southeast Asia
Published Online The southeast Asia subregion (ASEAN: countries listed
January 25, 2011
DOI:10.1016/S0140-
in the table) varies widely in populations, income,
6736(10)62181-2 progress as reected in the human development
See Series page 769 index,1 and in resources in mental health systems.13
See Series Lancet 2011;
Widespread poverty remains, and income inequal-
377: 429, 516, 599, and 680
See Online/Series
ity has substantially increased within countries. Rapid
DOI:10.1016/S0140- urbanisation, and social and cultural change, have
6736(10)61890-9
generated new problems, particularly among the young.
Mental health has been a low priority. The main
challenges are largely the product of lack of attention
and investment. Where legislation and policies exist
they are, at best, incompletely implemented, and eorts
to modernise mental health systems have faced many
obstacles.4 In most of the countries, mental health
spending is no more than 2% of the health budget,
with 8090% going to mental hospitals. There are
massive workforce deciencies; few consumer, carer, or
other civil-society organisations with a focus on mental
health advocacy; inadequate protection of the rights
of people with mental illness; few eorts to promote
mental health; little in the way of rehabilitation services
or eorts to promote social and economic inclusion; and
treatment services are concentrated in urban areas and
often of poor quality, inaccessible, and unaordable.
The direct consequences of neglect are many,
including avoidable disability, impoverishment, and
widespread human-rights abuses. Lack of attention to
mental health, particularly in mothers, is hampering the
achievement of several of the Millennium Development
Goals. Most treatment is delivered through poorly
700
Inuenza A (H1N1) vaccine ecacy in animal models is inuenced by two
amino acid substitutions in the haemagglutinin molecule. Virology 1989;
171: 21421.
7 Frey S, Vesikari T, Szymczakiewicz-Multanowska A, et al. Clinical ecacy of
cell culture-derived and egg-derived inactivated subunit inuenza vaccines
in healthy adults. Clin Infect Dis 2010; 51: 9971004.
8 Koudstaal W, Hartgroves L, Havenga M, et al. Suitability of PER.C6 cells
to generate epidemic and pandemic inuenza vaccine strains by reverse
genetics. Vaccine 2009; 27: 258893.
9 Minor PD. Vaccines against seasonal and pandemic inuenza and the
implications of changes in substrates for virus production. Clin Infect Dis
2010; 50: 56065.
10 Palache AM, Brands R, van Scharrenburg GJM. Immunogenicity and
reactogenicity of inuenza subunit vaccines produced in MDCK cells
or fertilized eggs. J Infect Dis 1997; 176 (suppl 1): S2023.
11 Topics & Objectives IndexHealthy People. http://www.healthypeople.
gov/2020/topicsobjectives2020/pdfs/HP2020objectives.pdf (accessed
Feb 4, 2011).
resourced mental hospitals, a legacy of European
colonisation, with all of the well-known deciencies
associated with such systems. A notable exception is
Cambodia which, after the Pol Pot era, had no hospital,
psychiatrists, or any other mental health professionals.
The rebuilding of a mental health system there,
from a primary care and community base, has been
remarkable.5 Although primary health care systems are
generally well developed, capacity is limited to deliver
mental health treatment and care through these
systems, and to develop community-based services.
In the many, particularly poor, provinces and districts
with neither a mental hospital nor community services
there is little or no access to treatment and care. Too
often the only option left to families and communities
is physical restraint and connement of people with
severe mental disorders.6
Reforms have focused on integration of mental
health into general health care, with establishment of
acute psychiatric units in general hospitals and eorts
to incorporate mental health into primary care.3,4,7,8
In Vietnam, the Doi Moi economic liberalisation
programme in 1986 greatly aected health-sector
reforms: the introduction of user fees at higher-level
public health facilities put considerable pressure
on a well-developed primary care system, private
medical practice was legalised, and the drug industry
was liberalised with deregulation of the retail trade
in drugs.3 Vietnam has had a community mental
health programme, delivered through primary care,
www.thelancet.com Vol 377 February 26, 2011
 Comment

since 1998. The programme, focusing on schizophrenia
and epilepsy, has been rolled out across most of the
country. Although the Indonesian Government has
been developing capacity at primary care level to deliver
mental health services for 20 years, real progress has
been made in Aceh during the post-tsunami period.
A particular feature has been the practical focus on
protection of human rights of people with severe
mental disorders.9 The government of Aceh and the
national government of Indonesia have explicitly
committed to eradicate restraint and connement of
mentally ill people in the community, the Aceh Free
Pasung programme.10 Aceh shows the opportunities for
the substantial strengthening of a mental health system
that can come from the tragedy of major disaster. An
essential and too often neglected component of such
health-system development is the introduction of
appropriate nancing and payment arrangements,
such as the increase in coverage and streamlining of
social health insurance in Indonesia, where movement
towards universal coverage is steadily progressing.11
The continuing development of eective and
accessible mental health systems in southeast Asia
will require leadership at all levels, most importantly
political leadership. Current weaknesses in leadership
and management will require building of the capacity
of national and local systems to plan, implement,
manage, monitor, and evaluate new programmes
for mental health services. National and more local
structures that enable inter-disciplinary and inter-
sectoral collaboration, such as the National Taskforces
on Mental Health System Development in Indonesia
and Vietnam,12 can contribute to such capacity
strengthening. A clear and long-term focus on
building community services, and redening the roles
of mental hospitals, will be essential. Greatly improved
education and training capacity, and re-orientation
of training curricula to community-based practice,
will be necessary to prepare professionals to work
in new ways and in unfamiliar settings. The crucial
workforce shortages can only be resolved in the short
to medium term through task shifting, which will
require traditional disciplines, such as psychiatry and
nursing, to redene their roles and assume greater
responsibility for training and mentoring.
Particular attention will need to be paid to generating
innovative solutions for long-term problems, solutions
that are not necessarily imported from elsewhere
but are developed in the contexts in which they will
operate. Building research capacity in mental health,
particularly for systems research, is among the lowest
of current priorities but also an essential contributor

Brunei Cambodia Indonesia Laos Malaysia Myanmar Philippines Singapore Thailand Vietnam
Government Monarchy Constitutional Republic, Communist Constitutional Military Republic, Republic, Constitutional Communist
monarchy, multiparty state monarchy, regime multiparty multiparty monarchy, state
multiparty democracy multiparty democracy democracy multiparty
democracy democracy democracy
Population (millions) 04 145 243 64 283 534 999 47 671 896
Life expectancy at birth1 774 622 715 659 747 627 723 807 693 749
GNI per head 49 915 1868 3957 2321 13 927 1596 4002 48 893 8001 2995
(US$PPP, 2008)1
HDI (composite Index)1 0805 0494 06 0497 0744 0451 0638 0846 0654 0572
HDI rank1 37 124 108 122 57 132 97 27 92 113
Psychiatric beds per 12 0 04 007 27 023 09 61 14 063
10 000 population2
Psychiatrists per 19 016 021 003 06 004 04 23 06 032
100 000 population2
Psychiatric nurses per 03 022 09 0 05 001 04 104 27 03
100 000 population
Psychologists per 03 045 03 0 005 005 09 1 02 006
100 000 population2
Social workers per 1 005 15 0 02 001 16 3 06 0
100 000 population2

GNI=gross national income. PPP=purchasing power parity. HDI=health development index.

Table: Demographic and health comparison of ASEAN countries

www.thelancet.com Vol 377 February 26, 2011 701

 Comment
to progress. Collaboration among ASEAN countries
on development initiatives and research projects in
mental health systems will facilitate the process and
discourse. Strengthening collaborative structures, such
as the International Observatory on Mental Health
Systems,13 will greatly facilitate the necessary exchange
of experience and knowledge and contribute to
maintaining the impetus for reform and development.
*Albert Maramis, Nguyen Van Tuan, Harry Minas
WHO Country Oce for Indonesia, Jakarta 12950, Indonesia (AM);
Department of Psychiatry, Hanoi Medical University, Hanoi,
Vietnam (NVT); National Institute of Mental Health, Hanoi,
Vietnam (NVT); and Centre for International Mental Health,
Melbourne School of Population Health, University of Melbourne,
Parkville, VIC, Australia (HM)
amaramis@indosat.net.id
Our opinions do not necessarily represent the decisions, policy, or views of
WHO. We declare that we have no conicts of interest. World Health
Organization, 2011.
1 UN Development Programme. Human development report 2010: the real
wealth of nations, pathways to human development. 2010. http://hdr.
undp.org/en/media/HDR_2010_EN_Complete_reprint.pdf (accessed
Nov 17, 2010).
2 WHO. Mental health atlas 2005. Geneva, Switzerland. 2005. http://www.
who.int/mental_health/evidence/mhatlas05/en/index.html (accessed
Nov 17, 2010).
Towards a truly universal Indian health system
Published Online Most are likely to agree that the accompanying call for
January 12, 2011
DOI:10.1016/S0140-
action1 towards achieving universal health care in India
6736(10)62043-0 by 2020 (hereafter referred to as the call) is timely and
See Series page 760 overdue. However, we disagree with the call in two
See Series Lancet 2011; 377: 252, crucial areas.
332, 413, 505, 587, and 668
First, the call treads dangerous territory by asserting
that Indias economic growth oers an opportunity
to address the serious inequities in health, rather
than acknowledging that this economic growth is
the basis of inequities in health in many ways. It is
not only, as the call states, that impressive economic
growth in India...has not yet resulted in commensurate
investments and health gains.1 Rather, the current
framework of economic growth is not designed to
address the concerns of very large sections of the
population, for whom it has directly perpetuated the
situation of ill health and inadequate health care.2,3
This position is not one of mere semantics, since any
sustainable recommendation needs to be set in an
honest and robust analysis of the causes of ill health
702
3 UN Development Programme. Impacts of basic public services
liberalization on the poor and marginalized people: the case of health,
education and electricity in Viet Nam. August, 2006. http://
europeandcis.undp.org/uploads/public/File/2_Impact_on_Poor_
Report_72.pdf (accessed Nov 30, 2010).
4 Conde B. Philippines mental health country prole. Int Rev Psychiatry
2004; 16: 15966.
5 Stockwell A, Whiteford H, Townsend C, Stewart D. Mental health policy
development: case study of Cambodia. Australas Psychiatry 2005;
13: 19094.
6 Minas H, Diatri H. Pasung: physical restraint and connement of
the mentally ill in the community. Int J Ment Health Syst 2008; 2: 8.
7 Parameshvara Deva M. Malaysia mental health country prole.
Int Rev Psychiatry 2004; 16: 16776.
8 Siriwanarangsan P, Liknapichitkul D, Khandelwal SK. Thailand mental
health country prole. Int Rev Psychiatry 2004; 16: 15058.
9 Irmansyah I, Prasetyo YA, Minas H. Human rights of persons with mental
illness in Indonesia: more than legislation is needed. Int J Ment Health Syst
2009; 3: 14.
10 Hasan, N. Aceh governor promises to remove the chains from the
mentally ill. Jakarta Globe Feb 23, 2010. http://www.thejakartaglobe.com/
health/aceh-governor-promises-to-remove-the-chains-from-the-
mentally-ill/360336 (accessed Nov 17, 2010).
11 Ministry of Health Indonesia. National health workshop: improving
synergy and coordination between national and sub-national centres.
May 5, 2010. Jakarta: Ministry of Health Indonesia, 2010 (in Indonesian).
http://www.depkes.go.id/index.php/berita/press-release/1066-
rakerkesnas-tingkatkan-sinergi-dan-koordinasi-pusat-dan-daerah.html
(accessed Nov 17, 2010).
12 Patel V, Garrison P, de Jesus Mari J, Minas H, Prince M, Saxena S, on behalf
of the advisory group of the Movement for Global Mental Health.
The Lancets series on global mental health: 1 year on. Lancet 2008;
372: 135457.
13 Minas H. International observatory on mental health systems: structure
and operation. Int J Ment Health Syst 2009; 3: 8.
in India. For example, the explanation of what ails
the health sector states that Several adverse social
determinants combine to corrode health of vulnerable
populations.1 However, little mention is made of the
severe, persistent, and near ubiquitous poverty that has
characterised this era of so-called economic growth, in
which 77% of Indians live on less than INR20 a day.4
The word poverty is mentioned only as a consequence
of ill health. Thus, although the call comprehensively
lists acts of omission, it carefully steers clear of
acts of commission. Its underlying premise, that
economic growth stimulated by neoliberal policies
can be translated into equitable sharing of resources,
is fundamentally awed. This premise severely
compromises its recommendations, the most impor-
tant of which is the need for integration of the private
sector into a universal Indian health system.
Second, just as the call accepts the present framework
of economic development as desirable and well
established, so also it accepts the value of integration
www.thelancet.com Vol 377 February 26, 2011