What are the principles that should guide mental health policies in low- and middle-income countries?

EDITORIAL

What are the principles that should guide mental health policies in low- and middle-income countries?

There is increasing international attention on mental health in low- and middle-income countries (LMIC), following the landmark Lancet series on Global Mental Health of 2007,¹ and the recently launched World Health Organization mhGAP programme² and Mental Health and Development Report.³ These developments place an explicit challenge at the door of governments in these countries to take mental health seriously as a public health and development issue.

This naturally begs the question: how should governments go about developing mental health policies to address the growing burden of mental disorders in LMIC? And what principles should guide the development of such policies? I will attempt to answer some aspects of the latter question, with the hope that this will assist in providing answers to the former. Some of these principles are based on our experience of five years of work on the Mental Health and Poverty Project (MHaPP), a research programme consortium that set about studying and intervening in mental health policy development and implementation in four African countries: Ghana, South Africa, Uganda, and Zambia.⁴ These principles also draw on the WHO Mental Health Policy and Services Guidance Package, which provides practical step-by-step guidance for the development and implementation of mental health policies.⁵ The principles relate to three interconnected areas: policy development processes, the content of policy, and policy implementation.

Policy development

1. Consult widely. In the development of mental health policies it is essential that governments consult with a range of stakeholders, including service users. This is important not only to include the proposals of these stakeholders in the policy, but crucially to obtain buy-in from these stakeholders for the implementation of the policy.

2. Use the best available evidence. It is essential that policy makers draw on the best available local and international evidence including epidemiological data, service-related data, and local needs, such as specific local cultural challenges.

3. Obtain a high-level political mandate. Policy development is likely to flounder without the support of senior policy makers. Successful case studies of mental health policy development have invariably been supported by senior policy makers such as the President/Prime Minister and Minister of Health.

4. Tackle stigma head-on. In advocacy work to obtain political support, it is essential to address the stigmatizing and misinformed beliefs of key stakeholders. Our experience with the MHaPP revealed that many well-educated senior policy makers continue to adhere to mistaken and discriminatory beliefs regarding mental health. These include beliefs that the burden of mental disorders is insignificant, mental disorders are "just in people's minds", mental disorders are caused by moral weakness or spirit possession, and the evidence base for interventions is weak. By actively addressing these beliefs through persuasive and persistent presentation of the evidence, the chances of successful adoption and implementation of the policy are greatly enhanced.

5. Link policy development to other health and development priorities. For example, HIV/AIDS carries a substantial mental health burden, and efforts to mobilize HIV/AIDS resources for co-morbid mental disorders can yield benefits.

Content of policy

1. Set out a clear and realistic vision and related values, principles, and objectives. Those involved in drafting the policy document should ensure that the vision is well served by the policy's values, principles, and objectives.

2. Promote and protect human rights. It is essential for the benefit of people living with mental disorders and their care-givers that policies embrace international human rights standards.

3. Promote inter-sectoral collaboration. Mental health policies should explicitly state the roles and responsibilities of a wider range of sectors, and not simply be limited to the Ministry of Health. Sectors such as Education, Labour, Criminal Justice, Housing, Agriculture, and Social Services are likely to play crucial roles in addressing the "upstream" social determinants of mental health and promoting the mental health of populations.

Policy implementation

1. Link the policy to a strategic plan. Mental health policies frequently serve little function other than to weigh down the shelves of Ministry of Health offices, unless they are implemented through a well formulated strategic plan, which is linked to the Ministry's budgeting cycle and includes explicit targets, indicators, timelines, and budgets.

2. Allocate adequate resources to implement the policy. Each objective of the policy should be linked to an explicit target in the strategic plan, which is allocated sufficient budget for its successful implementation.

3. Link policy to legislation. By linking policy to law, for example through legal imperatives for service providers to provide community-based care, the objectives of the policy can be more powerfully adhered to.

4. Monitor policy implementation. Establish reliable routine mental health information systems, at service and population levels, to monitor the implementation of policies over time.

It is important to emphasize that these principles need to inform both national governments and the wide range of extremely influential international development agencies and health research funders, who play a key role in determining the policy agenda of governments in LMIC. More detail on the experience of the MHaPP is available at www.psychiatry.uct.ac.za/mhapp and more detailed practical guidance regarding mental health policies can be found via WHO's Mental Health Policy and Service Guidance package: http://www.who.int/mental_health/policy/essentialpackage1/en/index.html

Crick Lund

Centre for Public Mental Health, Department of Psychiatry

and Mental Health, University of Cape Town, Cape Town,

South Africa

References

• 1. Lancet Global Mental Health Group. Scale up services for mental disorders: a call for action. Lancet. 2007;370(9594):1241-52.
• 2. WHO - World Health Organization. mhGAP Intervention Guide for Mental, Neurological and Substance Use Disorders in non-specialized health settings: Mental health Gap Action Programme (mmhGAP). Geneva: WHO; 2010.
• 3. Funk M, Drew N, Freeman M, Faydi E. Mental Health and Development: Targeting people with mental health conditions as a vulnerable group. Geneva: World Health Organization and Mental Health and Poverty Project; 2010.
• 4. Flisher AJ, Lund C, Funk M, Banda M, Bhana A, Doku V, Drew N, Kigozi FN, Knapp M, Omar M, Petersen I, Green A. Mental health policy development and implementation in four African countries. J Health Psychol 2007;12(3):505-16.
• ⁵
  5. WHO - World Health Organization. Mental health policy, plans and programmes. Mental health policy and service guidance package. Geneva: WHO; 2005.

Publication Dates

• Publication in this collection
  07 Feb 2011
• Date of issue
  Dec 2010