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Mental health reform: a global perspective on the barriers

A global perspective on the facilitators and barriers to mental health reform has been published in PLoS Medicine, by South African researchers: Why Does Mental Health Not Get the Attention It Deserves? An Application of the Shiffman and Smith Framework.

It examines why mental illness has not achieved visibility, policy attention, or funding, particularly in low and middle income countries, relative to its impact.

The authors use a framework that says a health issue gains political priority when three conditions are met:
(1) national and international leaders publicly and privately express sustained support for the issue;
(2) policies are enacted to address the problem; and
(3) resources (appropriate to the disease burden) are allocated to the issue.

“In the case of mental health, none of these conditions is currently being met in a substantial way,” they say, noting that more than two-fifths of African countries do not have a mental health policy, while WHO data suggest there has been little improvement in mental health care funding over the past decade, particularly in low and middle income countries

The article notes that, proportionally, lower income countries spend a smaller percentage of their health budget on mental health, while in rich countries, when health budgets are cut, quite often the first area to be cut is mental health. In the United States, US$2,100,000,000 has been cut from mental health budgets over the last three years.

The article explores the importance of cohesive leadership, organisational and other networks, and the mobilisation of civil society in order to advocate at national and international levels.

It says that in global mental health, it has been difficult to develop a common construct that can be promoted: “The mental health care community currently lacks a widely accepted framework on the classification, causes, and treatment of mental ill health.”

It says “internal debates” are being presented in the “external” arena of global policy debate, contributing to policy and political leaders’ confusion as to what the priorities for mental health should be, and how to define, measure, and narrow the treatment gap.

The authors state: “These debates should ideally occur ‘internally’, with a more unified position about how to advocate for mental illness when presenting to policy makers, politicians, or donors (the external frame).”

They say global mental health should strive to speak with a united voice: “This includes engaging in frank and open discussion with dissenting voices in order to build a coherent and common language.”

In Australia, meanwhile, Simon Tatz, director of communications at the Mental Health Council of Australia, argues that there is broad agreement in this country about the directions that reform should take.

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Where mental health reform should focus

Simon Tatz writes:

After almost 6 years at the Mental Health Council of Australia (MHCA), the priorities for reform have never been clearer.

There is almost unanimous agreement on the major areas requiring investment and transformation.

If governments are serious about delivering a mental health system that meets the needs of all Australians, most of us agree that they need to:

1.     Substantially increase their investment in mental health services;

2.     Ensure that these services are based on solid research and are evidence-based;

3.     Have in place services that properly reflect the demography and epidemiology of mental illness;

4.     Support housing services for people with a mental illness;

5.     Improve employment support and opportunities; and

6.     Create genuine accountability and quality improvement processes.

Some will have different priorities that reflect their own particular interest; some might add another issue or two, but there would be almost total agreement in the mental health sector that these six things are of the utmost importance.

It’s not true that there is widespread discord or disagreement within the mental health sector about what reforms are needed.

Some may place different emphasis or lobby for a particular focus or sector, but this is experienced in all policy areas.

And even when divergent views do emerge, is this wrong?

The label ‘mental health’ is a misnomer.  The term mental health is really a euphemism for mental illness and ill-health.  In no other field do we use the word ‘health’ to mean ill-health.

I recently saw a document from a health department which interchanged ‘mental health’, ‘mental illness’, ‘mental health consumers’, ‘mentally unwell’, ‘mental health problems’ and ‘mental health issues’.

There isn’t even a consistent and agreed on way to describe people with lived experience in mental illness.  Maybe we should let people decide how they want to be ‘labelled’, if indeed they want to be labelled at all?

An inability to settle on how to describe the sector may seem an insignificant issue but it is critically important when it comes to advocacy and input into government policies.

It’s not a dissimilar situation to the fractured way Indigenous Australians have been labelled by successive administrations: Aborigines, Aboriginal and Torres Strait Islanders, Indigenous Australians and First Australians – and then they point to the divisions and multiple voices among the 100 plus language and tribal groups as evidence of a community beset by apparently competing and conflicting goals and lack of unification.

In an environment characterised by complexity, such as Indigenous or mental health, there are several says to approach reform.

One is for lazy governments to hide behind this confected confusion and succumb to the politics of volume. ‘We hear your many concerns’, says government, ‘and we recognise the various issues, but we can’t possibly fund all of the areas of need, so we’ve chosen to invest in X or Y….’

In this case, X or Y is very often addressing the needs of only the most active, noisiest lobby group and as a consequence,  investment is skewed to a particular service, cause or condition.

Furthermore, saying there are lots of stakeholders with different agendas makes it easy to ignore an advocate or group as being merely one of many voices.

The other approach is actually a lot harder and involves government and its departments building an intimate understanding of the players, the issues and the competing ideas.

The level of expertise needed to establish this level of understanding is sometimes lacking, as evident by the Draft Ten Year Roadmap for National Mental Health Reform, which sets no targets, no goals, no funding parameters and fails to articulate what Australia’s mental health system will look like in 2022.

This is not to denigrate or downplay the hard work and commitment of many in government bureaucracies, however there is a culture that does not engender innovation or ingenuity.  They play it safe and governments are left delivering a morass of rhetorical road maps.

Key issues lie fallow, like mental health promotion.

Governments have never properly funded a mental health anti-stigma campaign.  As I understand it, the line is that there is no one single message to impart in an anti-stigma campaign, so they don’t see the worth of a major investment.

This is true insomuch as research from Canada shows that broad-brush anti-stigma campaigns don’t really work and the best campaigns are those targeted at specific conditions or groups.

Yet governments and NGOs don’t fund awareness campaigns/programs under the overarching banner of ‘cancer’ -  they recognise that different forms of cancer affect and impact on different people and communities; so they initiate targeted campaigns/polices for breast cancer, lung cancer, prostate cancer, skin cancer and so on.

Importantly, public awareness and information relates specifically to the factors affecting each cohort, such as early detection, smoking, protection from the sun, men over 50 etc.

The incredible work of Pink Ribbon Day and the McGrath Foundation and others shows just how important it is to define your specific target group, raise awareness and understanding, and then bring the wider community alongside as you change attitudes and behaviour.

The public is now well aware that someone with breast cancer has vastly different needs than someone with skin cancer, but I’m not so sure they fully understand that a student experiencing stress and anxiety may not necessarily think of themselves as being in the same category as someone with bi-polar disorder or schizophrenia.  They both have a mental illness but the information and services needed are different.

Minister Mark Butler always acknowledges that the cookie-cutter approach in mental health won’t work and that he is well aware that one-size-fits-all policies will fail.

But the evidence to date suggests that too many agencies and departments approach ‘mental health’ as an amorphous problem, rather than recognise that policies, practices and messages need to be tailored and delivered with consumers, carers and communities at the centre and with specific groups and even conditions not lumped into one basket.

The Federal Government is ideally placed to capitalise on the very strong agreement about priorities that now exists in the mental health sector and together with the sector build a more intelligent approach to mental health care in Australia.

 • The views expressed are the author’s and not those of the Mental Health Council.

 

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