COVID-19 Webinar 16: Integrating mental health into health systems
The Lancet Psychiatry, Mental Health Innovation Network, MHPSS.net and United for Global Mental Health organise a series of weekly webinars designed to provide policy makers and the wider health community with the latest evidence on the impact of COVID-19 on mental health and how to address it.
Chair: Shekhar Saxena - Professor of Global Mental Health, Harvard T H Chan School of Public Health
Speakers:
Githinji Gitahi - GCEO, AMREF Health Africa and Co-chair of UHC2030
Devora Kestel - Director of the Department of MH and Substance Use, WHO
Akwasi Osei - CEO of the Mental Health Authority of Ghana
Peter Yaro - Executive Director, BasicNeeds Ghana
Key messages:
Githinji Gitahi: Let’s all advocate for Universal Health Coverage (UHC) financing that is inclusive of mental health financing. We need to realise that, just as there is no UHC without mental health, so there is no mental health without UHC.
Devora Kestel: Antonio Guterres, UNSG and Dr Tedros, DG WHO have both emphasized the importance of mental health in the COVID-19 response and UHC. I echo those statements, and only add that we need to capture the opportunity to build back better, especially for those affected by the pandemic.
Akwasi Osei: We all need to recognise that mental health care is a collective responsibility: of individuals for self-care, of the community, of government, of civil society. If we can understand this, we will get very far.
Peter Yaro: I reiterate the theme of this webinar, that there is no health without mental health. However, it is key that mental health goes beyond medical considerations. We should find ways to include service users, civil society, and even link up to other sectors in socioeconomic development to make real better investment and more investment in UHC that would cover mental health.
Record of the meeting:
Shekhar Saxena:
The integration of mental health into health systems is not a new topic. In 1978, the Alma Ata conference brought in the concept of “health for all”, to be achieved by the year 2000. The year 2000 came and went, and some progress had indeed been made. However, many of us believe that we are still far from an adequate integration of mental health into health systems.
“No health without mental health” was the title of a paper that was part of the Lancet series on mental health in 2007. In addition, universal health coverage (UHC) was also part of the mental health action plan that was published by the WHO in 2013. And of course it is part of SDG 3.8.
In short, UHC means “health care for everyone everywhere”. In a slightly longer definition, it means ensuring that people have access to the healthcare they need without suffering financial hardship, and in a way that is person-centred and rights-based.
Since the definition of health by the WHO includes mental health, it is logical to believe that UHC should also include mental health, in all its parts: prevention, promotion, and care for people with mental disorders.
COVID-19 is affecting all of us, and has injected urgency into the requirement to integrate mental health into healthcare.
Githinji, what has stood in the way of UHC progress to date, and what opportunities and challenges has COVID-19 created in this regard?
Githinji Gitahi:
After 1978, there was a big drive to achieve primary healthcare for all. It was seen as a way to address the issue of providing health for all as a right, and was seen as achievable.
Many governments did move along this journey, but in the 1980s we ran into some headwinds. Governments started to view healthcare as a cost. This view was sustained by the ideology prevalent at the World Bank at that point. Thus, when governments ended up in debt, they were dissuaded from investing in healthcare, which was seen as a cost, and prioritised investment in other areas.
At this point, primary care, which should have been accessible to all without financial difficulty, started to see the introduction of fee-sharing. This is the problem we find ourselves in today: the biggest concern is out-of-pocket expenditure, and an increasing inability to access health services.
UHC aims to reverse this challenge. In reality, health is not a cost, it’s an investment. We’ve seen this especially now, with COVID-19. Health is needed for a healthy economy to function: for children to learn, and for adults to earn.
Over and above this initial challenge, we need political will to achieve UHC. For instance, last year, around the time of the UN declaration on UHC, we had debates with some WHO and UN member states to ensure that all populations were included under the concept of “health for all” (as certain population were not seen as ‘deserving’ by some member states); and we also had to work quite hard to embed some of the services that we are discussing even now into that declaration.
As a result, we came up with a number of key areas to focus advocacy on:
Positioning health as a political and a social contract between the politicians and the communities: declarations must be followed by actions
Leaving no-one behind: everyone must have access, and this must be properly financed
Ensuring that legislation enables the achievement of UHC, in the way that we envision it, especially when it comes to promotion and prevention. Within mental health specifically, we have countries that still view suicide as a criminal issue. These sorts of legislative issues need to be addressed, so that health can go beyond just service delivery
Investing more and investing better. We still have challenges with financing, especially in Africa, where the fiscal space is challenging - governments cannot raise enough money in taxes to pay for healthcare
Moving together: ensuring that the community is properly engaged
In addition, we need to work with politicians to ensure that they focus not just on secondary and tertiary care, which they sometimes see as short-term vote winners, but that they give sufficient focus to primary healthcare, which is community-driven and person-centric. Unless we can do this, investment in mental health will be left by the way-side, as it does not present a good opportunity for vote-hunting.
Shekhar Saxena:
Devora, why is integrating mental health into UHC important during the COVID-19 response and recovery plans?
Devora Kestel:
When announcing the need to have an initiative on mental health, Dr Tedros said: “The world is accepting of the concept of UHC. Mental health must be an integral part of UHC. Nobody should be denied access to mental health care because she or he is poor or lives in a remote place”.
This was said a long time before COVID-19. Now, however, it is even more relevant. We have seen the impact that COVID-19 is having on the mental health of people on the global level: psychological distress caused by the virus, impact on those involved in the response, consequences of isolation and economic turmoil. This is creating situations where the mental health and wellbeing of entire societies are impacted.
In addition, we know that, at the global level, mental health did not receive enough funding to absorb even pre-COVID-19 needs, let alone the extra challenges due to COVID-19.
We have also seen that, when mental health is deployed as a parallel system (e.g. managed by specialised or isolated services, such as tertiary hospitals), these systems are not as able to deal with challenges, and are not as well prepared, as more integrated systems.
Integrating mental health as part of UHC, therefore, is our best chance of making services accessible to all who need them, with a whole of society approach (both in healthcare and beyond). Indeed, now is an opportunity to see this dream realised, including integrating mental health into primary healthcare and other programmes, paying special attention to vulnerable groups that may need - now more than ever - this kind of support.
Ultimately, we must see COVID-19 as an opportunity to integrate mental health care in any response and recovery plan. We have seen examples of this integration in global frameworks, such as the Global Humanitarian Response Plan, but we also need to see this at the country level.
Shekhar Saxena:
Akwasi, now that we have heard the global background and perspective, could you tell us what efforts Ghana has made pre-COVID-19 in mental health integration into UHC, and have these efforts become more urgent since the pandemic?
Akwasi Osei:
We in Ghana have started UHC work even before 1978. By the time of the conference in that year, we had health posts in almost every village.
Initially, mental health was not exactly in line with this level of services, however. Through advocacy, though, we were able to improve the situation, including through the passage of the mental health law. Now, every district and regional hospital has mental health integrated into it. This is a big success.
In regards to COVID-19, the President of Ghana made a pronouncement that the pandemic has shown gaps in our healthcare generally, and specifically in mental health care. In response to this, and to fill the gaps, we will build 94 hospitals across the country. Despite initial scepticism, the President is pushing on with this initiative.
In terms of mental health, we have been able to negotiate that 2 of the hospitals will be psychiatric hospitals. These will be in the “middle” and the “northern” zones of Ghana to extend coverage across the country - all of our current psychiatric hospitals are in the “southern” zone. Apart from that, each of the other new hospitals will have a psychiatric component.
Shekhar Saxena:
Githinji, we know that there is a danger that, as health budgets become more strained due to COVID-19, mental health financing may be cut. What can be done to protect and increase mental health financing at this time?
Githinji Gitahi:
This is very true, and governments are going to struggle with fiscal space. Money is being diverted to finance COVID-19 health activities; and even beyond that, as we will be in a recession, some governments are giving tax breaks to populations (e.g. in Ghana, Kenya, and elsewhere), thus constricting their fiscal space further. As a result, conditions like mental ill health are going to struggle to get domestic funding allocations. It is also the case that, whereas infectious diseases are often supported by donor funding, chronic conditions (including mental health) are not.
A few actions are needed to protect and increase investment in mental health:
Work with governments to institutionalise universal health coverage and its financing. This means that governments need to have policies and legislation that make this social contract real, and deliver this as a right.
Encourage institutionalisation of mental health within the health benefits package that governments are financing, across the spectrum from community all the way to tertiary care.
Ensure that the community is at the centre - it should be a participant in the generation of mental health care, not just its recipient.
Hold governments to account, especially through leveraging people with lived experience, so promises can turn into action.
Shekhar Saxena:
Peter, can civil society provide the mechanism for government accountability, and to what extent is this happening (or is likely to happen) in Ghana?
Peter Yaro:
When it comes to civil society involvement, and to civil society demanding accountability, CSOs should be asking for what should be in place. Sometimes, people in government want to be commended for what little has been done. However, if this is not enough, the government needs to be held accountable by civil society. Indeed, CSOs need to bring to bear a degree of moral accountability to the government.
In Ghana, then, we have closely worked with the Mental Health Authority. Akwasi and his team are a lone voice trying to bring mental health to the government’s attention. Civil society comes in to amplify this voice, and to say to the government that it needs to be listened to. Being an external party to the government, moreover, we are also able to go into those areas that are “out of bounds'' for the Mental Health Authority.
Within the COVID-19 pandemic specifically, civil society has focused on advocating for relief and support to persons living with mental conditions. For instance, we have continued to ask for testing to be extended to people living with mental health conditions; and for mental health services to continue, despite the pandemic response.
Shekhar Saxena:
Devora, is there financial pressure on the WHO, following a country’s withdrawal of funding to the organisation? Are you still able to progress the mental health agenda, and seize the opportunity that COVID-19 might provide?
Devora Kestel:
The issues around mental health are clearly out there and being highlighted by different people, from senior UN authorities, to national governments, to CSOs. As a consequence, I think the opportunity presented by COVID-19 will be translated into action. As you know, our Special Initiative that was launched last year is on UHC and mental health, and as I said before, those countries with better systems are responding better to the mental health challenges of COVID-19. Indeed, I was very pleasantly surprised at the fact that, despite COVID-19, the countries that were involved in the special initiative have been able to move ahead.
Integration is critical. It was critical before, it is critical now. And efforts are going on to ensure that work to integrate mental health into health systems can be funded. (By contrast, I don’t think that any isolated services are likely to be funded.) I hope that soon we will be able to share with you our approaches and ideas to ensure that mental health can be seen as something to invest in.
Shekhar Saxena:
Akwasi, what does success look like for mental health services integration into UHC? What would you be hoping to achieve in one year?
Akwasi Osei:
The President intends to build 94 hospitals - and this is within the next year. As I said before, this means that specialised mental health care will be spread nation-wide, rather than being focused in the south of the country. In addition, every hospital will be able to attend to persons with mental health disorders.
In addition, we expect that every health worker, whether in mental health or not, will be trained in mhGAP, and be able to administer at least first aid mental health care.
We also expect that the availability of psychotropics will improve. This has been a major problem until now.
Finally, we want to ensure financial sufficiency. The key point is that, even if the current funding for mental health is doubled or even tripled, this will still not be enough. So we want to put in place a new sustainable financing mechanism - a mental health levy.
Shekhar Saxena:
This is a very ambitious plan. Peter, what is your ask to Akwasi? If you were in his boots, would you move even further?
Peter Yaro:
We are still to see the design of the hospitals, and whether they have factored in community mental health wings. In recent times, these have not always been included. There is also, for example, a need for continuous professional training of a broader cadre of health workers to ensure that mental health care is not centralised within a small group of overstretched staff. This will be a big upskilling effort.
Ultimately, though, the hospitals would be the icing on the cake. This is a very ambitious scheme, and while it is good to think big, a year is likely not realistic. What we should not lose sight of in the meantime are the more realistic, doable and cost-effective initiatives [such as those at community level].
Shekhar Saxena:
Devora, a question from our audience. What is WHO doing about improving self-care and informal community care for mental health?
Devora:
We have recently created a tool, in the context of COVID-19 (though it can be used in other similar contexts), that was designed to be user-friendly, specific, and deployable at the community level - focused on basic psychological skills for responders. This is the most recent tool of its kind.
We have also created a tool called “Doing what matters in times of stress”. This is another simple, agile, user-friendly guideline to help us do what matters in time of stress. It has been translated into several languages.
Shekhar:
It is worth stressing that the WHO has a number of technical documents, available in many languages, that are worth using. Another question from the audience to Akwasi: what is the role of community health workers, and what are you doing to train them?
Akwasi:
Community health workers - and community mental health generally - are a pivot of our new paradigm. We are moving from centralized to community-oriented care, and are focused on training community workers. Our handicap has been funding the training, but this year we hope we will be able to finance this programme sufficiently.
We are even roping in informal community mental health workers, such as traditional and faith healers, to support our paradigm.
Overall, then, community health workers have a very big role to play in our mental health care system.
Shekhar Saxena:
I now invite the panelists to leave our viewers with a top priority action or message for integrating mental health within UHC.
Githinji Gitahi: Let’s all advocate for UHC financing that is inclusive of mental health financing. We need to realise that, just as there is no UHC without mental health, so there is no mental health without UHC.
Devora Kestel: Antonio Guterres and Dr Tedros have both emphasized the importance of mental health in the COVID-19 response and UHC. I echo those statements, and only add that we need to capture the opportunity to build back better, especially for those affected by the pandemic.
Akwasi Osei: We all need to recognise that mental health care is a collective responsibility: of individuals for self-care, of the community, of government, of civil society. If we can understand this, we will get very far.
Peter Yaro: I reiterate the theme of this webinar, that there is no health without mental health. However, it is key that mental health goes beyond medical considerations. We should find ways to include service users, civil society, and even link up to other sectors in socioeconomic development to realise improved and greater investment in UHC, that would include mental health.
