Mental health requires meaningful integration

Those living with mental health problems can often feel isolated in their communities, particularly in countries where mental health still carries strong stigmatisation. This isolation is reflected in the way mental health is treated within health systems, especially in low- and middle-income countries. While there have been noticeable increases in mental health funding in international development in recent years, the piece of the puzzle that remains incomplete is meaningful integration.

The example of Ghana

One example of this funding is the support DFID have provided to mental health in Ghana as part of their main bilateral health programme, the Health Sector Support Programme. The project aims to improve mental healthcare delivery in Ghana by supporting a stronger policy environment, the scale up of access to treatment in health facilities, psychological support to communities, and a reduction in mental health related societal stigma.

Oxford Policy Management was asked to write a report providing DFID Ghana with accurate, up-to-date qualitative and quantitative information about the results of their investment between 2013 and 2018. The programme reported on four indicators, all of which showed significant improvement (number of trained medical staff able to provide mental healthcare, number of people treated, number of districts providing outpatient mental healthcare, and percentage of patient improvement).

A step in the right direction

Projects like DFID’s are important, and have helped Ghana make large strides, even if there is still progress to be made. The situation in the country has certainly improved. Until recently, mental health patients could only receive treatment at specialist psychiatric hospitals – of which there were three, all in the south of the country. It is important and encouraging that the need for mental healthcare was recognised by the Ghanaian government, but treatment was inaccessible to those living in the north of Ghana, which is also the part of the country with the highest levels of deprivation and vulnerability.

All 216 Districts in Ghana now offer mental health services, in addition several indicators in relation to mental health have been formally incorporated into the national Health Management Information System (DHIMS)). Before this, healthcare was not only difficult for some citizens to access geographically, but the management of information relied upon an informal, stand-alone parallel system. Now, around 50 indicators have been incorporated into the DHMIS of the Ministry of Health; this came relatively late in this particular project, and information about the number of people being diagnosed was being accessed through parallel systems. The process of migrating is ongoing – when complete, it should allow easy access to mental health information.

But more meaningful integration is needed

Lessons from Ghana can be applied to many other low- and middle-income countries in a similar position, and this progress are encouraging – but closer examination shows that integration on paper is not the same as integration in practice. While all 216 districts do now have some form of mental healthcare available to the community, there are varying levels of roll-out and areas that still require attention.

Successful integration might be harder to measure than, say, the number of districts with mental health services – but there are certainly some factors to take into account when ensuring that mental healthcare is meaningfully integrated into a health service. Each of these is symptomatic of meaningful integration – that is, they indicate that mental healthcare needs have been properly and appropriately considered by those who determine healthcare programming in the nation.

• Sufficient capacity

Capacity is a broad term, and its absence can be felt in myriad ways. Having a facility isn’t sufficient without the necessary number of mental health professionals, adequate training and education for those employed, and the necessary equipment and materials to provide mental health services. Access is an equally vital aspect of capacity: in Ghanaian districts largely comprising remote rural areas, it’s still difficult to access the community or vice versa.

• Sufficient supply of psychotropic drugs

Diagnosis is, of course, only useful if recommendations and prescriptions can be acted upon. Ghana (along with many lower-income countries) has an insufficient supply of the psychotropic drugs needed to treat mental health. While drugs can be bought from private pharmacies when there are shortages at government health facilities, this is unfeasibly expensive for most patients. For those patients that do get free access to psychotropic drugs – the frequent stock shortages inevitably hinder their treatment progress

• Sufficient funding

Mental healthcare often is not yet a funding priority in low- and middle-income countries. With many illnesses and conditions to consider, governments have many difficult and competing decisions to make, and may choose to prioritise interventions such as those related to HIV or maternal health, which are more established, have more international consensus, and so on. This can lead to a potential over-reliance on external sources (such as overseas aid) for a significant percentage of their health funding; in turn, this relies upon bodies such as DFID also prioritising funding for mental healthcare.

The future

It’s an important step forward that governments like Ghana have recognised the need for mental healthcare, and have started incorporating it into a national health strategy; it should lead to a fully integrated and accessible mental health system. Many other countries are at a similar or earlier stage of meaningfully integrating mental healthcare into their health systems; where the structures for integration exist, it’s important that they are fully operationalised – and, once operationalised, the government must ensure that it meets need. In any country, it’s vital that this integration is not just in name only.

Kailash Balendran is a consultant within Oxford Policy Management’s health monitoring and evaluation hub. He supports the monitoring and evaluation work across the globe.

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