Mental Health in
an Unequal World:
Together we can
make a dierence
WORLD FEDERATION
FOR MENTAL HEALTH
wfmh.global • info@wfmh.global
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference.
TABLE OF CONTENTS
A Call to Action for World Mental Health Day 2021
António Manuel de Oliveira Guterres
United Nations Secretary General
SECTION A | A message from the president
President’s foreword
Ingrid Daniels
SECTION B | Introduction
Mental health care for all: let’s make it a reality
Dévora Kestel
Mental health in an unequal world: Together we can make a difference
Gabriel Ivbijaro
SECTION C
International Organisations – Together we can
make a dierence
Why child and adolescent mental health should be on all our minds
Benjamin Perks, Cornelius Williams, Zeinab Hijazi, Emma Ferguson
The International Committee of the Red Cross. Mental Health and Psychosocial Sup-
port Approach
International Committee of the Red Cross
NGO’S making a dierence
Delivering Mental Health in an Unequal World – Making NGO’s Matter
Ingrid Daniels, Johannes John-Langba
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference.
Delivering Mental Health in an Unequal World - Making NGO’s Matter – Some case
examples
Claire Brooks, Kelly Davis, Kathryn Goetzke, Enoch Li, Gill Trevor
Schools, colleges and education – together we can
make a dierence
Supporting young people and promoting their self-esteem during the covid 19 pan-
demic
Zahir Irani
Making medical students and doctor training relevant to delivering mental health in
an unequal world
Marc M.H. Hermans, Christopher Dowrick, Linda Gask, Mohan Isaac, Norman Sartorius
Realising the Astana Declaration and mental health in an unequal world - the role of
family doctors.
Christos Lionis, Sandra Fortes, Alfredo de Oliveira Neto, Tamica Daniels-Williamson, Abdul-
lah al-Khatami, Kim Strong Griswold, Christopher Dowrick.
Leave no-one behind
The role of lived experience in tackling inequalities and improving mental health in
mental health services and beyond.
David Crepaz-Keay
Human Rights and Mental Health Inequality among older persons: Urgent need for a
global convention
Debanjan Banerjee, Gabriel Ivbijaro, Carlos Augusto de Mendonca Lima, Kiran Rabheru
Mental Health Financing in Africa: Building resources to overcome historical ine-
qualities
Crick Lund, Sumaiyah Docrat, Donela Besada
Redesigning Community Psychiatry to rise to the challenge of mental health delivery
in an unequal world
Adrian James, Mohammed Al-Uzri, Agnes Raboczki
The World Psychiatric Association 2020-23 Action Plan
Afzal Javed
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference.
Mental Health in an Unequal World: – Digital Transformation – Leaving No-one Be-
hind
Vishanth Weerakkody, Gabriel Ivbijaro, Lucja Kolkiewicz, Aliki Karapliagkou, Amizan Omar
Sustaining the Political Momentum on Mental Health and Psychosocial Support
Sarah Kline, Maximilien Zimmermann, Alberto Vasquez, Ann Willhoite
SECTION D | Regional Position Statements
“In search for the missing link”: Equality and Equity in mental healthcare in the
Asia-Pacific
Roy Abraham Kallivayalil, Debanjan Banerjee, Hariprasad Ganapathy Vijayakumar, Shu-Jen
Lu
Tackling Social and Health Inequalities to Promote Mental Well-being – A Call to
Action
Ingrid Daniels, Johannes John-Langba, Michael Kariuki, Charlene Sunkel
Introduction Mental Health in an Unequal World- the case of Latin America and the
Caribbean
Gerard Hutchinson
Pediatric Racial/Ethnic Mental Health Disparities in North America
Andres J. Pumariega
Urgent action needed to scale-up mental health services in an unequal world
Wafaa El Sawy, Suhaila Ghuloum, Unaiza Niaz, Jasmeen Ul-Haque, Nisreen Abdel Latif,
Nasser Loza, Khalid Saeed
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference.
Socioeconomic Inequalities and mental health - proposed actions.
The European perspective.
Roberto Mezzina, SP Sashidharan
SECTION E | Thanks
Thanks
Gabriel Ivbijaro MBE JP
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 6
A Call to Action for World Mental
Health Day 2021
ANTÓNIO MANUEL DE OLIVEIRA GUTERRES
United Nations Secretary General
U N I T E D N A T I O N S N A T I O N S U N I E S
THE SECRETARY-GENERAL
--
MESSAGE ON WORLD MENTAL HEALTH DAY 2021
10 October 2021
Around the world, the COVID-19 pandemic is taking a terrible toll on people’s mental
health.
Millions of people face grief over lost family members and friends. Many more are
anxious over unemployment and fearful of the future. Older people may experience isolation and
loneliness, while children and adolescents may feel alienated and distressed.
Without determined action, the mental health impact may last far longer than the
pandemic itself.
We must act to redress the glaring inequalities exposed by the pandemic – including the
inequality in access to mental health services.
In high-income countries, over 75 percent of people with depression report that they do
not receive adequate care.
And in low- and middle-income countries, over 75 percent of people with mental health
conditions receive no treatment at all.
This is the direct consequence of chronic under-investment, as governments spend an
average of just over 2 percent of their health budgets on mental health.
This is unacceptable.
At long last, we are beginning to see recognition that there can be no health without
mental health.
Member States have endorsed the World Health Organization’s updated Comprehensive
Mental Health Action Plan.
The United Nations family, together with partners across the global mental health
community, are introducing new guidelines and developing new tools to improve mental health.
These are positive steps – but we have a long way to go.
On World Mental Health Day and every day, let us commit to work together with
urgency and purpose to ensure quality mental health care for all people, everywhere.
SECTION A
A message from the president
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 8
President’s foreword
DR INGRID DANIELS
President of the World Federation for Mental Health
World Mental Health Day, a programme of the World
Federation for Mental Health (WFMH), provides us
with the opportunity to raise awareness about glob-
al mental health concerns, disparities, inequities
and social injustices which prevail and impact on
the mental health of all. The WFMH rst launched
World Mental Health Day in 1992 with the support
of the World Health Organisation and Carter Center
as active partners for this global event. World Men-
tal Health Day creates the opportunity for everyone
to call for action and advocate for an equitable
mental health dispensation for all global citizens. It
provides the global community with an opportunity
to come together and raise our concerns and advo-
cate for solutions and redress.
This year’s theme “Mental Health in an Unequal World: Together we can make a difference” was
chosen by a global vote reecting the feelings, views and concerns of the global community about
the position of mental health in our world today.
Historically, mental health has been less favoured and under-prioritised creating huge treatment
gaps and disparities in mental health care. Inequalities in mental health have deprived many people
with a lived experience of mental disorders from living fully integrated and dignied lives. The
relationship between equity and mental health is well understood however little has been done to
address the inequities and disparities. The world is increasingly polarised, with the wealthy becom-
ing wealthier while the number of people living in poverty notably increasing. The increase in pov-
erty and its devastating social determinants for mental health has been further exacerbated by the
socio-economic impact of the COVID-19 pandemic. Growing inequalities due to race and ethnicity,
sexual orientation and gender identity, lack of respect for human rights and, stigma and discrimina-
tion against people with mental health conditions have created visible societal divide and injustic-
es. Such inequalities have had a direct impact on peoples’ mental health in every country.
This theme chosen for 2021 will highlight that mental health care and the inclusion of persons
with mental disorders in all spheres of life remain unequal. It is a well-known fact that 75% to 95%
of people with mental disorders in low- and middle-income countries are unable to access mental
health care at all and access in high income countries is not much better. The COVID-19 pandemic
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 9
has exposed those social determinants of mental disorders and inequalities in our society which
result in the negative consequences for mental health. Health inequities are grossly unfair and
unjust often violating human rights and fails to protect of the most vulnerable. The inequalities in
mental health care can no longer be ignored. We require regional, country and individual commit-
ment to address the harm caused by the layers of systemic and historical inequalities and injustic-
es which impact of the mental health of all.
The excellent contributions received for this year’s WMHD educational materials will provide us
with the necessary information, insight into the challenges and disadvantages caused by these ine-
qualities and will assist in strengthening and recommending strategies and calls for greater equity.
All our efforts and collaboration in raising awareness on WMHD will unite us to place the spotlight
on our global concerns. This is our moment to coherently create global awareness and move for-
ward the solutions. Mental health is everyone’s business and together we have a responsibility to
make a signicant difference and create a world where there is mental health equity, equality and
social justice for all. A world in which every global citizen is protected, respected and able to live
their lives with dignity.
“Achieving health equity requires removing obstacles to health such as poverty,
discrimination, and their consequences, including powerlessness and lack of access
to good jobs with fair pay, quality education and housing, safe environments, and
health care.” Robert Wood Johnson Foundation (2019)
SECTION B
Introduction
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 11
Mental health care for all:
let’s make it a reality
DÉVORA KESTEL
Director, Mental Health and Substance Use
World Health Organization
By 10 October 2021, the world will have grappled
with the COVID-19 pandemic for over 18 months.
Billions of people have been affected. Many people
face economic turmoil, having lost their incomes
and livelihoods. Countless have struggled with
serious concerns about their physical health, or
the health of those they love. There has been wide-
spread fear of infection, death and loss of family
members. Numerous individuals and families have
been distanced from their social support networks
and communities. Throughout the pandemic, we
have seen the consequences of these issues on
people’s mental health, and each of us understands
how COVID-19 has impacted our well-being.
Still, these impacts have not been evenly distributed. We know that many groups are at greater
risk. Health-care and other frontline workers and rst responders have been frequently exposed
to complex stressors in overwhelmed systems. Children and adolescents continue to be forced to
adjust to disrupted education and remote learning. People living with physical and mental health
conditions have faced both disruptions in care and exacerbation of existing conditions. And people
caught up in fragile humanitarian settings confront incredible adversity compounded by the pan-
demic. Moreover, while many countries today are experiencing slow returns to some normality, with
social spaces re-opening, restrictions loosening and access to and uptake of vaccination increas-
ing, others continue to struggle with increasing rates of transmission and overwhelmed hospitals
and health systems.
COVID-19 has put the spotlight on the inequality that exists all around us. One example is the
unequal access to mental health care. Across the world, far too few people have access to quality
mental health services. In high-income countries, nearly 75% of people with depression report not
receiving adequate care. In low- and middle-income countries, more than 75% of people with men-
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 12
tal health conditions receive no treatment at all for their condition. Despite these inequalities, gov-
ernments spend on average just over 2% of their health budgets on mental health and international
development assistance for mental health has never exceeded 1% of development assistance for
health.
Yet, in the face of these grim realities, there remains reason for hope. Momentum is growing in-
ternationally to advance the mental health agenda and governments around the world have rec-
ognized that access to these services must be scaled up at all levels. In May 2021, this sentiment
was ocially expressed with the World Health Assembly’s endorsement of the updated appendi-
ces of the World Health Organization’s Comprehensive Mental Health Action Plan, now extended to
2030. This plan extends and builds upon the ambitious objectives laid out in its predecessor and
represents a renewed commitment to take action on mental health from nations around the globe.
In endorsing this updated Action Plan, Member States agreed to targets relating to expansion of
service coverage, increasing the number of community-based mental health facilities and integrat-
ing mental health into primary care.
In addition, they agreed to develop and strengthen mental health services and psychosocial sup-
port as part of universal health coverage and in preparedness and response to emergencies, with
a particular focus on improving the understanding and acceptance of mental health conditions,
vulnerable populations and use of innovative technologies. This represents one of many powerful
calls to action during the pandemic that have been made to bring about equal and universal access
to mental health services for those in need. Others include those of the United Nations Secre-
tary-General, numerous heads of state and government, UN agencies, nongovernmental organiza-
tions and countless professional associations, civil society actors, and community-based groups.
The collective voice and support for mental health is loud and growing.
Fortunately, many of the tools, approaches and strategies necessary to increase access to mental
health care are already available and have been shown to be effective when there is active engage-
ment, commitment and investment. Throughout the pandemic, we have seen numerous examples
of countries already taking action to improve access to quality and effective mental health services
despite the challenges of COVID-19. Many have continued the upward trajectory that began well
before COVID-19, sometimes many years before, to improve the mental health care available to
their populations. Meanwhile, others have been motivated to act by the immense suffering brought
on by the past 18 months. Throughout, innovative and scalable solutions have been developed to
promote access. These initiatives represent key advances in the global effort to increase quality
mental health care.
Nonetheless, there remains much work to be done. We must seize this historic opportunity for
action with both hands and not let go. Mental health cannot be ignored any longer.
On World Mental Health Day, the focus on mental health is global. It is an opportunity for all those
of us with responsibility for improving access to mental health care to take a critical look at what
we can do better. It is a time to listen to the experiences of people from across the world who have
been doing their best to take care of their mental health in the most challenging of circumstances.
And it is a day to look around us and offer our support to people who are struggling.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 13
Mental health care for all: let’s make it a reality.
• World Mental Health Day 2021 website
https://www.who.int/campaigns/world-mental-health-day/2021
• WHO Comprehensive Mental Health Action Plan 2013-2030
https://www.who.int/publications/i/item/9789240031029
• WHO mental health website
https://www.who.int/health-topics/mental-health#tab=tab_1
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 14
Mental health in an
unequal world: Together
we can make a dierence
PROFESSOR GABRIEL IVBIJARO MBE JP
WFMH Secretary General
The theme for World Mental Health Day 2021
‘Mental Health in an Unequal World: Together We
Can Make a Difference’ is very important because
of the global challenges that we all face.
This theme was chosen by a global vote includ-
ing WFMH members, stakeholders and support-
ers because the world is increasingly polarized,
with the very wealthy becoming wealthier, and
the number of people living in poverty still far
too high. 2020 highlighted inequalities due to
race and ethnicity, sexual orientation and gender
identity, and the lack of respect for human rights
in many countries, including for people living with
mental health conditions. Such inequalities have
an impact on people’s mental health. Poverty,
described by the WHO in 1995 as ‘The world’s most ruthless killer and the greatest cause of suffer-
ing on earth’ continues. The gap between the rich and the poor continues to widen, irrespective of
nation and we cannot continue to turn a blind eye.
We know that access to mental health services remains unequal, with between 75% to 95% of
people with mental disorders in low- and middle-income countries unable to access mental health
services at all. Access in high income countries is not much better. In addition, lack of investment
in mental health is disproportionate to the overall health budget and contributes to the mental
health treatment gap.
Many people with a mental illness do not receive the treatment that they are entitled to and de-
serve. Mental health service users together with their families and carers continue to experience
stigma and discrimination. The gap between the ‘haves’ and the ‘have nots’ grows ever wider and
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 15
there is continuing unmet need in the care of people with a mental health problem.
Research evidence shows that there is a deciency in the quality of care provided to people with a
mental health problem. It can take up to 15 years before medical, social and psychological treat-
ments for mental illness that have been shown to work in good quality research studies are deliv-
ered in everyday practice to the patients that need them.
The stigma and discrimination experienced by people who experience mental ill health not only
affects that person’s physical and mental health, stigma also affects their educational opportuni-
ties, current and future earning and job prospects, and their families and loved ones. This inequality
needs to be addressed because it should not be allowed to continue. We all have a role to play to
address these disparities and ensure that people with lived experience of mental health are fully
integrated in all aspects of life.
People who experience physical illness often experience psychological distress and mental health
diculties. An example is visual impairment. Over 2.2 billion people have visual impairment world-
wide, and the majority also experience anxiety and/ or depression and this is worsened for visually
impaired people who experience adverse social and economic circumstances.
The COVID 19 pandemic has further highlighted the effects of inequality on health outcomes. No
nation, however rich, has been fully prepared for this. The pandemic has and will continue to affect
people, of all ages, in many ways: through infection and illness, sometimes resulting in death bring-
ing bereavement to surviving family members; through the economic impact, with job losses and
continued job insecurity; and with the physical distancing that can lead to social isolation.
We need to act, and act urgently.
The 2021 World Mental Health Day campaign ‘Mental Health in an Unequal World’ provides an op-
portunity for us to focus on the issues that perpetuate mental health inequality locally and globally.
We want to support civil societies to play an active role in tackling inequality in their local areas. We
want to encourage researchers to share what they know about mental health inequality including
practical ideas about how to tackle this.
When WFMH was formed in 1948 the world had emerged from war and was in major crisis and
much of this was tackled by collaboration between WFMH, WHO, UN, UNESCO and other global
stakeholders and citizens with an interest in mental health wellbeing.
We are again in the midst of another global crisis that is resulting in widening health, economic and
social inequalities. The 2021 World Mental Health Day campaign provides an opportunity for us to
come together and act together to highlight how inequality can be addressed to ensure people are
able to enjoy good mental health.
Be a partner, be an advocate.
SECTION C
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 17
Why child and adolescent
mental health should be
on all our minds
BENJAMIN PERKS
Head of Thematic Advocacy, UNICEF
CORNELIUS WILLIAMS
Associate Director Child Protection, UNICEF
ZEINAB HIJAZI
Senior Mental Health Technical Adviser, UNICEF
EMMA FERGUSON
Mental Health Advocacy Lead, UNICEF
COVID-19 illuminates the urgency of a global and population-wide approach to child and adoles-
cent mental health. Three key ideas have converged to forge a path forward. 1) The evidence is
overwhelming that early risk for lifelong poor mental health is much more widespread than previ-
ously thought. 2) The societal costs of inaction in childhood are life-lasting and substantial. 3) We
are more equipped now than at any time in history to dramatically reduce risk factors in child and
adolescent populations.
Children only thrive when they feel safe and protected, when family and community connections
are stable, and when their basic needs are met. Poverty, Adverse Childhood Experiences (ACEs)
and humanitarian crises are seriousthreats to this primary attachment. A dense network of rela-
tionships in the family, community, and school provides a second buffer against risk factors for
mental health issues in children. This secondary attachment is important for all children and espe-
cially for those where the attachment with a primary caregiver is either absent or inconsistent.
Around the world, mental disorders among children and adolescents are far more prevalent than
previously thought. Diagnosable mental health conditions affect about one in seven (14 per cent)
of children and adolescents aged 6–18. A fth of adolescents aged 12–18 have a mental health
condition. Suicide is tragically claiming the lives of up to 700,000 people every year (1 person every
40 seconds) and it is the fourth leading cause of death among young people aged 15–19. And we
know that half of all mental health conditions start by 14 years of age, but most cases, while treata-
ble, go undetected and unmanaged.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 18
Global vaccine coverage against childhood disease leaped from 20% to 80% in the 1980s and led
to a dramatic reduction in child mortality. The departure point for that leap was a recognition that
most child death in the world had been rendered preventable by advances in science and technolo-
gy. Today we have enough evidence to recognize that many of the risk factors in childhood for poor
mental health are also preventable. This is rst and foremost a human and child rights and public
health imperative. It also makes huge sense economically in terms of potential for productivity and
learning, but also for prevention of associated costly social problems such as addiction, violence,
and crime.
If we could agree on a low cost, evidence-based essential package of parenting support, we could
potentially disrupt the inter-generational transmission of adversity and equip parents to protect
children impacted deeply by poverty, humanitarian crises, and other severely distressing events or
experiences. Such a package would include skills, problem-solving and self-awareness delivered in
real time with primary caregivers and infants, starting during pregnancy and with a particular focus
on the early years, and followed up at key stages during the development cycle-including adoles-
cence. This could be reinforced by an intentional policy of building kindergarten, school and com-
munity commitments to ensure all children are seen, soothed and safe and have the conditions of
connection and belonging.
To achieve these two population-level objectives and provide tailored services that support varying
and often complex needs, governments should prioritise investment in mental health for children.
This means investing in competent mental health and psychosocial support workforce across
health, education, and social services, to leverage a whole-of-society approach to mental health
prevention, promotion and treatment. On the continent of Africa, one mental health worker is avail-
able for every 100,000 citizens for example, yet we know that mental health makes up 30% of the
non-fatal global disease burden according to WHO. International development assistance that pri-
oritises mental health can also help break the cycles of conict and instability that hinder progress.
Increased expenditure is essential. Alone, it is not enough. We also need increased conversation,
trust and understanding of mental health, but also real action, particularly in many middle and
low-income countries where there have been limited public conversations about mental health. We
need global and community level conversations that takes away the shame, judgement and stigma,
promotes understanding and knowledge, and helps communities and families understand and take
action to promote child and adolescent protective factors and focus on effective family and com-
munity-based solutions.
In collaboration with partners such as WHO, UNICEF has made mental health an advocacy prior-
ity across 190 countries. We support the advocacy with concrete technical support to countries
implementing policy shifts and reforms that protect the mental of children and their caregivers. For
example in Ecuador, UNICEF has developed safe parenting support groups, which aim to increase
awareness on the importance of preventing violence against children, as well as how to deal with
anxiety and stress and how to develop safe spaces at home to talk to and support their children.
We are also tackling the challenge of stigma. Following the Beirut blast in Lebanon, UNICEF prior-
itized child and adolescent mental health, working closely with the National Mental Health Program
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 19
(NMHP), integrating mental health into school curriculums for adolescents, as well as developing
a training guide for social workers to address mental health and psychosocial needs of children,
adolescents and families. UNICEF also worked with the NMHP to address stigma surrounding child
and youth Mental Health, organizing eight interactive sessions with youth on coping with COV-
ID-19- reaching an estimated 2 million people.
Alongside key partners, UNICEF played a leading role in building interagency understanding of the
impacts of COVID-19 and consensus on the strategic response interventions for the protection of
children and on the mental health and psychosocial wellbeing of children, caregivers, and frontline
workers.
The COVID-19 pandemic has underscored just how critical mental health and well-being are for
all children, adolescents, caregivers and families, in all countries. But the magnitude of the mental
health burden the world faces is simply not being matched by the response it demands.
In October, building up to World Mental Health Day, we will launch our agship State of the World’s
Children Report at the Global Mental Health Summit in Paris and will be calling on governments to:
• Commit to increase investment in child and adolescent mental health across all
sectors, not just in health, to support a whole-of-society approach to mental health
prevention, promotion and care.
• Promote connection, through integrating and scaling up evidence-based interventions across
health,educationand social protections sectors - including parentingprogrammesthat pro-
mote responsive, nurturing caregiving and support parent and caregiver mental health; and
ensuring schools support mental health through quality services and positive relationships.
• Communicate, by taking a leading role in breaking the silence surrounding mental health,
through addressing stigmas and promoting mental health literacy, andengaging children
andyoungpeople in policy andprogramme design and implementation.
Like the vaccine movement of the 1980s we need a focused global push to end preventable risk for
all children everywhere, especially the most vulnerable. We hope many of you will join us in deliver-
ing that outcome.
In October, UNICEF will launch our agship State of the World’s Children Report, providing a compre-
hensive analysis and examination of child and adolescent mental health. Read the report from 5th
October: http://www.unicef.org/reports/state-of-worlds-children-2021
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 20
The International
Committee of the Red
Cross. Mental Health and
Psychosocial Support
Approach
-
mental healthcare that meets universally recognised standards. The ICRC aims to address mental
of individuals and communities in a culturally appropriate and multidisciplinary way.
Introduction
Mental health conditions are among the leading causes of ill-health and disability worldwide (Rehm
& Shield, 2019). In armed conicts and other situations of violence, these rates can increase such
that prevalence rates of mental health conditions (depression, anxiety, post-traumatic stress disor-
der, bipolar disorder, and schizophrenia) are estimated to be 22% at any point in time in conict-af-
fected populations (Charlson et al., 2019). In developing countries, health systems face many chal-
lenges, which can worsen in situations of armed conict and/or violence. Conict also contributes
to degraded living conditions, and this adds to mental health and psychosocial support needs. As a
result, people affected by armed conict and other situations of violence can develop new mental
health conditions, and/or pre-existing mental health and psychosocial needs may resurface or be
exacerbated.
Access to mental health care is unequally divided. Research has also shown that the ratios of
psychiatrists per capita in the Global North are around 10-16 per 100,000; in contrast, the numbers
of psychiatrists in Africa are 0.33 per 100,000; Western Pacic around 0.32; and Southeast Asia
around 0.2 (Jenkins et al., 2010). As a result, there is no equity of access.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 21
The International Committee of the Red Cross
response to mental health and psychosocial needs
The International Committee of the Red Cross (ICRC) works to ensure that people affected by
conict and other situations of violence have access to mental healthcare[1] that meets univer-
sally recognised standards. In 2020, ICRC ran over 230 mental health and psychosocial support
(MHPSS) projects worldwide. These programs were adapted to support the specic needs of the
people impacted by the negative effects of the COVID-19 pandemic. ICRC also developed new
MHPSS support services, such as, a hotline in Gaza for people affected by COVID-19.
The ICRC MHPSS teams operate under a set of established guidelines (ICRC, 2017). The guidelines
provide an organisational framework to implement a combination of international evidence-based
mental health recommendations with best practices from the expertise of ICRC working in various
contexts of armed conict and other situations of violence around the world.
The ICRC aims to address psychological and psychosocial needs, promote coping mechanisms, in-
crease functioning and decrease psychological distress. MHPSS teams work in an integrated way
to address the needs at individual, family and community levels. Using this aim, in December 2019,
a Movement-wide MHPSS Policy was adopted at the 33rd International Conference [2] of the Inter-
national Red Cross and Red Crescent Movement[3]. This Policy provides a framework for MHPSS
work and differentiates between basic psychosocial, focused psychosocial, psychological support
and specialized mental health care. See Figure 1 for the framework. The framework encompasses
the continuum of care from social support to psychiatric support, adapting the interventions at
each level.
Figure 1: The Movement’s mental health and psychosocial support framework (International Red
Cross and Red Crescent Movement, 2019)
The ICRC ensures programs are adapted to the cultural contexts and have a multidisciplinary
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 22
approach. This approach is achieved by regularly consulting the affected individuals and communi-
ties in order to better determine their needs and interests. This approach ensures that the activities
are adapted to the local culture and delivered in a manner that promotes dignity, and respects reli-
gious and cultural practices. ICRC works in a multidisciplinary way with other ICRC services, such
as primary health care, hospital services, physical rehabilitation, rst aid and pre-hospital services,
healthcare in detention, water and habitat, weapons contamination, and economic security. As a
result of the ICRC mandate, MHPSS also works together with protection teams that foster preven-
tion activities and the implementation of international humanitarian law (IHL). The ICRC’s MHPSS
programs aim to build local capacities by training community stakeholders, resident psychologists
and/or other mental health practitioners, depending on the context. ICRC’s focus is on training,
supervision, follow-up, monitoring and evaluation to ensure capacity building of national resources
and workforce and sustainability after ICRC leaves the context.
Mental health and psychosocial support
programmes: healing the hidden wounds
The ICRC’s mental health and psychosocial support projects respond to the needs of different
groups affected by armed conict and other situations of violence. These groups include people
affected by emergencies; victims of violence, including sexual violence and children; families of
missing persons; helpers (people in frontline humanitarian positions); people who are hospitalised
with weapon-wounds and/or physical disabilities; and people deprived of their liberty and/or former
detainees. Individuals across these groups present various mental health and psychosocial con-
sequences of violence. For example, trauma-related symptoms from being directly injured or due
to exposure to violence, or psychological distress such as symptoms of depression and anxiety.
It can also affect community functioning by decreasing the availability of services, resources and
support.
Violence can also be used by armed groups with the intention of spreading fear, creating an en-
vironment of chaos, and breaking down community cohesion. Affected individuals can feel emo-
tionally and socially isolated; they may also feel that no-one understands their suffering and that
they are unable to reach out for help. In many contexts, mental health and psychosocial needs are
not well understood and as a result people can face rejection, discrimination and stigmatization.
This makes it dicult for them to get the assistance they need and leaves them more vulnerable to
further ill-treatment.
The ICRC has developed mental health and psychosocial projects according to the MHPSS frame-
work:
• Mental health activities: − basic psychological support (individual and group) − psychothera-
peutic support (individual and group) − specialized care and referrals
• Psychosocial support activities: − psychosocial group activities − information and sensitisation
activities – referral pathways
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 23
Conclusion
Although MHPSS needs have gained more prominence in recent years, there remains a large gap
between the needs and the access to care provided worldwide (WHO, 2017). The ICRC aims to
reduce this gap by building local capacities, with a view to stabilising and improving the mental
health and psychosocial well-being of individuals and communities. In 2020, ICRC MHPSS projects
reached more than 554,000 beneciaries globally.
Note: The ICRC’s Guidelines on Mental Health and Psychosocial Support are available from the
ICRC’s online shop. They can be downloaded free in English, French Arabic, Spanish, Russian and
Portuguese.
References
• Charlson, F., van Ommeren, M., Flaxman, A., Cornett, J., Whiteford, H., & Saxena, S. (2019). New WHO prevalence
estimates of mental disorders in conict settings: a systematic review and meta-analysis. Lancet, 20:394(10194),
240-248.
• International Committee of the Red Cross (2017). Guidelines on Mental Health and Psychosocial Support. Geneva:
ICRC.
• International Red Cross and Red Crescent Movement (2019): International Red Cross and Red Crescent Movement
policy on addressing mental health and psychosocial needs. Council of Delegates of the International Red Cross and
Red Crescent Movement Resolution Dec 2019 CD/19/R5, Geneva: ICRC.
• Jenkins, R., Kydd, R., Mullen, P., Thomson, K., Sculley, J., Kuper, S., et al. (2010). International migration of doctors,
and its impact on availability of psychiatrists in low- and middle-income countries. PLoS ONE, 5(2).
• Rehm, J. & Shield K.D. (2019). Global burden of disease and the impact of mental and addictive disorders. Current
Psychiatry Reports, 7, 21(2),10.
• World Health Organization. (2017). Depression and Other Common Mental Disorders. Geneva: WHO.
Notes
1. The ICRC uses the term “mental health” to denote psychological well-being. Mental health interventions aim to im-
prove psychological well-being by reducing levels of psychological distress, improving daily functioning and ensuring
effective coping strategies. Such interventions are overseen by a mental health professional and target individuals,
families and/or groups.
2. The International Conference is a global forum that highlights dialogue and partnership between the ICRC, the Feder-
ation and all National Societies and States Parties to the Geneva Conventions. During this time, humanitarian issues
of common interest are discussed and decided together.
3. The International Red Cross and Red Crescent Movement comprises the ICRC, the International Federation of the
Red Cross (IFRC) and the National Societies around the world.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 24
Delivering Mental Health
in an Unequal World –
Making NGO’s Matter
DR INGRID DANIELS
President, World Federation for Mental Health
PROF JOHANNES JOHN-LANGBA
Academic Leader of Research and Higher Degrees. School of Applied Human Sciences, University
f Kwazulu-Natal, South Africa.
Introduction
Non-governmental organisations (NGOs)[1] have played a signicant role in providing mental
health services often in dire socio-economic conditions and resource poor communities where
poverty levels are alarming. Mental Health NGOs are either constituted as formal or informal
organisations and are regulated under various legal frameworks. Even though no accurate data is
available regarding the number of NGOs on the African continent, their work remains vital particu-
larly since their parallel interventions to address mental health needs within communities have also
focused on providing interventions to address the social determinants of mental health and com-
munity development. These NGOs have for many years lled the gap and provided mental health
interventions where governments have failed to intervene to ensure that access to mental health
care is made available.
Mental Health NGOs are largely driven by their mission, vision and objectives and human rights ap-
proaches to ensure equity and social justice to the most marginalised and vulnerable people. Their
role has often been to challenge the inequalities, lack of access and limited investment in mental
health and to hold governments responsible to ensure equality in care. They are often formed
voluntarily by ordinary people, parents and others when gaps in mental health services, neglect in
care, discrimination and violations against those with mental health needs are perpetrated.
Effective paradigm shifts in providing accessible bio-psychosocial community-based interventions
can only be achieved by working strategically in an integrated mental health services delivery mod-
el, which includes strategic partnership arrangements with NGOs. NGOs are also able to engage
easily and respectfully with service users, carers, traditional healers and community leaders/struc-
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 25
tures required to implement effective multi-sectoral approaches to integrate and sustain communi-
ty-based mental health programmes.
Regulatory Framework
Most formal NGOs are legally constituted and regulated according to every country’s specic legal
requirements and frameworks. Even though they operate independently, they are governed by and
function under government departments such as those of social development, welfare (or both)
and health.
In South Africa, a non-prot organisation (NPO), also known as an NGO, is registered with the
Non-prot Directorate and regulated by the South African Non-prot Organisations Act No. 71 of
1997. [1]. The Act denes a non-prot organisation as “a trust, company or other association of
persons – established for a public purpose; and the income and property of which are not distrib-
utable to its members or oce-bearers except as reasonable compensation for services rendered”
(RSA Non-prot Organisations Act No. 71 of 1997, p. 2).
Organisations operating within this legal framework are part of civil society and are established
not-for-prot or gain. NGOs function independently, but may deliver essential humanitarian servic-
es on behalf of, and in partnership with, State entities and may or may not receive State subsidies.
These subsidies generally provide partial funding and do not necessarily consider annual ination-
ary escalations, resulting in the NGOs having to carry the cost and nancial burden for the imple-
mentation of the mental health and other services. In South Africa, the value of these subsidies
varies from one provincial department to another and is inconsistently allocated. However, many
NGOs across Africa operate with little State support, if any.
Role of Mental Health NGOs in Providing Mental
Health Care
Mental health NGOs play a signicant role in implementing community-based mental health servic-
es. A national study conducted in 2018 explored the perceptions about NGOs as critical partners
for mental health provision [2]. The study, which recruited social workers from the 17 mental health
NGOs aliated with the South African Federation for Mental Health noted the following as shown
in Figure 1.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 26
Figure 1: NGOs as Critical Partners in Mental Health Service Provision
Figure 1, highlights that the majority of social workers (97.3%, n=106) agreed that mental health
NGOs contribute signicantly to community-based mental health programmes. It also indicates
that the majority of social workers (96.8%, n=106) agreed that social workers actively promote
patient-centred care interventions, whilst 86.3% (n=94) agreed that a strengths-based approach,
which recognises the abilities of service users, is actively promoted.
Mental health social work practice focuses less on the diagnosis, problems and limitations asso-
ciated with the condition and more on functional abilities and supportive interventions - a prac-
tice which identies and strengthens abilities and capabilities. In so doing, this links the abilities
of users with opportunities for recovery and reintegration. Hensley [3] stated that “Adherence to
patient-centred care has also been associated with higher satisfaction and in some cases better
outcomes in terms of patients’ experience of physical symptoms and adherence to care regimens”
(p. 135). Patient-centred or user-centred care places the mental health service user at the centre of
the intervention and fosters empowerment, respect, joint decision-making and dignity for the user,
despite their diagnosis, educational level and social circumstances.
Figure. 1 above shows that the majority of social workers (88.5%, n=91) agreed that families of
mental health service users received signicant support from mental health NGOs, whilst a major-
ity (94.9%, n=103) agreed that mental health service users received signicant support from their
social workers.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 27
Pathways to Care
Mental health NGOs play a vital and signicant role in the expansion and delivery of communi-
ty-based mental health interventions. The service delivery objectives of these organisations include
the ideal of comprehensive community-based mental health services but a lack of funding con-
strains their interventions. NGOs tend to focus mainly on counselling, mental health awareness and
promotion, and running protective workshops. As shown in Table 1, mental health NGO initiatives
in Africa are wide ranging including mental health advocacy, education, promotion, livelihood and
community-based treatment and prevention.
Table 1: Selected Mental Health NGO Initiatives in Africa
• Co-ordinating community mental health volunteers and “grandmother” counsellors;
• Selecting, training and supervising peer counsellors;
• Implementing Psychosocial Rehabilitation groups in districts/communities;
• Collaborating with non-specialist health workers, traditional structures, village committees and
primary health care clinics;
• Training other NPOs working in resource-poor communities to provide counselling and other
psycho-social interventions with back-up tele-mental health social work and or Skype support
to these NGOs;
• Strengthening advocacy groups and empowerment networks;
• Providing public education and awareness campaigns in partnership with service user advoca-
cy bodies – these could be initiated through school awareness programmes, embedding men-
tal health in the Life Orientation Curriculum, Mental Health Apps, radio, talking books, mobile
clinics and other awareness strategies;
• Offering MindMatters Programmes –comprehensive whole-school mental health intervention
and prevention programmes;
• Engaging in lobbying and advocacy for the rights of service users;
• Collaborating with other State or NPOs to ensure holistic service provision;
• Improving collaboration with the police and justice system;
• Initiating collaborative poverty alleviation and food sustainability projects with Agri partners
• Facilitating employment opportunities through self-employment initiatives, supported employ-
ment, Learnerships, transitional employment and independent initiatives;
• Participating in district and provincial multi-sectoral mental health structures to co-ordinate
mental health services.
The aforementioned initiatives are delivered in dynamic, rich and inclusive intervention expansion
models tailored for limited-resource settings.
NGOs have greater exibility to design and develop best practice innovative mental health services
and are not limited by the bureaucracy that is characteristic of State entities. Within these path-
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 28
ways of care, good practices have emerged to upscale and increase access to mental health par-
ticularly during the COVID-19 pandemic. Cape Mental Health, the oldest mental health NGO based
in Cape Town, South Africa is one such organisation where innovative practice to increase access
to resource poor communities has excelled in this regard.
Despite the challenges and initial dislocations in social and health care critical best practice inter-
ventions have emerged. The pandemic created the opportunity to shift, reinvent and reorganise
the way in which Cape Mental Health provided mental health care from facility to home and face
to face counselling to virtual interventions to retain contact, reduce isolation and continue virtual
interactions with beneciaries and all who required mental health support. Cellular phone appli-
cations, virtual IT technology and other platforms became vital tools for migrating daily mental
health services remotely to over 6000 beneciaries. Online counselling, COVID-19 crisis and case
management were provided by a dedicated team of social workers. Another example of the daily
virtual activations, at Special Education and Care Centres for children with severe and profound
intellectual disability, were identied as a best practice mental health innovation during the COV-
ID-19 pandemic by the Mental Health Innovations Network [4]. Interventions by social and health
professionals need to be revised and an exchange on further innovative alternatives stimulated to
address some of the huge inequalities.
Another best practice intervention is the Zimbabwean Friendship Bench Project, a mental health
innovation provided by lay “grandmother counsellors” also known as “gogos” who provided mental
health problem-solving interventions on village or park benches outside primary health care (PHC)
clinics to over 27 000 individuals with common mental disorders. These are offered mostly to
individuals who would ordinarily not seek assistance. This low-cost intervention has been highly
successful, consistent with evidence from a study by Chibanda and colleagues [5] that found that
“Patients with depression or anxiety who received problem-solving therapy through the Friendship
Bench were more than three times less likely to have symptoms of depression after six months,
compared to patients who received standard care” (p. 2618).
Conclusion
It is apparent that neither State departments nor mental health civil society organisations are
able to provide comprehensive mental health services as independent entities. Multi-sectoral
district-based mental health approaches are required to co-ordinate and include all role players,
particularly mental health service users, in mental health service delivery to effectively address the
injustices in mental health. This would bring together both medical as well as social approaches to
care, thus supporting integrated comprehensive community-based models that underpin recovery
in mental health [6]. Mental health NGOs evidently contribute signicantly to community-based
mental health programmes and contribute a wealth of innovative interventions that promote
patient-centred care and strengths-based approaches. Their interventions are culturally-sensitive
and tailor-made to the context of local communities and cultures. Their interventions are often
multipurpose and cost effective in addressing the inequalities and social injustices experience by
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 29
people with the lived experience.
References
1. Government of South Africa (1997). Non-prot organisation Act, No.71 of 1997. Pretoria: Government of South Africa.
Available: http://www.info.gov.za/view/DownloadFileAction?id=70816.
2. Daniels, I. (2018). An investigation into mental health care decits in South Africa: Exploring an alternative intervention
strategy. Unpublished Doctoral Thesis. South Africa: University of Cape Town
3. Hensley, M., A. (2012). Patient-Centred Care and Psychiatric Rehabilitation: What’s the Connection? International
Journal of Psychosocial Rehabilitation, 17(1), 135–141. Available: http://www.psychosocial.com/IJPR_17/Patient_
Centered_Care_Hensley.html.
4. Mental Health Innovation Network [MHIN] (2021). Mental health in Africa: A global Community of Mental Health
Innovators. Available: https://www.mhinnovation.net
5. Chibanda, D., Helen A., Weiss, D., Verhey, R., Simms, V., Munjoma, & R.,Araya, R. (2016). Effect of a Primary Care–
Based Psychological Intervention on Symptoms of Common Mental Disorders in Zimbabwe. JAMA, 316(24), 2618–
2626. doi:10.1001/jama.2016.19102. Retrieved from http://jamanetwork.com/journals/jama/fullarticle/2594719.
6. Daniels, I. (2018). An investigation into mental health care decits in South Africa: Exploring an alternative intervention
strategy. Unpublished Doctoral Thesis. South Africa: University of Cape Town
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 30
Delivering Mental Health
in an Unequal World -
Making NGO’s Matter –
Some case examples
CLAIRE BROOKS
KELLY DAVIS
KATHRYN GOETZKE
ENOCH LI
GILL TREVOR
KEY MESSAGES
• Globally, inequalities in funding mean that many people lack access to mental health services
which meet their needs, and COVID-19 has increased demand for services in non-healthcare
settings.
• MHNGOs address these inequalities by expanding access to person-centred services in innova-
tive ways and new settings, by contributing to research and by advocating for change.
• Lived experience, peer support and collaborative partnerships are drivers of NGO innovation
and success in expanding access, meeting service user needs, conducting research which is
relevant to service users and advocating for equality.
Introduction
Around the world, many people lack access to quality mental health services which meet their
needs and respect their dignity and human rights [1]. Mental health attracts less than 2% of global
health expenditure and there is shocking inequality between high- and low-middle-income coun-
tries (LMIC), who spend less than $2 per person annually, mostly on psychiatric institutions[2]. This
inequality results in shamefully high treatment gaps for easily treatable disorders[3] owing to a lack
of healthcare professionals, poor access to services and an over-reliance on a biological model
of mental healthcare, when what is most effective and ecient is an integrated and collaborative
approach[4]. Access to services is not the only issue. Stigma prevents many people from seeking
help from traditional mental health services, especially in LMIC [5], and results in fewer people
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 31
choosing to train as mental healthcare professionals[6].
NGOs harness the power of lived experience and civil engagement to address inequalities by
expanding access to innovative person-centred services and advocating for change in policy and
public attitudes. NGOs are dened as citizen organizations which aren’t motivated by prot[7],
including social enterprises[8] which seek prots to reinvest in social purpose. NGOs can act as[7]:
1) Implementers, providing services; 2) Partners with government or private sector to provide ser-
vices; 3) Catalysts, driving change through advocacy. NGOs are values-driven and more trusted by
the public than government or private enterprise to do the right thing and work to improve socie-
ty[9], including acting to alleviate the social determinants of mental ill-health[10].
Globally, mental health NGOs (MHNGOs) have developed effective community-based services
which increase access[5, 11, 12] and launched person-centred treatment alternatives which have
“recrafted a new narrative for mental health”[13]. COVID-19 has further increased the demand for
services in non-mental health settings[14] such as schools and workplaces, which are being met
by MHNGOs and innovative social enterprises. MHNGOs are free from political or corporate obliga-
tions to act as catalysts, advocating for what is just[15] and MHNGO staff have been found to have
less desire for social distance than health professionals and the public[16]. NGOs, including MH-
NGOs, are increasingly contributing to medical research which is more equitable and relevant[17],
which will improve healthcare quality and access, shape policy and increase the voice of service
users.
This article discusses ve international case studies which illustrate how MHNGOs matter, now
more than ever.
Case Study: Bearapy
Enoch Li, Managing Director
Bearapy is an award-winning consulting and training social enterprise, with a Mission to promote
workplace mental health as a strategic goal and upskill executives and teams in mental wellbeing
applications. Our business revenue funds social impact in the community, particularly in China and
Asia-Pacic. Everyone on the team has lived experience of a mental health condition, or of caring
for or supporting someone who does. This is essential in running effective training, sharing experi-
ences and enabling conversations about the issues.
When we founded Bearapy, “mental wellbeing” was not yet recognized being as important as it is
today. The rhetoric was about illness and mainly discussed by medical professionals. I wanted to
change mindsets and behaviours, and approach it as education and prevention, not treatment. I
wanted the private sector to take responsibility and act. This meant changing company culture and
leadership styles. I wanted to have budget control, instead of writing fundraising proposals. So, I
applied consulting rm approaches in change management, company culture and team collabora-
tion to workplace mental health, and brought playfulness into the delivery. I also brought the hu-
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 32
man side; having lived through depression and suicide attempts.
Our major challenge is creating market demand – many companies don’t think about the signi-
cance of employee wellbeing and aren’t willing to nd budget. Another challenge is nding social
impact investment that is not tech focused, which is still nascent in China. However, since incep-
tion, we have upskilled thousands of executives in companies, start-ups, and governmental organ-
izations in workplace mental health skills, and advised senior leaders on strategic approaches to
overhaul mental health initiatives in their organisations. Feedback shows that our sessions are
having a real impact on employee engagement with mental health in the workplace:
“Your talk was a wake up call and an eye-opener. Straight after, I asked HR if I could attend
the Mental Health First Aiders training. I want to help those around me and help me as well
remain mentally healthy.”
Our social impact work relies on our committed volunteers and involves thought advocacy through
conferences, talks, media and collaboration with other organizations – this is our soul, made possi-
ble by the revenue we generate. Together, these two elements mobilize the change we want to see.
http://bearapy.me/
Case Study: The World Dignity Project
Claire Brooks, Co-Founder, Research Director
The World Dignity Project is a global NGO whose mission is to ensure equality of treatment and
dignity in service user experience for those with a mental health condition. ‘Dignity’ is in common
use in mental health services but is hard to dene because of its complexity [18] and patient digni-
ty remains ‘understudied’ [19]. Worldwide, patient dignity is undermined by stigmatising behavior
from healthcare professionals and by other aspects of the mental health patient experience [20-
22].
To highlight this shocking situation, Professor Gabriel Ivbijaro launched the World Dignity Project
in 2015, by proposing a Taxonomy of Dignity from a Service User Perspective[23] (https://theworld-
dignityproject.org/research/) and unveiling the rst global symbol for Dignity in mental health [24].
The taxonomy of dignity was developed specically and uniquely to inspire the symbol design
process, by describing the different narratives, including the emotional responses and social pro-
cesses which mental healthcare workers, patients and care-givers associate with dignity in mental
health and identied three core narrative components:
1. Embrace Me. This narrative has an external perspective: how others see and treat me.
2. Journey of Hope. This narrative has an internal perspective: how I see myself and approach my
mental health condition.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 33
3. Universal Dignity. This narrative reects the idea of human dignity embodied in the Universal Dec-
laration of Human Rights.
Further research has been conducted to dene the aspects of service user experience which con-
tribute to or violate dignity, and a global Strategic Empathy®[25] project, which will involve health-
care professional and service user in co-creation of patient experience guidelines, will rollout in
2022.
The World Dignity Project is a coalition of volunteers including individuals with lived experience,
mental health professionals, academics and civic leaders. Our goals are:
• Driving public awareness of the importance of dignity for mental health service users and en-
courage wider discussion around mental health and stigma, by gaining visibility for the Dignity
symbol and what it means.
• Helping mental health professionals to tackle self-stigma and promote dignity by increasing
understanding of the service user experience through research, scientic publications and con-
tributing to Continuing Professional Development through events such as the joint conference
with the WFMH in June 2022 (https://www.wfmh2022.com/).
• Engaging policy makers and inuencing them by contributing to advocacy efforts such as
World Mental Health Day.
http://theworlddignityproject.org/
#WhatisDignity?
Case Study: Mental Health America
Kelly Davis, Associate Vice President of Peer and Youth Advocacy
Founded in 1909 by Clifford W. Beers, Mental Health America (https://www.mhanational.org/) is
the United States’ leading community-based nonprot dedicated to addressing the needs of those
living with mental illness and promoting the overall mental health of all. During his stays in public
and private institutions, Beers witnessed and was subjected to horrible abuse and started a reform
movement based on his lived experience. Guided by our history of lived experience leadership, peer
support has been a critical resource and is essential to our work as an organization. Among our
initiatives, we focus on expanding access to peer support through our programs, policy advocacy,
and local organizations.
Similar to Beers, I had access to a number of mental health resources and spent much of my early
life trying to gure out what was “wrong” with me. After a decade, I was diagnosed with Bipolar
Disorder and given the message: “Lower your expectations for your life and keep your mental health
challenges to yourself.” It was not until I connected with people in the peer support community that
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 34
I learned that these messages did not have to be true.
Peer supporters are people with lived experience of mental health conditions and/or substance use
disorders who receive training to support others in living the lives they want. Research shows that
peer support improves hope, social connection, empowerment and self-care, and reduces depres-
sion, substance use, and hospitalizations[26]. The peer support movement taught me that I could
advocate for my needs and take steps to support my wellbeing in community with others. I was
not alone or ashamed but part of a movement of people using their challenges to make the world
better for others.
We must rethink mental health services. People with lived experience tell us that a medical model
focused on individual-level interventions does not meet their needs. Peers, peer supporters, and
peer-run organisations must be central to how we build solutions. Leaders must invest in peer
support skills training, creating community-based models of care which integrate peer specialists.
It is a pivotal time for how we invest in wellbeing for all. Lived experience must be the starting point
for how we build a better way.
Case Study: Phoenix Health and Wellbeing
Gill Trevor, Founder and Director
Phoenix Health and Wellbeing (https://www.phoenixhealthandwellbeing.org.uk/) is a charity and
social enterprise based in West Yorkshire, UK. It was set up in 2013 to make complementary thera-
pies accessible to people with low incomes and chronic mental and physical health issues.
As a marketing executive who retrained as a therapist and then volunteered in care homes, founder
Gill Trevor saw that complementary therapies are powerful in improving quality of life, but individ-
uals on low incomes can’t access them. Phoenix Health and Wellbeing offers therapeutic support
on a sliding scale with contributions of £5-30. Phoenix now supports about 400 people per year,
referred to us by healthcare professionals, who register with us and form a receptive market for
other services.
Phoenix can provide subsidised support by generating revenue via social enterprise to cover costs.
Roughly 90% of income is derived from social enterprise with the remainder coming from fund-rais-
ing events and donations. Our social enterprise offers the same complementary therapies as our
charitable service and also offers workplace wellbeing and stress management programmes. The
management team includes people with lived experience of mental health issues.
Phoenix does not receive statutory or grant funding, which enables the management team to be dy-
namic, introducing new services and products without time-consuming commissioning meetings.
It does however mean that our existence is dependent upon the success of our social enterprise.
This weakness became evident in the current pandemic. In Lockdown 1 we had to close our prem-
ises. At that time all of our services were provided face to face, so our income stopped virtually
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 35
overnight. We quickly introduced online services for counselling and stress management which
continue to be very popular and now form a part of our standard service offering.
Now we are looking for a nancial investor to enable us to take the next leap. It is a delicate bal-
ance to grow commercially without losing sight of the very people who we are here to support but
we feel that involving all stakeholders will enable this. Indeed, we are condent, having recently
received a Queen’s Award for Enterprise, that we will be an attractive proposition to investors.
Case Study: iFred
Kathryn Goetzke, Founder
iFred is a nonprot dedicated to shining a positive light on mental health through stigma preven-
tion, research and education. Kathryn Goetzke started iFred in honor of her late father who died
by suicide when she was a freshman in college, and to understand her own lived experience with
PTSD, ADHD, depression, anxiety, addiction, and a suicide attempt.
iFred’s focus is eradicating mental health stigma by using the framework of moving from hopeless-
ness (despair and helplessness) to hope (positive feelings and inspired actions). Hopelessness is
a predictor of suicide and a primary symptom of depression and anxiety. Higher levels of hope cor-
respond to decreased anxiety and depression, greater psychological wellbeing, improved academic
performance and enhanced personal relationships. By teaching hope skills to children, teens and
adults, iFred enables people to live more successful, happy lives.
iFred’s Hopeful Minds program has reached nearly 250,000 children globally through free, down-
loadable curriculums (https://hopefulminds.org/). A study by Ulster University found that the
program has a signicant positive impact on child and adolescent wellbeing and a range of protec-
tive factors against mental ill-health and suicide[27]. Hope has been demonstrated to be a robust
source of resilience to anxiety and stress, and there is evidence that hope may function as a trans-
diagnostic mechanism of change in psychotherapy[28].
Partners are key to the effectiveness of Hopeful Minds because without strong partnerships, NGOs
can easily fall apart when the Founder steps away. Also key, is working on prevention as much as
intervention. If we wait until a person is in a major depressive episode, the cost of treatment is
much greater.
Mental health, and hope, are human rights. We must work collectively to ensure all have access to
care.
Conclusions
MHNGOs, including social enterprises, play an essential role in addressing inequalities of access
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 36
to mental health services that meet service user needs in innovative ways and in non-healthcare
settings. MHNGOs also play a critical role in relevant and effective mental health research and
advocacy. The case studies demonstrate that the passion and understanding of service user needs
that comes from lived experience, peer support and collaborative partnerships drives innovation
and success. However funding and social investment are an even greater challenge as the world
emerges from the pandemic.
References
1. World Health Organization W. Guidance on Community Mental Health Services. Promoting Person-centred and
Rights-based Approaches2021.
2. World Health Organization W. Mental Health Atlas. 2017.
3. Saxena S. Disparity between burden and budget for mental health. The Lancet Public Health. 2019;4(2):e75-e76.
4. Funk M, Ivbijaro G. Integrating mental health into primary care: a global perspective. World Health Organization; 2008.
5. Kohrt BA, Asher L, Bhardwaj A, et al. The role of communities in mental health care in low-and middle-income coun-
tries: a meta-review of components and competencies. International journal of environmental research and public
health. 2018;15(6):1279.
6. Ngui EM, Khasakhala L, Ndetei D, Roberts LW. Mental disorders, health inequalities and ethics: A global perspective.
International Review of Psychiatry. 2010;22(3):235-244.
7. Lewis D, Kanji N, Themudo NS. Non-governmental organizations and development. Routledge; 2020.
8. Salamon LM, Sokolowski SW. The size and scope of the European third sector. Brussels: European Union FP7 (grant
agreement 613034) Third Sector Impact. 2016;
9. Edelman. Trust Barometer. 2020.
10. Cresswell-Smith J, Macintyre AK, Wahlbeck K. Untapped potential? Action by non-governmental organisations on
the social determinants of mental health in high-income countries: an integrative review. Voluntary sector review.
2020;doi:10.1332/204080520X15874661935482
11. Thornicroft G, Alem A, Antunes Dos Santos R, et al. WPA guidance on steps, obstacles and mistakes to avoid in the
implementation of community mental health care. World psychiatry : ocial journal of the World Psychiatric Associa-
tion (WPA). 2010;9(2):67-77. doi:10.1002/j.2051-5545.2010.tb00276.x
12. Thornicroft G, Deb T, Henderson C. Community mental health care worldwide: current status and further develop-
ments. World Psychiatry. 2016;15(3):276-286.
13. UNHRC. Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable stand-
ard of physical and mental health. 2017:4.
14. Gilbody S, Littlewood E, Gascoyne S, et al. Mitigating the impacts of COVID-19: where are the mental health trials?
The Lancet Psychiatry. 2021/06/01/ 2021;doi:https://doi.org/10.1016/S2215-0366(21)00204-2
15. Brody EB. The World Federation for Mental Health: its origins and contemporary relevance to WHO and WPA policies.
World psychiatry : ocial journal of the World Psychiatric Association (WPA). 2004;3(1):54-55.
16. Rose G, von Hippel C, Brener L, von Hippel B. Attitudes of people working in mental health non-governmen-
tal organisations in Australia: A comparison with other mental health professionals. Health psychology open.
2018;5(1):2055102918765413.
17. Delisle H, Roberts JH, Munro M, Jones L, Gyorkos TW. The role of NGOs in global health research for development.
Health research policy and systems. 2005;3(1):1-21.
18. Hadland R, Lambert N. The challenge of dignity in mental health. British Journal of Mental Health Nursing.
2014;3(3):132-136.
19. Plunkett R, Kelly BD. Dignity: The elephant in the room in psychiatric inpatient care? A systematic review and themat-
ic synthesis. International Journal of Law and Psychiatry. 2021;75:101672.
20. Sartorius N. Stigma and mental health. Lancet. Sep 8 2007;370(9590):810-1. doi:10.1016/s0140-6736(07)61245-8
21. Ivbijaro GO. Mental Health in Primary Care stigma and social distance for schizophrenia in psychiatrists, general
practitioners and service users. 2018;
22. Ivbijaro G, Brooks C, Kolkiewicz L, Riba M, Kay G. Fighting for Dignity in Mental Health. presented at: World Psychiat-
ric Association 19th World Congress of Psychiatry; 2019; Lisbon, Portugal. Session Scientic.
23. Brooks C. Taxonomy of Dignity in Mental Health. presented at: International Mental Health Congress; 2015; France.
Session Plenary.
24. Edo. Dignity Symbol. 2015.
25. Brooks C. Marketing with Strategic Empathy: Inspiring Strategy with Deeper Consumer Insight. Kogan Page Publishers;
2016.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 37
26. SAMHSA. Value of Peers. https://www.samhsa.gov/sites/default/les/programs_campaigns/brss_tacs/value-of-
peers-2017.pdf2017.
27. Kirby K, Sweeney S, Armour C, et al. Developing Hopeful Minds: Can Teaching Hope Improve Wellbeing and Protec-
tive Factors in Children? Child Care in Practice. 2021:1-18. doi:10.1080/13575279.2021.1924121
28. Kirby K, Lyons A, Mallett J, et al. The Hopeful Minds Programme: A Mixed-method Evaluation of 10 School Curricu-
lum Based, Theoretically Framed, Lessons to Promote Mental Health and Coping Skills in 8–14-year-olds. Child Care
in Practice. 2021/04/03 2021;27(2):169-190. doi:10.1080/13575279.2019.1664993