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.
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WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 38
Supporting young people
and promoting their self-
esteem during the covid
19 pandemic
PROFESSOR ZAHIR IRANI
Deputy Vice-Chancellor, University of Bradford and, Chair of the Bradford Council Economic Recov-
ery Board
KEY MESSAGES
• Let’s characterize the pandemic as a health, education, social and economic crisis to force a
mindset change in the way we view what we have all survived, whilst not forgetting those that
did not.
• Let’s stop running down the tremendous efforts made by all students whether in schools,
further education or higher education during what has been an unprecedented crisis, which has
disproportionately hit sections of our communities. Instead, let’s celebrate, motivate, and in-
spire our children, our relatives, our future, as in one way or another, we will all become depend-
ent on them for our very own futures.
• Let’s take the opportunities that have resulted from covid to reassess what we do, how we do
it and, for what purpose. Excellence takes many forms, so let’s evolve our systems, processes
and practices to accommodate excellence whilst maintaining quality and standards.
Equality, fairness and opportunity have to be central to developing our young people in order to
address existing inequalities and their effects on young people’s mental health wellbeing. World
Mental Health Day 2021 ‘Mental Health in an Unequal World: Together we can make a difference,’
provides an opportunity for us to consider how we might achieve this.
COVID 19 has had differential effects on different age groups and has imposed many additional
challenges on for young people and their teachers, accentuating educational inequalities that have
existed over the last 50 years.
Young people are not only having to cope with having limited access to the education, they are also
having to cope with the anxiety of the effects of so called ‘grade ination’ on their life prospects
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 39
and its potential to further devalue the success that they have managed to achieve during the peri-
od of the pandemic.
The closure of schools is known to have a negative impact on children, and the impact is worsened
where there is socio-economic disadvantage (Cooper et al 1996; Meyers and Thomasson 2017;
Tsai S-L et al 2017). So why should young people who have already suffered school closure and
it’s consequences now have to worry about their certicates and achievements being devalued by
applying the pejorative concept of so called ‘grade ination’ when instead we should be celebrating
young people’s resilience during this dicult time.
So called ‘Grade Ination’ – does it really exist?
Lockdowns and pandemic restrictions on schooling have led to fears of a ‘lost generation’: pupils
who have missed out on the minimum of expected contact time, guided learning, classroom activi-
ties, interactions and opportunities to be assessed on learning, as well as the all-important support
and motivation from teachers and each other. Young people have experienced two years of dis-
ruption, isolation, and a creeping sense of being the exceptions; a so-called, special group. Special
cases who can’t be considered to have covered the same extent of the curriculum as previous
bodies of students.
Now there are increasing question marks awash in the media over the comparable value of school
qualications being awarded with other years. Can universities — or even employers — be certain
of how Covid-19 era grades compare? Is comparison even fair or real? The sheer level of variabil-
ity involved is a shock to the whole education system. It means passing on the challenge of ‘lost’
learning to FE, HE and potentially also to employers. Not doing so, may impact a future economy.
The major issue here is what the questioning and uncertainty does to social mobility. Access for
all to education has been intended to be the gateway to a free ow of opportunities: a level playing
eld that, at least in principle, allows for the creation of a more representative and inclusive socie-
ty. It will be the schoolchildren from disadvantaged backgrounds who will feel the greatest effects
from disruption, whose condence will be most damaged, who struggled with home learning, who
won’t be able to ll in the gaps in learning with tutors and other ways of bolstering the appearance
of CVs with valuable content. These are the students that are most likely to question their own
ability and treat any setback or new barrier to higher study at university as conrmation of their
lack of potential. In turn, this has the potential to be a mental scar for the longer-term, as a thorn of
demotivation.
There is likely to be a fundamental impact on the self-esteem of young people from this situation.
For most of us, it’s the education system that delivers our sense of achievement, progress, rec-
ognition and self-worth, all the way through to adulthood, with reassurance of comparability from
one year to another. Instead learning, and gaps in learning, have become a source of anxiety and
increased pressure on the need for ‘catch up’, for more intensity and alertness to what might be
missing and how less ‘rounded’ one may be, when compared to those before. Doubts, interruptions
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 40
and any downgrading to this process of character-shaping are a problem for mental wellbeing,
already made fragile by the pressures of social media and consumer culture. We already live-in
societies which encourage the idea of instant celebrity, quick xes that lead to fame and glamour,
rather than the day-to-day effort of learning. It’s already hard enough in this context to persuade
young people of the need to invest in themselves.
In the UK, in particular, where grades were this year based solely on teacher assessment, there is
now also the accusation of so called ‘grade ination’. In August 2021, a record-breaking 44.8% of
A-levels were awarded the highest A* or A grade, compared with 25.5% in 2019; where a different
system of awarding grades was used. Among media and the public there has been an acceptance
and assumption amongst many that the results are just the product of unreliable, preferential
teacher assessments of their students’ capabilities. For many of course, there is a view that those
best placed to offer a fair and accurate assessment, did so, in the form of Teacher Assessed
Grades (TAGs).
Plans for curbing so called ‘grade ination’ have already been put in place by the UK government,
which expects new leadership for the changes to come from a new head of the national qualica-
tions regulation body Ofqual and through broader consultation.
But is there really such a thing as grade ination? Perhaps it’s just an oversimplied term used to
describe a complex issue that has been solved with a relatively simple intervention. Nevertheless,
the question remains ‘How could there be grade ination when there has been no consistent year-
on-year baseline to make comparisons from?’. ‘Ination’ as a concept only works when there is a
clear, transparent point of comparison — like last month’s or last year’s prices or values.
A-levels in the UK have been a state of ux for many years. The exams have been updated and re-
structured, with tranches of new versions of subject exams released in 2017, 2018 and 2019. Four
years’ ago A-level students were used to a modular structure and coursework as the norm, with AS
levels contributing to nal grades. In 2017 there was the beginning of the changes to where most
courses would be assessed by exams (a maximum of 20% coursework for the exceptions).
Then in the rst year of Covid-19 in 2020, came the sudden need for a way to replace exams with
Centre Assessment Grades (CAGs), the use of an algorithm combining previous attainment with
teacher assessment to determine likely exam results. After a backlash from schools, colleges, stu-
dents and parents and, the threat of legal action, this year saw the reliance on TAGs. It is clear that
the only consistency, has been changes in grade denition and how these denitions have been
determined.
So there’s no actual basis to make judgments about ination. Indeed, I profess that the term is
itself not only unhelpful and misleading but incorrect. You certainly wouldn’t be able to character
economic ination in this way so, why should education be any different? But it’s too late, as the
term has been hijacked by the popular press and, those seeking to undermine educational attain-
ment and, does little other than undervalue all the hard work of our next generation. A mis-use
of the term ‘grade ination’ has now become commonly accepted parlance for talking about the
period. And it’s derogatory and insulting to students and to the teaching profession who have done
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 41
their best to support and work with students in schools and colleges through extraordinary times.
There is now the prospect of a return to exams (in some form) and a major re-adjustment or ‘grade
deation’ as it will no doubt be characterized. Leaving a generation of young people with questions
and questionable results.
However, if there is more Covid-19 induced disruption — or even no exams again in 2022 — then
the Higher Education sector will be looking at applications from a whole year of students who have
never sat a formal, national exam. There will be a generation that missed out on both GCSEs as
well as during A-levels. Universities continue to be on the receiving end of the reforms and revi-
sions. To make sure we’re being fair, continuing to support the ow of social mobility and help with
transitions, there must be condence in exam results in FE, HE and among employers. But the con-
stant changes to the nature of A-levels and likely results have made planning for admissions very
dicult, and the need for multiple budgetary scenarios as a result. Higher grades have led to crises
for some university admissions oces in the UK: the need to reduce numbers of undergraduates
and to encourage deferrals on certain courses, where there are either student number caps or lim-
itations in terms of physical resources (space or even teaching staff). One institution, for example,
is offering to pay students £10,000 and their campus accommodation for a year, if they defer entry.
A great deal of work is also passed on to HE in terms of support for levelling up and the transition
to higher study. Universities have the responsibility of ensuring all students have the same foun-
dation of subject knowledge (which is now very much not a given, given the Covid-19 and isolation
issues). They need to play an active role in giving students the condence and tools to catch up
or simply refresh their skills; and support students via an extended induction, to meet their peers,
socialise and adjust to the particular social norms of university student life. Consequently, there
are new and greater demands on university planning and resources, new schemes, activities and
calls on staff time.
The risk is that universities resort to introduce localised forms of assessment where there is a loss
of grade-quality condence, to take their own, rmer grip on admissions and to support student
number planning. This would however, only undermine A-levels still further and the biggest impact
being amongst non-traditional students. These kinds of tests are normally based on psychometrics
that disadvantage students from a non-selective route who are unused to the principles involved
and the specic type of test experience. Unlike their peers from more auent backgrounds they
are unable to afford paid support for preparation and coaching. Unfamiliar testing just acts another
barrier to people who may already be feeling fragile when it comes to their attitude to their abilities
and potential — providing another reason to opt for an easier or what they see as a more ‘suitable’
route into work. There is evidence from the introduction of tougher GCSE exams since 2017 of the
disproportionate impact on pupils from disadvantaged backgrounds. Work by Professor Smith-
ers, director of the Centre for Education and Employment Research at Buckingham University,has
pointed to how ‘lower-ability candidates’ have been more likely to “select themselves out” of A-level
options after nding the revised GCSEs too challenging.
A nationwide, standard model of assessment for school-leavers is a platform for encouraging
social equality. Because it’s the students from disadvantaged backgrounds who nd new assess-
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 42
ments daunting, who tend to undervalue their abilities so will be dissuaded from going to take on a
university assessment of any kind — brow-beaten by the idea of being judged by a ‘name’ university
before they’ve even been given an offer.
Recent years have been a sharp reminder that we live in a shared, interdependent ecosystem.
Disruption to school exams has had all kinds of knock-on effects within societies, not least to the
social mobility of young people both now and as a legacy for the future. And when it comes to
nding solutions, we need to keep in mind the full picture of implications, the benets of fair, reli-
able and supportive systems for education and equality. We need to keep in mind the longer-term
aftershocks to the global economy from the Covid-19 period. There will only be increased needs for
motivated, ambitious young people with the right skills, new expertise in emerging areas of enter-
prise, equipped to be adaptable. In other words, more opportunities — as long as our education
system is able to act as an open channel for all.
So what are the key take-away messages from my piece. Well, let’s rst of all characterize the
pandemic as a health, education, social and economic crisis. In doing so, it should force a mindset
change in the way we view what we have all survived, whilst not forgetting those that did not. Then,
let’s stop running down the tremendous efforts made by all students whether in schools, further
education or higher education during what has been an unprecedented crisis, which has dispro-
portionately hit sections of our communities. Instead, let’s celebrate, motivate, and inspire our
children, our relatives, our future, as in one way or another, we will all become dependent on them
for our very own futures. Finally, let’s take the opportunities that have resulted from covid to reas-
sess what we do, how we do it and, for what purpose. Excellence takes many forms, so let’s evolve
our systems, processes and practices to accommodate excellence whilst maintaining quality and
standards.
References
1. Cooper, H., Nye, B., Charlton, K., Lindsay, J., Greathouse, S. The Effects of Summer Vacation on Achievement Test
Scores: A Narrative and Meta-Analytic Review. Review of Educational Research. 1996. 66 (3): 227-268 https://doi.
org/10.3102/00346543066003227
2. Meyers, K., Thomasson, M.A. “Panics quarantines and school closures: did the 1916 poliomyelitis epidemic affect
educational attainment?” NBER Working Paper, 2017.
3. Tsai, S-L., Smith, M.L., Hauser, R.M,. Families, schools, and student achievement inequality: a multilevel MIMIC Model
Approach. Sociology of Education. 2017, 90(1): 64-88. DOI: 10.1177/0038040716683779
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 43
Making medical students
and doctor training
relevant to delivering
mental health in an
unequal world
MARC M H HERMANS
Past-president, Section of Psychiatry, UEMS.
CHRISTOPHER DOWRICK
Emeritus Professor. University of Liverpool.
LINDA GASK
Emerita Professor. University of Manchester.
MOHAN ISAAC
Clinical Professor of Psychiatry. The University of Western Australia.
NORMAN SARTORIUS
President. Association for the Improvement of Mental Health Programmes (AMH).
In recent years mental health has become a topic of interest for many. It became a focus of atten-
tion within the global medical community and in society in general. The quality of care delivery, the
education of students, the continuous professional development of doctors working within this
eld is strikingly variable among countries in the world. Not surprisingly, one nds these aspects
reected in a huge level of differences for doctors with regard to specic training, clinical practice
and continuous professional development, but regrettably also in a remarkable level of inequalities
of all kinds for patients.
Prior to starting their medical education, medical students vary considerably in their exposure to
the type of social and economic inequalities in society that play such a large part globally in the
variations in incidence, prevalence and access to care for mental health problems. In the United
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 44
Kingdom in 2016, only 4% of medical students came from working class backgrounds- something
which is replicated across other high-income countries [1].
These facts might encourage stakeholders to reect on the question how to set up a training in
mental health issues relevant for medical students and doctors. This process must address the
particular training environment, respect for patients’ needs, taking into account regional, geograph-
ical and cultural factors. Probably two major aspects predominate in this reecting process: the
structure and the content of training.
Efforts to bring mental health into primary health care began during the early 1970s. As early as
1974, a World Health Organization (WHO) Expert Committee on Mental Health discussed the de-
velopment of mental health services in developing countries [2]. Based on the recommendations
of the Expert Committee, WHO carried out a collaborative study on Strategies for the Extension of
Mental Health Care in Columbia, India, Nigeria, and Philippines which showed that simply trained
general health care workers including primary care doctors can help many of those affected by
mental illness [3, 4]. Other studies and initiatives followed and notably the Alma Ata Declaration in
1978 mentions mental health as an essential ingredient of primary health care [5].
The title Mental Health: New Understanding, New Hope gured on the 2001 World Health Report
from the World Health Organisation (WHO) [6]. The next year there followed a position paper: Men-
tal Health Global Action Programme (mhGAP): close the gap, dare to care [7]. Recently, WHO pub-
lished a eld test version to support its mhGAP [8]. It’s still open for evaluation for the interested
reader. Though WHO sketches a global background about mental health, when it comes to training
of professionals, it appropriately offers the scene to other organisations.
The Royal College of Physicians and Surgeons of Canada published in 2015 an updated version of
its well-known Physician Competency Framework [9]. It offers a number of roles a doctor must be
able to perform, with a list of key competencies a doctor should acquire. It also adds each time its
supporting competencies. This CanMEDS framework is globally seen as a very valuable compass
for developing structure in a medical training. One can easily imagine that in countries where other
medically trained professionals are performing these roles, these descriptions of competencies
can be adjusted accordingly.
With respect to content of training, WONCA, the general practitioners’ global association, published
in collaboration with the UK Royal College of General Practitioners their document Core Competen-
cies of Family Doctors in Primary Mental Health Care [10]. It stresses six important domains with re-
gard to mental health: values, communication skills, assessment, management, collaboration and
referral, and reective practice. It differentiates among more advanced competencies and offers
examples supported by key resources and references. Finally, it addresses issues related to policy,
training and research.
Though written for general practitioners, in our opinion, this WONCA document is ideal reading
material for all trainees across all specialties. This overarching perspective has also been taken by
the European Union of Medical Specialists (UEMS) in its European Training Requirements (ETRs)
series, documents developed by its different specialty related Sections [11]. Following a template,
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 45
these documents, approved by European national medical associations as well as different UEMS
bodies, describe European Standards in Medical Training for all specialties. Following a proposal
from the British Medical Association, approved by the UEMS Council this year, future ETRs shall be
completed with a particular position statement Policies on Safeguarding Children, Adolescents and
Vulnerable Adults [12]. It’s a request to all colleagues involved in training, to behave respectfully not
only towards the youngsters but also towards adult people with intellectual disabilities as well as
people with mental health problems.
The World Psychiatric Association (WPA) published on its website WPA Recommendations: Princi-
ples and Priorities for a Framework for Training Psychiatrists, prepared by a Task Force chaired by
the president of the WPA Section on Education [13]. This document rstly lists a number of roles
adapted from the CanMEDS 2015, with particular knowledge, skills and attitudes to be acquired by
a future psychiatrist. But the members of this Task Force did realise that one single curriculum for
the whole world would be a nonsensical proposal. Therefore, they suggested also a minimum core
curriculum describing knowledge, skills and attitudes within a three-year training period.
WPA has also tried to set up a number of online courses but unfortunately saw itself forced to
postpone some initiatives due to a lack of nancial resources. This is strongly in contrast with the
huge amount of information available through different channels on Youtube©. But, as usual, the
level of trustworthiness here is hugely variable due to an evident lack of the necessary peer review
process.
This is quite different from online courses offered by universities, e.g., the University of Melbourne
(UoM). The faculty offers an online course, leading to a Master degree in Psychiatry [14]. However
interesting this may be, for those interested from lower income countries, the price will most prob-
ably be a limiting factor. For a broader public the same institution offers also a Graduate Diploma
in International Psychiatry, as the website tells us “developed for medical professionals worldwide
who work with mentally ill patients in any capacity...” [15]. It’s an initiative jointly developed by the
UoM and WPA, offering a compact, six-month program, leading to a diploma after successfully
passing an exam. And last but not least, non-medical professionals are suggested to subscribe to
a free course on Foundations of International Psychiatry [16].
But reality shows that all these initiatives, however worthwhile documents offering guidance on
how to provide training may be, developed by all these many associations globally, with many val-
uable concepts written down and explained, widely accessible through numerous websites, it’s all
evidently insucient when it comes to their implementation. The material is there but it doesn’t t
the recipient(s). There’s a clear mismatch between what can be offered and what is needed.
Would it be useful to give mental health care training a far more prominent place in general medical
training? This process can only prove itself successful enough when the training at this level offers
relevant theoretical knowledge, allows to acquire culturally relevant attitudes and skills, and shows
itself suciently adjusted to patients’ needs as well as trainees’ needs.
Getting to this goal probably requires a task force composed of medical clinicians (i.e., general
practitioners, psychiatrists and other specialists), academic medical trainers, specialists in med-
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 46
ical education. Such a task force could perhaps deliver a more fruitful outcome when also other,
less commonly involved professionals are engaged in this kind of initiative. Wouldn’t it be useful
to have professionals with a background training in humanities (e.g., psychologists, sociologists,
anthropologists), working not only with patients and service users and carers, both ‘experts by
experience’, but also specialists in implementation with whom medical doctors rarely collaborate.
It should challenge stigma, towards not only patients but also fellow students and doctors experi-
encing mental health problems. Such a task force could develop a specic strategy, based upon a
perspective commonly shared by this group of stakeholders. Such a strategy should form the basis
for small program adjusting changes, evaluated after implementation, and leading to a circular
process of gradual quality improvement.
Most probably the coordination of such a task force should be given to governments. But is mental
health relevant enough to policy makers, to politicians? In the past, mental health has been ad-
dressed quite poorly by them. The ongoing pandemic can have created, is probably still creating
some change, even an increasing interest within that particular societal group (17).
20 years later the WHO report’s title would indeed become very relevant: Mental Health: New Under-
standing, New Hope.
KEY MESSAGES
• Education about dealing with mental illness and about promoting mental health are essential
parts of education of health care workers.
• Trainers of medical students should be aware that prior to starting their medical education,
students vary considerably in their exposure to inequalities in society.
• A training is only relevant when it considers the training environment, the patients’ and trainees’
needs, the cultural background of all involved.
• A valuable training program does not depend on individual trainers only, but needs the involve-
ment of a broader group of many professionals.
• Quality improvement is acquired by implementing small adjusting steps, monitored and evalu-
ated, leading to a continuing circular process
References
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Physicians and Surgeons of Canada; 2015.
10. World Organisation of Family Doctors/Royal College of General Practitioners 2018): Core Competencies of Family
Doctors in Primary Mental Health Care. http://www.globalfamilydoctor.com/site/DefaultSite/lesystem/documents/
Groups/Mental%20Health/Core%20competencies%20January%202018.pdf
11. Union Européenne de Médecins Spécialistes. European Standards in Medical Training. https://www.uems.eu/are-
as-of-expertise/postgraduate-training/european-standards-in-medical-training visited on 19.06.2021
12. Union Européenne de Médecins Spécialistes. Policies on Safeguarding Children, Adolescents and Vulnerable Adults.
2021 https://www.uems.eu/__data/assets/pdf_le/0015/132234/Safeguarding-Supporting-Document-brieng.pdf
visited on 19.06.2021
13. World Psychiatric Association. WPA Recommendations: Principles and Priorities for a Framework for Training Psychia-
trists. 2017 https://3ba346de-fde6-473f-b1da-536498661f9c.lesusr.com/ugd/e172f3_9e614f64a8ee4675b8b3ded-
bc6488686.pdf visited on 19.06.2021
14. University of Melbourne. Master of Psychiatry (Online). https://study.unimelb.edu.au/nd/courses/graduate/mas-
ter-of-psychiatry-online/ visited on 19.06.2021
15. University of Melbourne. Graduate Diploma in International Psychiatry. https://study.unimelb.edu.au/nd/courses/
graduate/graduate-diploma-in-international-psychiatry/ visited on 19.06.2021
16. Coursera. Foundations of international psychiatry. https://www.coursera.org/learn/international-psychiatry visited on
19.06.2021
17. World Health Organisation. World Health Assembly recommends reinforcement of measures to protect mental health
during public health emergencies. WHO (2021), https://www.who.int/news/item/31-05-2021-world-health-assem-
bly-recommends-reinforcement-of-measures-to-protect-mental-health-during-public-health-emergencies, visited on
18.06.2021
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 48
Realising the Astana
Declaration and mental
health in an unequal
world - the role of family
doctors.
CHRISTOS LIONIS
MD, PhD, FRCGP(Hon), FWONCA, FESC. Professor of General Practice and Primary Health Care at
the School of Medicine, University of Crete and Head of the Clinic of Social and Family Medicine at
the School of Medicine, University of Crete. lionis@galinos.med.uoc.gr
SANDRA FORTES
MD, MSc, PhD. Principal Investigator. Interdisciplinary Research Laboratory on Primary Care,
Universidade do Estado do Rio de Janeiro, Rua São Francisco Xavier, 524, Maracanã, Rio de
Janeiro, RJ 20551-030, Brazil. sandrafortes@gmail.com
ALFREDO DE OLIVEIRA NETO
MD, PhD. Family Physician,Assistant Professor, Primary Health Care Department, Federal
University of Rio de Janeiro, Brazil. alfredoneto@medicina.ufrj.br
TAMICA DANIELS-WILLIAMSON
M.B.B.S, MMedFM instead of M.B.B.S, MMedFM. My address is 796 Providence East Bank Deme-
rara, Guyana instead of 796 Providence EBD, Georgetown, Guyana. tamicadw@gmail.com
ABDULLAH AL-KHATAMI
ABFM, FFCM, MSc.Med Edu (Cardiff-UK), DTQM, MSc/Diploma PMHC (Nova-Lisbon). Consultant
Family and Community Medicine, Director of the Primary MH Program-MOH Saudi Arabia. mabna@
yahoo.com
KIM STRONG GRISWOLD
MD, MPH, RN, FAAFP. Professor of Family Medicine, Psychiatry, and Public Health and the Health
Professions. Department of Family Medicine, Jacobs School of Medicine & Biomedical Sciences.
UB Downtown Gateway Department of Family Medicine Primary Care Research Institute 77 Goodell
Street, Suite 220U Buffalo, New York 1420. griswol@buffalo.edu
CHRISTOPHER DOWRICK
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 49
BA MSc MD FRCGP. Emeritus Professor, University of Liverpool UK; Chair, WONCA Working Party
for Mental Health. 10 Moss Lane, Liverpool L9 8AJ, UK. cfd@liv.ac.uk
KEY MESSAGES
• Family doctors can play a central role in improving mental health in an unequal world.
• Challenges in translating the Astana Declaration into action are present across differing health
systems.
• By working together, we can translate aspiration into achievement.
Introduction
In October 2018 WHO convened a global conference on primary health care in Astana, Kasakhstan.
The ensuing Declaration included the following statements:
We strongly arm our commitment to the fundamental right of every human being to the
enjoyment of the highest attainable standard of health without distinction of any kind.
We are convinced that strengthening primary health care (PHC) is the most inclusive,
effective and ecient approach to enhance people’s physical and mental health, as well as
social well-being.
Remaining healthy is challenging for many people, particularly the poor and people in vul-
nerable situations. We nd it ethically, politically, socially and economically unacceptable
that inequity in health and disparities in health outcomes persist.
Promotive, preventive, curative, rehabilitative services and palliative care must be accessi-
ble to all. We must save millions of people from poverty. [1]
As family doctors we fully endorse this commitment to the fundamental rights of people with
mental health conditions. We support WHO in promoting a shift from stigmatizing long-stay mental
hospitals, to more acceptable and dignied care in community-based settings.
Primary care, with its emphasis on the connections between mental and physical health, and its
unique ability to tackle problems of co-morbidity and multimorbidity, is exceptionally well-placed to
enhance mental health within universal health coverage systems. Family doctors are well placed to
assess patients’ vulnerability, the impact of poverty and disadvantage, and their association with
mental and psychological conditions. [2] We can intervene to reduce the mortality and morbidity
of people with severe mental illness, who die prematurely, spiraling into homelessness, unemploy-
ment and poverty and with greatly increased risk of developing non-communicable diseases such
as diabetes. [3]
We agree with the need for mental health promotion, requiring multi-sectoral collaboration to build
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 50
a healthy environment with the focus on those factors that reduce chronic stress, poverty and
health inequalities. We include potential anti-stressors and supportive actions including social con-
nectivity and (for many) spirituality and religiosity.
We now consider how these principles apply in four health care systems.
Brazil: middle income country
The territorial basis of Brazilian Family Health Strategy (ESF), the cornerstone of Primary Care Sys-
tem in the National Health System, connects each of 40,000 Family Health Teams (FHT) of doctor,
nurse, nurse technician and up to six community workers to a community of around 3,750 people.
These teams guarantee access for all Brazilians to health care; they also develop health promotion
and preventive measures, including socioeconomic interventions, integrated with other sectors
such as education, housing, culture and social assistance [4].
However, there are not enough family doctors and nurses to cover all these FHTs, bringing chal-
lenges when building a patient-centered approach and an integrated health system. The implemen-
tation of new Mental Health Care Internship is developing new models of undergraduate training in
mental health. To translate the Astana Declaration into practice we need to expand psychosocial
and secondary care teams working within a collaborative care model with PHC professionals. Get-
ting these teams to work together through the Brazilian Collaborative Care model, the Matrix Sup-
port, will allow for an Integrated Care System to be implemented where each person can receive
the best quality care needed in different levels of the health system [5].
The biggest challenge to actually apply the Astana declaration, in addition to structural inequalities
in societies, is the lack of human resources to expand intersectoral actions between the PHC and
other sectors [6]. Advocacy for mental health care in those territories could enhance community
participation and intersectoral coordination, and reduce inequalities and inequities in relation to the
integrated approach to a person with psychosocial suffering and their family members and caregiv-
ers.
Guyana: middle income country
Primary health care in Guyana has its challenges, especially as it relates to the management of
mental health conditions. Referring all cases to the psychiatric department is overwhelming, given
a population of over 700,000 and less than twenty public health psychiatrists. Family medicine was
formally instituted in 2015 [7], and with mh-GAP training since 2016 has helped to reduce suicide
rates.
There are unique challenges in Guyana in relation to sustainability and consistency in providing
medications and human resources. There is a serious brain drain: 89% of university-educated Guya-
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 51
nese leave the country, the highest rate in the world. [8]. We have to continuously train doctors and
nurses to ll these gaps, which puts a serious strain on our health care system.
In PHC, staff such as psychologists and social workers need to be on board to provide comprehen-
sive care. Mental health needs to be seen as equally important as any other organic illness, in order
for there to be equity of care in Guyana. There is still a lot of stigma associated with these condi-
tions.
The Mental Health Unit and the Georgetown Public Hospital are the two main public entities in
Guyana that provide mental health care. Working together, monitoring and surveillance are key to
addressing the gaps, so that Ministry of Health knows what needs improving. More opportunities
should be provided for Fellowship training in Psychiatry to enable our primary care physicians to be
more condent and competent in their management of mental health conditions. Resources need
to be provided to all ten administrative regions across Guyana.
To ensure comprehensive and holistic care we need more collaboration and advocacy with interna-
tional bodies.
Saudi Arabia: high income country
A situation analysis (1995-1999) identied that family doctors were unable to identify mental
health problems in primary health care and showed that traditional training programs were ineffec-
tive (9). From 2002 to 2015 a long-term training program was implemented for primary health care
workers and family doctors in primary health care centers, in collaboration with WHO, WONCA and
other countries. Beginning in eleven primary health care centres in Eastern Province, this program
has been extended across all provinces, with more than 436 training courses across all provinces.
In total 1435 family and PHC doctors, 931 nurses, 42 social workers, 31 psychologists have been
trained; 253 PHC centres are now able to provides Primary MH care; more than 76,000 patients
have been served in over 330,000 PHC visits; and each month more than 2000 patients show im-
provement in their conditions. One of the most important fruits of this experience was creating an
innovative patients’ interview approach «5-Step Model» in line with the needs of PHC doctors in the
Arab culture (10). This program is now being implemented in Egypt, Morocco and Sudan.
United States: high income country
The US remains without a solid system of national health care, though the Affordable Care Act has
afforded access and coverage to millions of individuals and families. On the primary care front,
value-based care is gaining momentum and with it stronger demands for reimbursement reform.
Events over the past year have forced a reckoning with the stark imbalance in health outcomes for
people of color; inequities as a consequence of racism and other key social determinants of health.
[11]
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 52
The COVID-19 pandemic has offered US primary care opportunity and challenge. Can we make
mental health care more accessible, affordable and equitable? [12] Can we recognize how pover-
ty, discrimination, prejudice, and many other traumas affect mental health – and act to eliminate
these barriers?
A robust public health system in concert with primary care is key to addressing mental health and
well–being. Community engagement can engage people in need, particularly those who are un-
der-served, such as homeless individuals, those whose primary language is other than English, and
individuals with serious mental illness. [13,14]
We must provide to those who seek refuge in the US due to violence or conict in their home coun-
tries, utilizing a trauma informed approach – emphasizing resilience and approaching treatment
through family, community and cultural contexts. [15] Totally integrated primary and behavioral
health care is a recipe for successful care, decreased stigma, and better health outcomes. [16, 17]
With an already stretched primary care system, primary care doctors and their teams encountered
enormous stressors, including increased risks of contracting the virus. We need support to im-
prove medical well-being [18-20].
Conclusion
We have highlighted the challenges of translating the Astana Declaration into global action, and
recommended what primary care doctors can do to make a difference in promoting equity and
equality in mental health in differing health systems. To fully realize the Astana recommendations
will take the power of governments as well as private sector foundations. We encourage family
doctors to work collectively to turn these aspirations into achievements.
References
1. World Health Organisation, Declaration of Astana. 2018, page 5.
2. https://ec.europa.eu/health/sites/default/les/expert_panel/docs/026_health_socialcare_covid19_en.pdf
3. https://www.globalfamilydoctor.com/groups/WorkingParties/MentalHealth3/SMI.aspx
4. Menezes, Alice Lopes do Amaral et al. Parallels between research in mental health in Brazil and in the eld of Global
Mental Health: an integrative literature review. Cadernos de Saúde Pública [online]. 2018, v. 34, n. 11 [Accessed 11
June 2021] , e00158017
5. Onocko-Campos, Rosana Teresa. Mental health in Brazil: strides, setbacks, and challenges. Cadernos de Saúde
Pública [online]. v. 35, n. 11 [Accessed 11 June 2021],e00156119. Available from: <https://doi.org/10.1590/0102-
311X00156119>. ISSN 1678-4464
6. Giovanella, Lígia et al. De Alma-Ata a Astana. From Alma-Ata to Astana. Primary health care and universal health
systems: an inseparable commitment and a fundamental human right. Cadernos de Saúde Pública [online]. 2019, v.
35, n. 3 [Acessado 11 Junho 2021]
7. https://med.uottawa.ca/family/guyana
8. https://www.kaieteurnewsonline.com/2018/10/20/guyanas-brain-drain-at-worrying-levels-us-state-dept-high-
lights-shortage-of-even-semi-skilled-individuals/#:~:text=Guyana’s%20brain%20drain%20is%20at,but%20even%20
semi%2Dskilled%20persons.&text=In%20fact%2C%20the%20Department%20reports,seventh%20highest%20in%20
the%20world.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 53
9. Al-Khathami, A. Traditional mental health training’s effect on primary care physicians in Saudi Arabia. Mental Health
Fam Med Journal, 2011; 8: 3–5.
10. AlKhathami A, et al. A primary mental health program in Eastern Province, Saudi Arabia, 2003-2013. Mental Health in
Family Medicine; 10:203-210.
11. https://www.nimh.nih.gov/about/director/messages/2021/one-year-in-covid-19-and-mental-health
12. http://www.ihi.org/communities/blogs/questions-to-guide-the-future-of-primary-care
13. Westfall JM, Liaw W, Griswold KS, et al. Uniting Public Health and Primary Care for Healthy Communities in the COV-
ID-19 Era and Beyond. JABFM doi: 10.3122/jabfm.2021.S1.200458M.
14. Stareld B, Shi L, Macinko J. Contribution of primary care to health systems and health. The Milbank Quarterly,
2005;83:457–502
15. Griswold KS, Loomis DM, Pastore PA. Mental Health and Illness. Prim Care Clin Oce Pract. 2021;48:131-145.
https://doi.org/10.1016/j.pop.2020.09.009
16. Shim R, Rust G. Primary Care, Behavioral Health and Public Health: Partners in Reducing Mental Health Stigma.
AJPH 2013. doi:10.2105/AJPH.2013.301214
17. https://nam.edu/components-of-the-next-generation-of-integrated-care/?gclid=CjwKCAjwtdeFBhBAEiwAKOIy5y6G-
vD1MQzj8R_zJ4X1jm_BKu2IKB8IdjjSrEhK8PRfaeq-ipVgzYhoC4PMQAvD_BwE
18. https://www.ama-assn.org/delivering-care/public-health/managing-mental-health-during-covid-19
19. http://www.ihi.org/resources/Pages/Tools/psychological-PPE-promote-health-care-workforce-mental-health-and-
well-being.aspx
20. https://weill.cornell.edu/national-conference-medical-student-mental-health-and-well-being
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 54
The role of lived
experience in tackling
inequalities and
improving mental health
in mental health services
and beyond.
DR DAVID CREPAZ-KEAY
Fellow, Royal Society for Public Health. Fellow, Institute of Mental Health. Dprof. Head of Applied
Learning. Mental Health Foundation.
OBJECTIVE(S)
• To showcase how people with lived mental health experience are making changes in mental
health delivery and the challenges they face
• To describe mental health service users expectations and how these can be achieved
KEY POINTS
• Involvement/co-production has been around a long time but its access and impact is unequally
distributed.
• Effective involvement and broader community engagement needs to tackle social determinants
of mental ill-health to make mental health services sustainable.
• Involvement/co-production is good but it can and must be better.
Introduction
Whether it’s called service user involvement, patient and public involvement (PPI), co-production or
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 55
involving people with lived experience – engaging people in improving mental health services has
been policy and practice in many countries for many years [1]. In other places it is a relatively new
approach and in some it doesn’t happen at all. Done well it has the potential to improve services
and broader public mental health and reduce inequalities; but done badly it can cause damage,
distress and do more harm than good [2].
Although a range of terms are used, there may be differences in how people understand the differ-
ent terms. The following denitions will be used throughout this piece:
• Service user involvement refers to the engagement of people already using a particular service.
This may be complemented by carer involvement which refers to involving family or other infor-
mal carers.
• Patient and Public Involvement (PPI) will include broader involvement of people who have a lay
(non-professional) interest. This may include potential service users and broader communities.
The term patient usually implies someone using an existing (mental) health service.
• Co-production refers to involvement in developing something new or joint delivery of an exist-
ing service. Co-production would usually involve service users but may also involve carers or
people who have previously used services.
• Lived experience has become more widely used recently. Lived experience is usually self-de-
ned and does not rely on being professionally diagnosed or using (or having used) a particular
service.
It is also worth noting that there is no consensus on the language and terms used and there will
be regional and cultural variations. It is, however, important that there is a common understanding
amongst those involved in any piece of involvement.
What does good involvement look like?
Involvement can occur in a range of places and at different stages of service development, delivery
and evaluation from national strategy to individual care plans [3].
Involvement at an individual level
At its most basic, and in many ways the most important and potentially empowering form of en-
gagement is in our own care, treatment and ultimately being more in control of our own lives. This
is in line with current legal developments in the UK and elsewhere (based in part on international
human rights legislation), making shared decision-making between clinicians and patients based
on evidence and values the basis of consent in all areas of health and social care [4].
When we think about service user involvement or co-production this is where it starts. Until we feel
more in control of our day to day lives, involvement in anything bigger seems like an add-on. The
great thing about co-producing care for ourselves is that it allows us to put treatment and support
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 56
in the context of our broader lives. This means we can talk about the external factors that may
exacerbate or mitigate our good or poor mental health; these are often referred to as social deter-
minants of (mental) health and can include among others: poor housing, debt, other health or dis-
ability concerns, experience of bullying, abuse, racism or other forms of violence. All of these are
known to have a potentially detrimental effect on mental health and may trigger or worsen mental
ill-health but may get ignored if the focus is solely on treatment of diagnosed symptoms. This type
of involvement could include self-management and peer support. This is a structured approach
designed to enable people with lived experience to support themselves and each other and which
may be supported by mental health professionals [5].
Peer support is particularly useful for people who have felt isolated and experienced poor self-con-
dence which can make getting involved seem daunting. It also offers people with lived experi-
ence an opportunity to help others and share our learning with each other which can help to build
self-condence and prepare people for more involvement or co-production. Peer support also en-
ables people to group around particular shared experiences which may be related directly to their
mental (ill-)health like self-help for bipolar or hearing voices groups, or it may bring people with
other shared experiences together, for example ethnicity, gender or sexuality. Peer groups can also
provide an important and supportive way of highlighted and starting to address inequalities.
Involvement at an operational level
Many people will associate service user involvement and co-production with the day-to-day oper-
ation of mental health services. In many places this is the most well-established form of involve-
ment. It may require more skills and condence than involvement in our own care, but it offers
people the opportunity to more directly shape the support on offer and benet more people.
There are many examples of progressive co-produced services that help bridge the gap between
purely clinical services designed to deliver treatments and more community-based services which
address the social determinants that will be beyond the control of mental health professionals, but
still have an adverse impact on mental health [6][7][8].
Because they may require more skills and condence, it is important to ensure that involvement
and co-production at this level supports diversity and is accessible to a wide range of people. It is
possible for work with the best of intentions to inadvertently exclude people who experience addi-
tional disadvantage (particularly by ethnicity or disability) and thereby increase inequality. It may be
more time consuming or even expensive to make engagement accessible, but that time and effort
can be a signicant contributor to addressing and reducing inequalities.
Getting the basics right
Although there are many types of involvement and many things to consider, there are a few
simple things to consider before starting any involvement process.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 57
Be clear about the purpose
Involvement/co-production needs a clear purpose to be effective. Having a clearly articulated
and well thought through reason for any engagement will make sure that people know what
they are getting involved with and why. It will also allow everyone to understand whether it
achieves its aims and if there are lessons to be learned or ways to improve the process.
Be clear about the limits
Just as it is important to understand why you want people involved; clarity about what can
and cannot be created or changed as a result of involvement/co-production is essential to
ensure that people are comfortable with engagement and the constraints on potential out-
comes.
Limits of engagement are inevitable: some come from funding or other nancial constraints,
some come from technical, legal or other existing guidelines, and some will be practical. If
people know and understand these constraints when they get involved, it will help people to
focus their energy on what can be achieved and reduce the risk of frustration associated with
wasting time or effort on things that are xed.
Understanding and articulating constraints are important skills for all involved in co-produc-
tion. It may also be an opportunity to question whether these limits and constraints are xed
and whether they can be removed for future engagement.
Build in regular feedback
Involvement is not a one-off event, it’s an ongoing process. People need to be connected
throughout the whole endeavour. One-off events are not meaningful involvement and even
good processes can feel unhelpful if people can’t nd out what is going on or what has hap-
pened as a result of engagement or co-production. Good feedback that explains what has
changed as a result of co-production will enable people to see and understand the benets
and will be more likely to stay engaged and encourage others to join them. Even when things
are slow to improve feedback can explain why and may even support better problem solving
to improve future results.
Involvement at a strategic level
Involving people in shaping the future is probably the most abstract type of involvement. This
might include involvement in governance, in planning and commissioning services, in shaping re-
search, policy and legislation. It can be rewarding, have a good long-term impact but it can also feel
intimidating and remote to many people. It is certainly not the best way for everyone to be involved
but good quality service user involvement can increase the quality and diversity of thinking [9].
One important way to ensure that involvement and co-production engages as many people as pos-
sible and contributes to reducing inequalities is to join up the work across the individual, operation-
al and strategic levels. If people and organisations involved in these different ways are talking to
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 58
each other; sharing ideas, skills and learning; and even providing support and mentoring for people
who want to develop their own involvement and co-production skills; then we will be able to spread
the benet of involvement to all [10], [11].
Conclusion
Involvement, engagement and co-production are not easy to do well, and there are plenty of pitfalls
for the unwary – but they should no longer be seen as an optional extra. Done well they help to im-
prove everyone’s mental health, reduce pressures on overstretched services and make them more
sustainable, make working in mental health more rewarding and help give meaning to people’s
lived experience as an asset for public benet.
References
1. R. Bowl, “Legislating for user involvement in the United Kingdom: mental health services and the NHS and Communi-
ty Care Act 1990,” Int. J. Soc. Psychiatry, vol. 42, no. 3, pp. 165–180, 1996, [Online]. Available: http://search.ebsco-
host.com/login.aspx?direct=true&db=cmedm&AN=8889641&site=ehost-live.
2. J. Brett et al., “A Systematic Review of the Impact of Patient and Public Involvement on Service Users, Researchers
and Communities.” Nov. 22, 2014, [Online]. Available: https://www.socprox.net/login?url=http://search.proquest.
com/professional/docview/1547762623?accountid=138535.
3. D. Crepaz-Keay, “Empowering mental health service users and their family carers. Practical examples from the United
Kingdom *,” Inf. Psychiatr., vol. 92, no. 9, pp. 718–722, 2016, doi: 10.1684/ipe.2016.1544.
4. J. Herring, K. Fulford, M. Dunn, and A. Handa, “Elbow Room for Best Practice? Montgomery, Patients’ values, and
Balanced Decision-Making in Person-Centred Clinical Care,” Med. Law Rev., vol. 25, no. 4, pp. 582–603, Nov. 2017,
doi: 10.1093/medlaw/fwx029.
5. D. Crepaz-Keay and E. Cyhlarova, “A new self-management intervention for people with severe psychiatric di-
agnoses,” J. Ment. Heal. Training, Educ. Pract., vol. 7, no. 2, pp. 89–94, 2012, [Online]. Available: http://dx.doi.
org/10.1108/17556221211236493.
6. M. Semrau et al., “Service user and caregiver involvement in mental health system strengthening in low- and mid-
dle-income countries: systematic review,” BMC Health Serv. Res., vol. 16, no. 1, p. 79, 2016, doi: 10.1186/s12913-016-
1323-8.
7. the new economics foundation, “Co-production in mental health: A literature review.”
8. L. Lea, “Acute solutions and beyond: lessons on service user involvement,” J Ment. Heal. Work. Dev., vol. 1, no. 2, pp.
34–37, 2006, [Online]. Available: http://search.ebscohost.com/login.aspx?direct=true&db=bnh&AN=126096&site=e-
host-live.
9. M. Crawford and D. Rutter, “Are the views of members of mental health user groups representative of those of ‘ordi-
nary’ patients? A cross-sectional survey of service users and providers,” J. Ment. Heal., vol. 13, no. 6, pp. 561–568,
2004, doi: 10.1080/09638230400017111.
10. C. de Freitas, “Aiming for inclusion: A case study of motivations for involvement in mental health-care governance by
ethnic minority users,” Heal. Expect., vol. 18, no. 5, pp. 1093–1104, 2015, doi: 10.1111/hex.12082.
11. S. Samudre et al., “Service user involvement for mental health system strengthening in India: a qualitative study.,”
BMC Psychiatry, vol. 16, pp. 1–11, 2016, doi: 10.1186/s12888-016-0981-8.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 59
Human Rights and
Mental Health Inequality
among older persons:
Urgent need for a global
convention
DEBANJAN BANERJEE (MD, DM)
1Department of Psychiatry, Geriatric Unit, National Institute of Mental Health and Neurosciences
(NIMHANS), Bangalore, India
GABRIEL IVBIJARO MBE (PHD, FRCGP, FWACPSYCH)
Professor, NOVA University, Lisbon, Portugal & Medical Director, Waltham Forest Community &
Family Health Services, London, UK
CARLOS AUGUSTO DE MENDONCA LIMA (MD, DSCI.)
Chair, Old Age Psychiatry Section, World Psychiatric Association (WPA), Switzerland
KIRAN RABHERU (MD, FRCPSYCH)
Professor of Psychiatry, University of Ottawa; Chair of the Board, ILC, Canada
* Corresponding author (Dr.Debanjan Banerjee)
KEY POINTS
• Psychosocial burden among the older persons is rising with global population ageing
• The COVID-19 pandemic has widened the marginalization, ageism and health inequality in the
older persons
• Dignity, respect, autonomy and equality are the basic dimensions of human rights in the older
persons
• The proposed UN Convention for Rights of Older Persons holds promise to restore health
equality and dignied care.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 60
Psychosocial morbidity in the older persons
Globally population is rapidly ageing due to reduced fertility as well as mortality. The proportion of
older persons (age greater than 60 years) across the world is expected to double by 2050. The neu-
ropsychiatric disorders contribute signicantly (6.6%) to the overall disability burden [1]. Though it
is often noted that resilience, coping, subjective feeling of fullment and well-being improve with
age, old age comes with its own unique challenges in terms of both health and social situations.
Several physiological changes happen in the organ systems as the age progresses. The ability of
the body to resist or counteract stress by maintaining homeostasis reduces. When the psychoso-
cial adversities get added to it, the vulnerability to both physical and mental illnesses as well as
disability increases (Table 1).
The most common neuropsychiatric disorder observed in old age is the neurocognitive disorder or
dementia with a global prevalence of around 5%. The prevalence doubles every 5 years after the
age of 60 years [2]. This is closely followed by depression and anxiety disorders. Other psychiatric
illnesses like psychosis, obsessive-compulsive disorder, substance abuse, etc. are less common
than in younger adults [2]. These disorders in older persons may have atypicality or differential
presentations, often resulting in missed diagnosis. Subsyndromal symptoms are much more
common in older persons. Apart from the clinical or subclinical illnesses, psychosocial challenges
particularly observed in old age are retirement, loneliness, bereavement, social isolation, marginal-
isation, societal ageistic beliefs and discrimination [3]. These may lead to signicant distress and
impaired well-being, further compounded by chronic medical illnesses, pain, frailty, immobility, etc.
The Coronavirus Disease 2019 (COVID-19) pandemic has led to a whole new plethora of challeng-
es for this population besides the increased propensity for morbidity and mortality [4] (Table 2).
Table 1: Causes of disability and healthcare burden in older persons
• Sensory impairment (vision & hearing loss)
• Frailty
• Chronic pain
• Chronic obstructive pulmonary disease (COPD)
• Late-life depression
• Falls
• Diabetes and hypertension
• Osteoarthritis
• Mobility restriction
• Dementia
• Polypharmacy
• Multi-morbidity
Table 2: Psychosocial toll of COVID-19 pandemic on older persons
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 61
• Increased fear of infection being a vulnerable population
• Fear of dying alone
• Social isolation
• Loneliness
• Grief and ‘survivor’s guilt’
• Worsening of pre-existing dementia and depression
• Anxiety
• Limited access to healthcare and social support
• Stigma and ageism
• Rise in elder abuse (especially in institutions)
• Prone to misinformation
• Restriction of mobility and autonomy
Health inequality and human rights gap in the
older persons
The global population ageing has also brought to light specic vulnerabilities in older persons. The
World Health Organization (WHO) denes healthy ageing as “the process of developing and main-
taining the functional ability that enables wellbeing in older age” [5]. It encompasses the ability of
an older person to make independent decisions, develop and maintain relationships, stay mobile,
meet his/her basic needs and continue participation in society. Diversity and inequity are important
considerations in healthy ageing which needs adequate healthcare access and dedicated services
for the older persons.
The Sustainable Developmental Goal 3 highlights the need to “ensure healthy lives and promote
wellbeing for all at all ages” which focuses on a life-course based approach to healthcare needs.
Age is considered to be one of the most important determinants of health and ageing process also
involves frailty (cumulative decline in multiple physiological domains), risk of poor health out-
comes and limited access to affordable healthcare. Besides the biological changes of ageing and
neurological senescence, there are several social vulnerabilities including loss of autonomy, nan-
cial and physical dependence, death of loved ones, grief, loneliness and social isolation. Besides,
poor diet, restricted mobility, physical inactivity and lack of sensory stimulation can further lead to
health inequalities in this population [6, 7].
Older persons due to varying socio-economic circumstances often nd it dicult to access and
afford quality healthcare, the crevices of which are more widened in mental health, due to lack of
awareness, misinformation, under-detection of psychiatric symptoms and increased prevalence
of depression and dementia in this population [7]. According to the United Nations Department
of Economic and Social Affairs (UNDESA), a large number of older persons across the world are
deprived of adequate healthcare access and long-term care. Data on the same is also restricted
from the developed nations and it is imperative that the crisis is probably more concerning in the
low-and-middle-income countries where health infrastructure is already burdened with popula-
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 62
tion ageing and other related challenges. A recent study from India involving 9181 older persons
showed that most of them had no source of income in last one year, were dependent, suffered
from multi-morbidity, had various disabilities and low instrumental activities of daily living [8].
Various factors that can lead to genesis of health inequalities in old age are depicted in Figure 1.
These can get further exacerbated through gender, ethnicity and race-based discrimination within
the elderly.
There are multiple dimensions to human rights in the older persons (Figure 2) which include the
right to freedom, right to health as well as reproductive/sexual rights. The ongoing COVID-19 pan-
demic has indeed been an eye-opener in many ways where the biopsychosocial marginalization
of older persons has surfaced leading to an “invisible human rights crisis” [4]. Lack of dignied
healthcare, neglect, discrimination in healthcare and elder abuse are the predominant ways in
which rights are deprived in them. Based on the WHO data, one in six individuals worldwide over 60
age are the victims of abuse in the last one year and majority are under-reported [9]. The rates have
increased during COVID-19 especially in nations with increased population ageing [9]. The serious
‘social evil’ of elder abuse arises from ageist stereotypes (what we think), prejudice (how we feel)
and discrimination (how we act). The risk factors of elder abuse are enumerated in Figure 3. The
need to focus on dignity and autonomy in healthcare is vital to ght ageism and support dedicated
care for the older persons [10]. Similar action areas of ensuring age-friendly environment, long-
term and integrated geriatric healthcare and combatting ageism have been resonated in the U.N.
International Decade of Healthy Ageing 2021-2030 [11]. This needs to be facilitated by engagement
of older persons, giving them a ‘voice’, connecting interested stakeholders and care providers and
nally, promoting ageing research.
Need for rights based and dignied geriatric mental health care in today’s
world
World Mental Health Day 2021, Mental Health in an Unequal World, provides an opportunity for us
to reect on how we treat older persons with health care needs. Although each new generation of
older persons has made a signicant contribution to building our contemporary society when they
require medical or social care they feel as if they are treated as wasting resources and their previ-
ous contributions seem forgotten.
Quote (1) from a patient; “When I went to the hospital for my heart condition they did not take
me seriously. It was as if I was wasting their time.” 85 year old male.
Quote (2) from a patient; “My GP told me I needed an urgent scan but I was told by the hospi-
tal I would have to wait. I’m sure this would not have happened when I was younger.” 82 year
old woman.
Such comments from older persons are not uncommon. Many feel powerless in their suffering
and in meeting their needs. Part of this is because of societal expectations of what it is to be old,
expectations that should change because people are now living longer in better health and better
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 63
maintaining their independence.
We need a framework that respects human rights and dignity of the individual so that when and
older person seeks health and social support they are given the appropriate care that they need
and deserve when they need it. We also need an enforceable rights framework for older persons
that challenges exclusion and lack of participation. The fundamentals of a rights-based approach
in policy making should enhance an individual’s participation and social care should not be seen
as a handout or charitable gift from the government. Participation is important and includes, ‘the
rights and responsibilities of people to make choices and …have power over decisions that affect
their lives’ [12].
One way that this can be achieved is for health and social care organisations to include older
persons in their governing bodies who will ensure that pathways and services monitor the rights of
individuals who are older persons and make their ndings public including how they have tackled
shortcomings when they occur. Those who commission or pay for health and social care services
should include a rights-based framework that specically includes older persons in the service
specications they develop including mechanisms for monitoring these.
These type of interventions are already happening. Policy makers have started to look at human
rights law in framing national health policy and global health governance and this approach is pos-
sible even in manging an infectious disease such as COVID 19 [13]. Several such strategies at var-
ious levels to ensure health equality and rights-based approach in older persons are summarized
in Table 3. We can only ensure that their needs are met and their dignity respected and monitored
by adopting a rights based approach to the planning, delivery and monitoring of health and social
care. Every encounter matters.
Table 3: Strategies to restore health equality and social inclusion for older persons
• Encourage healthy ageing
• Recognize older persons’ contribution in society
• Promote community participation in older persons
• Ensure voice of older adults (representatives) in policy and welfare-related committees
• Balance and allocate resources for equitable healthcare
• Develop specialist and dedicated services for the older persons
• Improve public awareness
• Increase healthcare utilization at old age
• Dementia care (prevention, treatment, caregiver education and rehabilitation)
• Affordable and accessible preventive, curative and long-term healthcare
• Legislations to prevent age-based discrimination in any sector
• Encourage social welfare schemes and post-retirement socio-economic independence
• Fighting ageism
• Prevention and prompt reporting of elder abuse
• Funding and conducting longitudinal ageing research
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 64
• Fight ageist stereotypes and misinformation
• Integrated care
Healthy Ageing and Human Rights
Healthy ageing and human rights are closely related. The promotion and the protection of the basic
human rights is a necessary prerequisite for aging in good health. Human Rights protect people
against any kind of stigma and discrimination because of age, promote the development of good
health policies, programmes and services and assure the access to health and social care. Hu-
man Rights particularly protect the determinants of health that are the conditions in which people
are born, grow, live, work and age and which are shaped by the distribution of money, power and
resources at global, national and local levels [10,14].
The respect of basic Human Rights is essential to age in dignity. Health ageing is an asset of indi-
viduals, communities and populations whose value can change throughout the life course. Human
Rights sustains the ethical and the legal framework to support ageing with good health and to
protect those losing his/her autonomy and independence as a result of health conditions.
Unfortunately, basic Human Rights are frequently violated. An example of this is happening now
during the COVID-19 disaster when this pandemic has put the spotlight on the tensions among
the different generations suffering together, which causes discrimination such sd ageism [4,15].
Pandemics, wars and natural disasters may reveal the best and the worst of us while struggling for
survival: selsh attitudes or empathy, compassion and solidarity are all present. The present pan-
demic is an opportunity to recall that intergenerational solidarity is essential: the respect of Human
Rights is more needed than never.
Key themes that underpin Human Rights and Healthy Ageing include autonomy, dignity, care, and
treatment, safety, and privacy. The Human Rights most relevant to age in good health are summa-
rized in Table 4. However, there are many more related rights that can intersect with healthy age-
ing.
Table 4: Human rights relevant to ageing and old age
• Enjoyment of the highest attainable standards of affordable global health, and the respect of
specic needs of people in different stages of life
• Access to justice at any stage of life
• Dignity and quality of life
• A discrimination and stigma-free world
• Safeguarding against violence, undue inuence and abuse, freedom from cruel, inhumane, de-
grading treatment, and punishment
• Participating in the cultural and social life of the community
• Making contributions to the community through work or other activities, and to be protected
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 65
during these activities
• Provision of adequate income to meet basic needs for food, housing, clothing, and other neces-
sities
• Accessible leisure and education
• Respect for family, relationships, sexual health, and the right to intimacy
• Condentiality and privacy
• To practice a spiritual life of one’s choosing.
Elder abuse which is a major human rights violation for the older persons and mandates immedi-
ate action. Based on the WHO recommendations [9], some salient strategies for its prevention are
mentioned in Table 5.
Table 5: Prevention strategies for elder abuse
• Public awareness (involvement of media)
• Promote early identication and reporting of elder abuse
• Caregiver education and interventions (especially in dementia and SMI)
• Institutional care (staff-training) and long-term care policies
• Self-help groups
• Emergency (safe) homes
• Organizations/helplines/support for distress calls
• Legislations for appropriate punishment in case of abuse
Human Rights assure each one of us the peaceful attainment of our personal objectives in life, and
the promote the feeling that each life counts for the global community.
Way Forward: Urgent Call for a Convention for the rights of older persons
The United Nations (UN) 2030 Agenda for Sustainable Development, a blueprint for global peace
and prosperity, details 17 Sustainable Development Goals (SDGs) [16], and is aligned with the UN’s
Decade of Healthy Ageing (DHA) (2021-2030), bringing together all sectors of society [11]. The
COVID-19 crisis has disproportionately impacted older people, largely driven by ageism [17], and
highlighted serious gaps in human rights policies, systems and services. Global action is urgently
needed to ensure that older people can full their full potential in dignity, equality, in a healthy envi-
ronment, essential for sustainable development and just and peaceful societies.
Older persons’ rights are conspicuously absent in the Universal Declaration of Human Rights
(UHDR) [18]. A coherent, comprehensive and integrated international legal framework on the rights
of older persons is urgently needed. This framework must respond to the reality of our changing
world, specic human rights challenges and protection gaps, faced by older people, and allow them
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 66
to reap the full benets of longevity. The experience of the Convention on the Rights of Persons
with Disabilities [19], clearly demonstrates that development of a dedicated legal instrument can
effectively contribute to changes in law and practice.
On the UN’s 75th anniversary, a global survey identied human rights as a top priority with a spe-
cic recommendation to “promote a creation of an UN Convention to protect the rights of older
persons” [20]. The UN Secretary-General’s Policy Brief on the impact of COVID-19 on older people
[21], calls for accelerated efforts to develop proposals for an international legal instrument to
promote and protect the rights and dignity of older persons. The UN’s Open-ended Working Group
on Ageing (OEWG) established in 2010 [22], has an unfullled mandate to date to “present to the
General Assembly, at the earliest possible date, a proposal containing, inter alia, the main elements
that should be included in an international legal instrument to promote and protect the rights and
dignity of older persons”. Evidently, full commitment is required by all Member States, civil society,
NHRIs and older persons to accomplish this goal. In the background of the pandemic era, speedy
population ageing and increasing psychosocial morbidity, such an international convention will
hold true promise for restoring health equality and human rights of older persons in resonance with
the theme of this World Mental Health Day 2021.
: None
Acknowledgements: None
References
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2. Lilford P, Hughes JC. Epidemiology and mental illness in old age. BJPsych Advances. 2020 Mar;26(2):92-103.
3. World Health Organization. Mental health of older adults [Internet]. 2017 [cited 2021 Jun 23]. Available from: https://
www.who.int/news-room/fact-sheets/detail/mental-health-of-older-adults
4. D’cruz M, Banerjee D. ‘An invisible human rights crisis’: The marginalization of older adults during the COVID-19 pan-
demic–An advocacy review. Psychiatry research. 2020 Aug 3:113369.
5. World Health Organization. Ageing: Healthy ageing and functional ability [Internet]. 2020 [cited 2021 Jun 25]. Availa-
ble from: https://www.who.int/westernpacic/news/q-a-detail/ageing-healthy-ageing-and-functional-ability
6. Artazcoz L, Rueda S. Social inequalities in health among the elderly: a challenge for public health research. 2007;
61(6): 466-467
7. Faculty of Old Age Psychiatry, The Royal College of Psychiatrists. Suffering in silence: age inequality in older peo-
ple’s mental healthcare [Internet]. 2018 [cited 2021 Jun 25]. Available from: https://www.rcpsych.ac.uk/docs/
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t=James%2C%202015).-,The%20number%20of%20people%20aged%2075%20or%20over%20is%20expected,in%20
the%20next%2030%20years.&text=Depression%20is%20the%20most%20common,(Age%20UK%2C%202016
8. Srivastava S, Purkayastha N, Chaurasia H, Muhammad T. Socioeconomic inequality in psychological distress among
older adults in India: a decomposition analysis. BMC psychiatry. 2021 Dec;21(1):1-5.
9. World Health Organization. Elder abuse [Internet]. 2021 [cited 2021 Jun 25]. Available from: https://www.who.int/
news-room/fact-sheets/detail/elder-abuse
10. Banerjee D, Rabheru K, de Mendonca Lima CA, Ivbijaro G. Role of Dignity in Mental Health Care: Impact on Ageism
and Human Rights of Older Persons. The American Journal of Geriatric Psychiatry. 2021 May 25.
11. World Health Organization. UN Decade of Healthy Ageing 2021-2030 [Internet]. [cited 2021 Jun 25]. Available from:
https://www.who.int/initiatives/decade-of-healthy-ageing
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ease. InInfectious Diseases in the New Millennium 2020 (pp. 217-253). Springer, Cham.
14. Venkatapuram S, Ehni HJ, Saxena A. Equity and healthy ageing. Bulletin of the World Health Organization. 2017 Nov
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1;95(11):791.
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[cited 2021 Jun 26]. Available from: https://www.un.org/development/desa/disabilities/convention-on-the-rights-of-
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Figure 1: Factors leading to health inequality in older persons
Figure 2: Dimensions of human rights in the older persons
Dignity Autonomy Respect
Capacity Inclusion Equality
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 68
Figure 3: Risk factors for elder abuse
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 69
Mental Health Financing
in Africa: Building
resources to overcome
historical inequalities
CRICK LUND [1, 2]
SUMAIYAH DOCRAT [3]
DONELA BESADA [1, 4]
Aliations:
1. Centre for Global Mental Health, Health Service and Population Research Department, Institute
of Psychiatry, Psychology and Neuroscience, King’s Global Health Institute, King’s College London
2. Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health,
University of Cape Town
3. Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town
4. Health Systems Research Unit, South African Medical Research Council
The nancing of mental health is a neglected priority in sub-Saharan Africa. According to the latest
World Health Organization Atlas report, African countries spend $0.10 per capita on mental health
(in contrast with $21.7 per capita in the European region)1. There is also weak nancial risk protec-
tion for mental health; in 43% of African countries, people pay mostly or entirely out of pocket for
mental health services. These nancing decits are reected in inadequate human resources to
provide mental health care; there are 9 mental health workers for every million people in the African
region. In turn this is reected in a massive treatment gap; more than 90% of people living with a
mental health condition receive no evidence-based care.
This dire situation is likely to have been worsened by the COVID pandemic, in at least three impor-
tant ways. First, the pandemic has had a direct effect on the mental health of populations in low
and middle-income countries (LMIC);2 second the economic impact of the pandemic on employ-
ment rates, poverty and food insecurity, may in turn have adversely inuenced mental health;3 and
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 70
third the treasuries of African governments and international development agencies now have
reduced scal space to invest in mental health care systems.
Nevertheless, the current crisis also brings new opportunities. Now, perhaps more than ever before,
there is a growing public awareness of the importance of mental health, through discussion in the
media and other public fora of the mental health consequences of COVID.
There is also growing evidence for how African countries can better invest in mental health. An
example of a set of optimal nancing models has been identied by the “Emerging mental health
systems in low and middle-income countries” (Emerald) project.4 Emerald recommended the in-
clusion of packages of care for mental health in ongoing universal health coverage (UHC) reforms,
and suggested approaches for improving the eciency of current spends and generating new
resources.
While approaches to the integration of mental health within the health nancing reform process
will be unique to each context, core components of such an endeavor should include several com-
mon features, as follows:
• A comprehensive understanding of the burden of disease due to mental health conditions and
extant treatment coverage is required for adequate needs assessment.
• Developing context-specic investment or business cases for mental healthcare is essential to
advocate for increased domestic and international resourcing.
• A budgeted resource plan is needed that explicitly identies a dened package of care drawing
on the evidence base for cost-effective interventions to address mental health conditions.
• Ensuring strong engagement across key governmental and non-governmental stakeholders is
vital to ensure political buy-in and consensus. Enhanced governance and planning capacity, as
well as improved monitoring and evaluation processes will be key to facilitating these process-
es. [4].
In addition to nancing models, there is also emerging evidence for how eciencies can be im-
proved to optimize expenditure in African countries. This includes addressing current inecien-
cies in the use of resources by shifting from hospital-based models of care to new investments in
primary health care and community service provision; the integration of mental health in broader
primary healthcare services, including task-shifting mental healthcare to non-specialist providers
in tandem with increased training and strong specialist supervision structures; and the provision of
early interventions for at-risk populations. [5]
In Ghana and South Africa, work has recently been conducted to develop national investment
cases for mental health. In Ghana, preliminary work on an investment case was conducted as part
of the Ghana Somubi Dwumadie programme (https://options.co.uk/sites/default/les/learning_
product_developing_an_investment_case_21012021.pdf). In South Africa, our investment case for
mental health has involved three key steps: [6]
• We calculated the current cost of mental health service expenditure.5 Among other things,
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 71
this showed that the national Department of Health currently spends approximately 5% of its
budget on mental health (provincial range: 2.1–7.7% of provincial health budgets); that most of
this funding (86%) is spent on hospital services when it could be more eciently and effectively
spent on primary care and community-based services; and that 18% of the total mental health
budget is spent on re-admissions to inpatient facilities, reecting a highly inecient revolving
door pattern of care.
• In consultation with a wide range of stakeholders at national and provincial level, we identied
a core package of services, health system inputs and related infrastructure investments that
need to be scaled up. This focused on modeling an increasingly decentralized system of care
over a 15-year period, with new investments in primary care and community-based care. It
also included investments in three other key sectors: (1) in the education sector, in the form of
social and emotional learning programmes, to be delivered in schools to promote the mental
health and well-being of children and adolescents, and to prevent mental health problems; (2)
in the social development sector to address alcohol and substance-use; and (3) in the housing
sector to ensure capital investments in community-residential care infrastructure.
• Using an adapted version of the WHO Inter-UN OneHealth Tool, we calculated the return on
investment, in terms of healthy life years, prevalent cases and mortality averted, as well as
improved economic productivity over a 15-year period. This showed clearly that the cost of
inaction to the South African economy far outweighed the cost of investing in the mental health
of the population. When expressed as an annual amount, lost workforce productivity estimat-
ed for South Africa translates to approximately US$ 10.9 billion annually; or approximately 4%
of the country’s gross domestic product (GDP). This is in stark contrast to an average annual
estimate of US$ 1.8 billion to scale-up mental health services in South Africa over the 15-year
period. In short, investing in mental health is not only important from a human rights perspec-
tive, but also makes good economic sense.
These new methodological innovations in calculating the costs and the return on investment for
scaling up mental health care in South Africa can be adapted to other African countries. They rep-
resent a new opportunity to mobilise nances from governments as well as International Develop-
ment assistance from external organizations, in order to improve the mental health and well-being
of African citizens. Recent analysis of international development assistance for mental health in
LMIC shows that this assistance is not always well aligned with mental health needs in these coun-
tries.7 The development of African-based mental health investment cases, tailored to the needs
of African countries represent a step change, with the potential to fund mental health services in
places where it is needed most.
To conclude, there has been growing global awareness about the importance of mental health as
both a driver of social and economic development and a worthy goal of such development. The
time is long overdue for improved and sustained investment, with the goal of building the mental
health and resilience of African populations, particularly children and adolescents, who will face
tomorrow’s social, environmental and economic challenges.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 72
References
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ment Goals: a systematic review of reviews. Lancet Psychiatry 2018; 5(4): 357-69.
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WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 73
Redesigning Community
Psychiatry to rise to the
challenge of mental
health delivery in an
unequal world
DR ADRIAN JAMES
President Royal College of Psychiatrists
PROFESSOR MOHAMMED AL-UZRI
RCPsych Presidential Lead for International Affairs
MS AGNES RABOCZKI
RCPsych International Liaison Manager
Globally, people with mental health conditions have a higher likeliness of premature mortality, with
a reduction in life expectancy ranging from 10-25 years (WHO). If left unaddressed, the already
underestimated mental health burden, exacerbated by COVID-19, will lead to major societal mental
health consequences, such as widespread anxiety and depression, leading to secondary disability.
Concrete action is needed to overcome this burden through implementation of conducive mental
health legislation, integration of mental health care into medical education, and building capacity
within the workforce.
Health inequality is an interconnected issue, enfolding within itself various factors, such as socio-
economic status, race and ethnicity, sexual orientation, gender identity, lack of human rights, etc.
However, people living with mental health conditions are not only disproportionately affected by
the aforementioned, but are most likely casualty to severe treatment gaps, lack of investment into
services, poor quality of care and not least, stigma.
World Health Organisation gures show that suicide mortality is on the rise for young people and
elderly women in lower- and middle-income countries, especially in areas heavily affected by con-
ict, amounting to approximately 800,000 deaths per year. Community psychiatry is an effective
and pragmatic method to address these issues, alleviate suffering and to support the provision of
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 74
well-functioning mental health services.
The 1960s brought forth a shift from institutionalised mental health to community health centres
(BJ Beck) and a wider move towards a holistic approach within psychiatry. Asylums were increas-
ingly converted to community health centres and attached to general hospitals (al-Uzri, Dyer).
However, much of the emerging world was left struggling with capacity issues and poor supply of
trained mental health workforce, which has left heavy implications felt to date. Service develop-
ment and upskilling workforce are essential to redesigning community psychiatry to meet these
needs, however other elements must be in place for it to have a sustained effect on public mental
health. Such as, mental health legislation and policymaking, robust research and audit practices,
mental health curriculum, established standards of care, and formal recognition of unmet health
needs. Furthermore, the need to appreciate the link between changing lifestyles and associated
stress leading to increased mental health problems. Covid-19 provided global evidence of how
mental health needs increase in times of distress due to social isolation and changes to lifestyle.
The paper will outline the main challenges that contribute to mental health inequalities, as well
as the steps needed to address these - including concrete recommendations to ensure improved
outcomes for mental health professionals and the wider community.
One of the most signicant barriers to global mental health is stigma. Stigma in mental health is
dened as the “devaluing, disgracing, and disfavouring by the general public of individuals with
mental illnesses” (Abdullah). Undoubtedly, stigma poses one of the most substantial challenges to
mental health care worldwide. It presents a huge obstacle to access medical care and increases
risk of premature mortality. A recent study (Philip et al.) has found that stigma also leads to height-
ened psychiatric symptoms and hopelessness. Furthermore, even if a patient does overcome the
access barrier and seeks care, stigma will worsen compliance around adhering to a treatment
plan and settling back into society. Ultimately leading to social isolation and rapid deterioration
of mental wellbeing. Secondly, the wide treatment gap means that worldwide approximately 70%
of people who need mental health services lack access to care (Wainberg et al.) This is not a
phenomenon restricted to low- and middle-income countries and heavily compounds the already
existing mental health burden. For example, Uganda is ranked among the top six countries in Africa
in rates of depressive and anxiety disorders (Kagaari). The country, which has a population of 44
million people, currently has 30 psychiatrists, with most working in private practice, in the capital
city of Kampala. In terms of importance, access and capacity are two issues that rmly move in
lockstep. Lastly, training, retaining, and maintaining a competent healthcare workforce has been
a huge challenge across the global South. Data shows that over a third of South African medical
graduates leave to pursue careers in Europe and North America. Consequently, countries like the
United Kingdom, have a largely foreign medical workforce with an estimated 31% of its doctors
born overseas. (Pang et al.) The reasons behind brain drain vary and include a lack of funding or
government support, poor renumeration, subpar working conditions, and conict.
The paper recommends three steps to address these challenges with a community psychiatry
approach, starting with the most crucial: legislation. Mental health legislation is vital to protect the
rights of patients, regulate the role of the health institution, the family, and dene governmental
responsibilities towards caring for people with mental illness. Appropriate legislation lends itself to
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 75
a “rights-based approach” to tackling stigma in mental health, as it is underpinned by moral author-
ity and can depend on enforcement of rights (Smith), lending patients a platform of equality to be
treated the same as peers with physical ailments.
Secondly, structural improvements such as incorporating mental health care into medical school
curricula, primary care training, and Continuing Medical Education (CME) will help spread aware-
ness of mental illness as well as signicantly reduce stigma within the community (al-Uzri, Dyer).
Guides such as the WHO mental health GAP (mhGAP) training for non-specialised health settings,
have been successfully implemented to support several primary health care settings, aiming to
decrease the treatment gap and to strengthen community-based staff capacities to deliver mental
health and psychosocial support interventions, and to overcome the scarcity of specialised staff. A
systematic review undertaken by King’s College in 2017, has found that mhGAP training had sub-
stantial impact on positively improving attitudes towards mentally ill patients, improved attitudes
towards psychiatry, greater condence in managing mental health problems, as well as increased
job satisfaction (Keynejad et al). Consequently, building capacity within the mental health work-
force is fundamental and must be prioritised within public health decision-making. A way ahead is
ensuring that staff have access to quality training opportunities, supervision, and exposure to psy-
chiatric subspecialties. Additionally, keeping sustainability at the forefront of all policy decisions
will be key to ensure development and continuity of high-quality community care.
Finally, to fortify legislation and governmental decision-making, there must be formal recognition of
unmet health needs to ensure successful integration of mental health education to current training,
allow for professional development opportunities, tackle stigma, as well as to ringfence a portion
of the health budget to treat the mental health burden. Good quality health data will further aid the
process of identifying community needs and improve treatment outcomes. Investment into audit
and research is indispensable as it will contribute to effective prevention, increased quality of care,
and the development of specialised services.
In conclusion, the overall trend in psychiatry has been to move away from institutionalised mental
health towards a community approach. However, capacity concerns and poor access to servic-
es persist in many low- and middle-income countries. Further challenges include notable stigma
against people with mental illness and inadequate working and training conditions for the health-
care workforce. This is further intensied by the pandemic that brought about social isolation,
increased stress, and extreme changes in lifestyles. To overcome this inequality, the paper sug-
gested three steps to address these challenges:
• Advocating for the implementation of mental health legislation,
• Structurally integrating mental health care into medical education,
• Building capacity within existing workforce.
The paper advises formal investment into robust audit and research practices to ensure that health
needs are continuously monitored and that adequate services are developed to effectively treat
patients.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 76
References
• Abdullah, T., Brown, T.L. (2011). Mental illness stigma and ethnocultural beliefs, values, and norms: an integrative
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• al-Uzri M., Dyer A.R. (2020) Reconstructing Post-Conict Iraq: Focus on Mental Health. In: Okpaku S. (eds) Innova-
tions in Global Mental Health. Springer, Cham. https://doi.org/10.1007/978-3-319-70134-9_117-1
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doi.org/10.1016/s2214-109x(17)30080-3
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da-mental-health
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do, M. A., & Arbuckle, M. R. (2017). Challenges and Opportunities in Global Mental Health: a Research-to-Prac-
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WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 77
The World Psychiatric
Association 2020-23
Action Plan
AFZAL JAVED
President WPA
This year’s World Mental Health Day 2021 theme ‘Mental Health in and Unequal World; Together
We Can Make a Difference’ coincides with a period during which psychiatry is facing several chal-
lenges, and there are many opportunities that can help us consolidate psychiatry as an inspiring
branch of medicine.
WPA is the umbrella organization for psychiatrists worldwide and thus has a major responsibility
for leading the profession. This leadership can only be achieved through full participation from our
membership and engagement of our professional colleagues.
WPA Action Plan for 2021-23 denes emerging needs and priorities, from a worldwide perspective,
in some specic areas of mental health. There is an outstanding need to provide access to high
quality mental health care in all countries and to support psychiatrists in their important roles as
policy makers, direct service providers, trainers and supporters of health care workers in primary
and community health care systems.
The key features of the Action Plan are:
• To improve the standing of psychiatry as a medical specialty in clinical, academic and research
areas and to promote public mental health as a guiding principle.
• To highlight the specic role of psychiatrists in working with other professionals in health, legal
and social aspects of care
• To ensure WPA’s positive engagement with member societies and WPA components
The proposed Action Plan looks at targeted areas that need attention and input from various WPA
components during the next triennium. It will work within an international perspective focusing
specically on promotion, interventions and teaching and training of mental health professionals.
This Action Plan will also build on the previous Action Plan to ensure continuity in the WPA’s work.
Salient features of the Action Plan 2020-23 include the following areas:
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 78
PSYCHIATRY & PUBLIC MENTAL HEALTH CHILD, ADOLESCENT & YOUTH MENTAL
HEALTH:
From CLINIC TO COMMUNITY
DEALING WITH CO-MORBIDITY IN MEN-
TAL HEALTH
PARTNERSHIP WITH OTHER ORGANISA-
TIONS
CAPACITY BUILDING CONTINUATION & COMPLETION OF
PREVIOUS ACTION PLANS WORK
Psychiatry & Public Mental health:
Public mental health is assuming an important place in the delivery of general health care. It
involves a population mental health approach, which includes assessments, efforts to improve
outcomes, coordination of different levels of mental disorder prevention, and mental wellbeing
promotion. Evidence shows that programmes improving population mental health through coordi-
nated work with a range of public and other organisations, local communities and individuals show
a great impact.
The suggested action plan includes:
• Raising awareness, acceptance, and prioritization of public mental health in national health poli-
cies
• Promoting public mental health intervention grant proposals
• Ensuring public mental health training programmes
• Integrating mental health care into chronic disease management and prevention and engaging
with primary and general health care systems.
Children, Adolescent & Youth Mental Health:
Identifying needs for targeted groups (0-Children, Adolescent & Youth Mental Health: Identifying
needs for targeted groups (0-25years of age), including children, adolescents, persons with learn-
ing disability, refugees, and young adults with chronic and enduring mental health problems
Mental disorders are the single most common cause of disability in young people. First onset of
mental disorders usually occurs in childhood or adolescence, although treatment typically follows
several years later. The evidence shows that around 70% of mental disorders begin before the age
of 25. The adolescent years are a critical time, when mental health needs promotion, and mental
health problems need intervention. If left untreated, mental disorders can impede all aspects of
health, including emotional well-being and social development, and leave young people feeling
socially isolated, stigmatized, and unable to optimize their social, vocational, and interpersonal
contributions to society. There is ample evidence that addressing mental health problems early in
life can decrease emotional and behavioural problems, functional impairment, and contact with all
forms of law enforcement. It can also lead to improvements in social and behavioural adjustment,
learning outcomes, and school performance in later life and prevent development into chronic
disorders. The promotion of child and adolescent mental health is a worldwide challenge, but a
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 79
potentially rewarding one.
Wars and natural disasters have led to the refugee population reaching numbers not seen since
the Second World War. The current data show an increasing prevalence of mental disorders in the
younger population going through migration and displacement. International organisations gener-
ally focus on providing food and shelter, but much more needs to be done to support this younger
population and to address their mental wellbeing.
The failure to address child and adolescent mental health problems, including developmental and
intellectual disorders, especially in low-resource settings, adds signicantly to major public health
issues and inicts far-reaching consequences. Evidence shows that a substantial proportion of
adult mental health problems originate early in life and has long-lasting effects beyond childhood
and adolescence. There are signicant gaps in what we know about how best to treat mental
illness in children and youth. There is inadequate support for research into developmental neurobi-
ology; the causes of mental illnesses; and the most effective, safest and best-tolerated treatments.
The stigma of mental illness, together with the outdated models of child and youth mental health-
care, illustrate the negligence of our society.
Digital child and adolescent psychiatry uses innovative technologies to support and enhance the
understand, diagnose, and treatment of mental illness. Digital psychiatry ranges from electronic
health record (EHR) systems, clinical decision support systems (CDSS) to patient-focused smart-
phone apps, and innovative digital mental health promotion campaigns.. An increasing body of ev-
idence supports the use of computers and the internet in the provision of interventions for depres-
sion and anxiety in children and adolescents. Comprehensive evaluations of the effectiveness and
cost-effectiveness of multiple delivery systems to address anxiety, depression, and other disorders
are needed in order to shape and disseminate new approaches to DHI.
Some of the proposed work will thus include:
1. Supporting epidemiological work exploring the prevalence of mental health problems in the
targeted population
2. Promoting early detection for psychosis and developing crisis intervention centres for adoles-
cents
3. Screening and brief intervention in primary care for substance and alcohol misuse among ado-
lescent and youth populations
4. Developing school-based social and emotional learning programmes to prevent psychosocial
and conduct problems in childhood; preventing school dropouts; and promoting programmes
for school mental health. Parenting interventions for preventing persistent conduct disorders in
children and dealing with mental health problems among youth
5. Workplace screening for early detection of mental health problems among the young workers
and promoting wellbeing in the workplace
6. Implementing collaborative care for mentally ill patients with other medical co-morbidity
7. Conducting a series of educational -multidisciplinary symposiums highlighting the challenges
and opportunities which digital child and adolescent psychiatry
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 80
Dealing with co-morbidity issues in psychiatry and
developing strategies to engage with other medical
and health professionals
Comorbidity is one of the most important issues facing health systems in the world today, and the
single disease approach cannot address this problem appropriately. Patients with multiple long-
term conditions are becoming the norm rather than the exception, and the number of people with
comorbidities is set to increase in coming years.
Comorbidity in mental illnesses is gaining signicant importance in our day-to-day practices. There
are two key populations with comorbidities, and each of these populations requires a distinct ap-
proach:
• Those who have comorbidities mostly due to increased life expectancy and therefore a longer
exposure to risk factors.
• Those who have comorbidities mostly from more intense exposure to risk factors, particularly
smoking, alcohol, physical inactivity and obesity. This intense exposure is due to a combination
of life challenges, including persistent and widening inequalities.
Patients in both groups face complex physical, social and emotional problems and are more likely
to have mental health diculties. It is important to address these issues of comorbidity as a prior-
ity. While many lives may be saved in the short term from improved management of comorbidities,
the system-wide action that is needed to address comorbidities will take longer to implement, and
the benets will be seen over a longer period.
The WPA needs to discuss these issues from a worldwide perspective and focus on promotion, in-
terventions, teaching, and training of mental health professionals in these areas. Proposed actions
include:
1. Supporting epidemiological work exploring prevalence of other medical co-morbidities in the
targeted population
2. Developing guidelines for programmes involving joint work with non-psychiatrist professionals
3. Early detection for co-morbid conditions in mentally ill patients and early recognition of mental
health problems in the context of chronic medical illnesses
4. Screening, preventing, and initiating early treatment of such disorders.
5. Capacity building, with strategies for teaching and training psychiatrists and other mental
health professionals and non-psychiatrist colleagues about joint work
6. Planning joint research activities and developing policy documents for improving mental health
care in sub-speciality settings
Developing partnerships for collaborative work
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 81
and strengthening partnerships with mental health
organisations
Health is a complex phenomenon, which needs joint work among different health professionals to
benet patients and provide the best available care.
There are mutual benets to all stakeholders working jointly if patients are the prime beneciaries
of such efforts. Psychiatrists adhere to the principles of joint work based on fundamental princi-
ples of shared vision, equity, transparency, mutual benet and respect. Trust, transparency, and
accountability are key to getting joint-work projects off the ground
The WPA would therefore like to explore opportunities for partnerships with medical professionals
such as general physicians, neurologists, paediatricians, geriatricians, cardiologists, diabetologists
and other allied specialities in medicine; NGOs; and non-medical mental health organisations.
Proposed activities may include:
• Collaboration and liaison with mental health organisations, NGOs, and other non-medical mental
health organisations in identifying initiatives for joint work
• Inviting other organisations to WPA congresses and developing links for joint work in teaching,
training, and capacity building
• Planning joint research activities and developing policies for improving mental health care in
sub-speciality settings
• Developing capacity building and training policies in global mental health
Developing Capacity building and training policies
in global mental health
The optimal approach to building capacity in mental health care around the world will require part-
nerships between professional resources and promising health-related institutions.
These partnerships need to be sustainable, develop quality in clinical care and research, and build
a productive environment for professionals to advance their knowledge and skills.
Fostering the continuous improvement of psychiatric education and training among medical stu-
dents is an equally essential step in this process and a premier objective of the WPA
Continuation and completion of previous WPA Action Plans
Previous WPA Action Plans, particularly the 2017-2020 Action Plan, set out strategies for expand-
ing the contribution of psychiatry to improved mental health across the globe. Three characteris-
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 82
tics frame the strategic intent of the Action Plan: continuing WPA’s contribution to developing the
profession of psychiatry; addressing critical mental health topics; and attracting new investment to
support this work.
Mental health promotion, prevention and treatment of mental illness are also incorporated into the
plan.
The plans formulated in 2017-2020 will be implemented through current partnerships and new
funding. This plan is actualized through a strategic framework based on three dimensions:
• Impact on population groups
• Facilitation of activities
• Partnerships and collaboration.
The identied population groups are young girls and women and all young people having mental
health problems resulting from adversities.
Way Forward
All areas covered in the proposed Action Plan are high priority. However, due to time limitations and
scarcity of resources, only specic areas may be addressed. During the current triennium, expert
working groups will start pilot projects in different areas of the Action Plan. Once the ndings of
these pilot projects are available, we will seek funding to implement these ideas in different set-
tings and countries.
It is hoped that the 2020-23 Action Plan will generate interest among all WPA components to devel-
op guidelines and directions for future work and seek higher mental health services budgets from
relevant sources.
WPA is optimistic that it will receive support, active input, and advice from our membership in set-
ting these priorities and making a real difference in mental health.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 83
Mental Health in an
Unequal World: – Digital
Transformation – Leaving
No-one Behind
VISHANTH WEERAKKODY PHD
Professor of Digital Governance. Chair of Bradford Business and Social Enterprise Board. Universi-
ty of Bradford. Email: v.weerakkody@bradford.ac.uk
GABRIEL IVBIJARO MBE JP
Secretary General WFMH. President & Founder The World Dignity Project. Visiting Professor Popu-
lation Mental Health NOVA University Lisbon Portugal. Honorary Visiting Fellow Bradford University
School of Management UK. E-mail: gabriel.ivbijaro@gmail.com
LUCJA KOLKIEWICZ MBBS MRCPSYCH
Visiting Professor NOVA University Lisbon Portugal. Consultant Rehabilitation Psychiatrist East
London NHS Foundation Trust UK. E-mail: lucja.kolkiewicz@gmail.com
ALIKI KARAPLIAGKOU
Lecturer in Sociology. School of Social Sciences. University of Bradford. Email: A.Karapliagkou@
bradford.ac.uk
AMIZAN OMAR
Associate Professor. School of Management. University of Bradford. Email: a.omar4@bradford.
ac.uk
KEY MESSAGES
To address inequality and support mental well-being health services, local and central government
should design and deliver pathways to digitally enabled services that promote inclusion and ac-
cess to welfare among disadvantaged groups and communities.
Governments and health services must in equal measure:
• simultaneously address issues of exclusion, cohesion and wellbeing when designing digital
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 84
services
• simultaneously plan digital strategies, when designing welfare policies and practices
• develop and implement pathways for digital inclusion that enable all citizens to benet from
the digital revloution
The Need for Digital Inclusion
The Covid-19 pandemic has exposed an issue highlighted decades ago; “digital exclusion” which
not only affects proper access to higher education but also access to healthcare and social welfare
services. Local authorities and other public services, on the front lines of many interventions to
ameliorate the effects of the pandemic and lockdowns, suddenly had to confront the challenge of
supporting groups that do not have access to or use the internet. Numerous mental health servic-
es responded to the challenges faced by the COVID 19 pandemic by providing web-based inter-
ventions, leading to a decline in face-to-face support services, increased online psychoeducation,
e-Therapy, online self-help resources, online support groups, video-conferencing and increased use
of SMS and other mobile telephone based technologies which have turned out to be a preferred
alternative.
Although the younger population in areas with access to appropriate internet infrastructure have
embraced such web and telephone-based technology, this is not the case for many, an unintended
consequence of the exclusion of several groups, including those with Severe Mental Illness (SMI)
further amplifying existing mental health related inequalities (Spanakis et al 2021). Data from the
UK states that 5% of the population (2.7 million people) do not use the internet (Ons.gov.uk) and
for those with severe mental illness (‘SMI’) conditions such as schizophrenia and bipolar disorder,
the percentage is considerably higher i.e. 17.5% of people with SMI engaged with a community
psychiatric rehabilitation team were able to use a computer and 14.4% of this group were able to
use the internet (Tobitt et al 2019).
Even regarding those who are well versed with IT and are tech-savvy, there is still a great deal of
work required to be done in order to gather information regarding the most ecient method to de-
ploy technology and IT Resources to support mental health interventions. We know that web based
psychological interventions have low utilisation, low adherence and a high number of drop-out
rates (Mohr et al 2013; Christensen et al 2009) and this can be improved by the provision of profes-
sional guidance and support.
Those who are digitally literate can use this as an important resource, and in 2015 more than 7
billion people globally had access to mobile telephone technology, with 70% of them residing in low
and middle-income countries. Challenges faced by these programmes include the use of multiple
platforms that are not well-connected, no clear plans to improve the scale of access, poor integra-
tion with existing platforms, absence of standardized tools and lack of a proper evidence base to
support e-interventions resulting in citizens expressing a lack of faith in engaging with such sys-
tems (WHO 2018).
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 85
During 2017, 76% of European Citizens were accessing the internet on a weekly basis, meaning
that approximately 24% of citizens and 47% of older adults were not using this technology. In the
United States of America, 98% of people aged between 18 to 29 years were using the internet
regularly, compared to only 66% of people aged 65 years and over (Gann 2019). [By the way, more
recent data says 75% of over 65s in the US are online but fewer with only a high school education
https://www.pewresearch.org/fact-tank/2021/04/02/7-of-americans-dont-use-the-internet-who-
are-they/]. If we are to tackle the poor life expectancy faced by individuals with mental illnesses
through the digital revolution, then we must ensure that we do not create a set of ‘digital haves’ and
‘digital have-nots.’ To avoid this, we must upskill the population to improve digital literacy, improve
access to digital technology and care delivered through these methods.
In the UK, the local government has a role to play and the case example presented illustrates some
issues and solutions.
Digital Inclusion and The Local Government – The
UK Case-Study
Digital inclusion is an important concern for humanitarian and legal reasons. During the COVID-19
pandemic, as well as the life-threatening consequences for those lacking access to the default
“digital” methods, the adoption of such non-inclusive channels for carrying out public functions and
services can also contravene established legal and public administrative principles, within which
such laws exist.
In the UK, public bodies must comply with several laws; particularly with the Human Rights Act
1998, the Equality Act 2010 and its Public Sector Equality Duty at s149, the Data Protection Act
2018 (including restrictions on proling and automated decision making), and laws concerning
public functions or services being exercised. In the UK, Local government authorities must meet
the Principles of Good Administrative Practice to:
• ensure people can access services easily, including those needing reasonable adjustments,
• deal with people promptly and sensitively, taking account of their individual circumstances,
• responding to the users of said services requires exibility and where appropriate coordinating
a response with other service providers,
• recognise and respect the diversity of service users and adopt an inclusive approach.
There is evidence that a response to the pandemic that depended heavily on digital channels of
communication fell short on these standards in several cases and reasons for this inter-alia in-
clude:
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 86
Government Strategy
The UK government’s strategy expected the provision of IT resources and equipment to lead to
widespread use of online public services and assumed that once people use online services, they
will continue to do so.
This government’s digitisation strategy was described as a ‘grand idea’ or a ‘dream’ which proved
‘unrealistic’ and ‘idealistic’, and furthermore failed the citizens because it exhausted public funding
and widened the gap between frequent internet users and those who remain digitally excluded.
It provided digital public services that were simultaneously more centralised, standardised and
impersonal, undermining and contradicting the principles of the ‘duty of care’ at the core of welfare
services resulting in a loss of identity of public services, losing the force that traditionally binds
citizens together.
Closure of public services and spaces
During the pandemic there was uneven benet from digital changes to administrative procedures
because the closures of public spaces such as libraries and community centres widened the
disparities in the distribution of these resources. Disadvantaged groups and certain communities
become isolated and disconnected from the civic facilities and interactions that traditionally sus-
tained cohesive communities.
The type of data that members of the community as a whole have access to, drastically depends
upon their societal status, their ethnicity, age, class, health status, gender, professional capacity
and social networks, these all may vary considerably person to person. The entire experience of
being online and accessing e-services varies depending upon a person’s background and status.
Issues of inclusion extend beyond resolving the concern of access to technology and online servic-
es; it is about access to types of ‘social capital’ that aims to bridge the digital divide. A bottom-up
approach to digital development can promote greater and far more meaningful and interactive
employment and usage of the options offered.
Putting Caring Relationships at The Centre of
Digital Strategies
The Covid-19 pandemic emphasised the continuing need for caring relationships and interactions,
and mobilised keyworkers and care professionals to take a proactive approach and reach out and
identify the needs of the community, among those who remain digitally excluded.
Cases were shown regarding people who remained isolated and disconnected from their families
in temporary accommodation, as they had no means to claim welfare support and no funds to
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 87
charge their phones or connect to the internet. Students had to submit their coursework in a series
of text messages directly sent to the teacher, highlighting how disparities attributed to poverty are
exacerbated by digitisation.
Solutions during the pandemic were ascribed to the resourcefulness of local governments, which
supported community initiatives, conscientious professionals, engaged citizens and cohesive
communities. Sucient and suitable capability was mobilised at short notice to meet local needs
and many of these initiatives took a hybrid approach, mixing face-to-face and virtual interactions.
Community actions supported by digital technology, provided evidence that digitisation is about
the meaningful application to benecial purposes that boost resilience. Public services need to
formulate digital strategies within the context of their unique ethics, purpose and design to offer
valuable assistance and facilities.
A bottom-up approach towards digital development can promote greater and far more meaningful
and interactive engagement regarding the services offered.
Digital innovations are required to intelligently calculate and address the causes and effects of
multiple layers of social shortcomings into their core design to enable equitable access, engage-
ment and participation.
Culturally diverse and socially disadvantaged urban communities may face additional challenges
when accessing digital service provisions, and pressure for accelerated technology-led develop-
ment risks aggravating pre-existing divisions. Poverty, educational and cultural differences and
inequalities call for a signicantly more nuanced and participatory approach to service provisions
with communities placed at the centre of the conceptualisation and development of digital and
other infrastructures.
Some potential solutions
• The private sector under ‘corporate social responsibility’ needs to take a more proactive and
long-term approach to community partnerships, that move beyond transactional services and
includes stakeholder consultation and engagement in decision-making processes regarding IT
resources, and explicitly their design, distribution, application, and delivery.
• Local authorities ought to take a capability-based approach and utilise existing skills, abilities
and community infrastructure to facilitate inclusion via volunteering and organised community
initiatives.
• Public services, private sector initiatives and local authority welfare-support need to take into
consideration and represent within their digital services to offer the culture, ethics, values, pref-
erences, meanings and lifestyles of local communities to appeal to their needs and to promote
inclusion.
• In other words, digital options are obligated to enable normal and routine processes, activities
and interactions, appeal to the meanings and enhance the quality of life of the citizens.
• Public services need to formulate digital strategies capable of offering valuable welfare and
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 88
support to citizens and register ongoing collaborations and commitment.
• Functions should be designed with most marginal communities and communities with a
pre-disposed risk to exclusion in mind.
• The private sector needs to take a more proactive and long-term approach to engage in deci-
sion-making processes regarding IT resources, specically; their design, distribution, applica-
tion and delivery.
• Inclusive digital services can facilitate informal ‘warm hands’ care in local cohesive networks
which are very important during Covid-19.
The Role of ICT (Information and Communication Technology)
• Local authorities have a share in the responsibility to act as a trusted party in connecting com-
munity networks and other infrastructure into a coherent and ecient system.
• Local authorities should be involved in outreach activities throughout the community and
should employ multiple means and methods to promote social inclusion through access to
services, be it digital or otherwise.
• The signicance and appeal of a combination of digital and face-to-face interactive options and
opportunities were found to promote inclusion.
• Data driven humanitarian responses address basic needs and crisis such as food shortages,
but there are concerns that the data available may not be representative of the population or
the coverage may be limited.
• Data driven initiatives promote inclusion when they represent local cultures, ethics, values,
meanings, preferences and ways of life in their digital services because they tend to attract
unexpected stakeholders (people are inclined to voluntarily register their involvement because
they see their needs being represented).
References
1. Spanakis, P., Peckham, E., Mathers, A., Shiers, D., Gilbody, S. The digital divide: amplifying health inequalities for peo-
ple with severe mental illness in the time of COVID-19. The British Journal of Psychiatry. 2021. 23:1-3. Doi: 10.1192/
bjp.2021.56
2. Ons.Gov.Uk, Internet access – households and individuals, Great Britain: 2020, Available at: https://www.ons.gov.uk/
peoplepopulationandcommunity/householdcharacteristics/homeinternetandsocialmediausage/bulletins/internetac-
cesshouseholdsandindividuals/2020
3. Tobitt, S. Percival, R. Switched on or switched off? A survey of mobile, computer and internet use in a community
mental health rehabilitation sample. Journal of Mental Health. 2019. 28 (1): 4-10
4. Mohr, D.C., Burns, M.N., Schueller, S.M., Clarke, G., Klinkman, M. Bheavioural intervention technologies: evidence
review and recommendations for future research in mental health. General Hospital Psychiatry. 2013. 35: 332-338
5. Christensen, H., Griths, K.M., Farrer, L. Adherence in internet interventions for anxiety and depression. Journal of
Medical Internet Resources. 2009. 11(2): e13.
6. World Health Organisation. mHealth. Use of appropriate digital technologies for public health. A71/20 26 March
2018 Seventy First World Health Assembly. 2018. WHO: Geneva.
7. Gann B. Transforming lives: combating digital health inequality. International Federation of Library Associations and
Institutions. 2019. 45(3): 187-198 DOI: 10.1177/0340035219845013
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 89
Sustaining the Political
Momentum on Mental
Health and Psychosocial
Support
SARAH KLINE
United for Global Mental Health
MAXIMILIEN ZIMMERMANN
Handicap International
ALBERTO VASQUEZ
Sociedad y Discapacidad
ANN WILLHOITE
Unicef
On October 5-6, 2021 the Government of France is hosting the Global Mental Health Summit, “Mind
Our Rights Now!”. This article is written by the organisers of a workshop that will be held during the
summit; the focus is sustaining political momentum. More information about the summit.
Sustaining and increasing political momentum on mental health and psychosocial support
(MHPSS) requires four things:
1. Keeping mental health and psychosocial support a priority on the political agenda and securing
sustainable funding
2. Mental health policies and processes follow a rights-based approach
3. Addressing the underlying social determinants of mental health
4. Transparent and independent monitoring and accountability mechanisms track progress
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 90
Keeping Mental Health and Psychosocial Support
on the Political Agenda and Securing Financing
From 2019-2021 MHPSS has risen up the political agenda globally (and in some cases national-
ly) leading to an increased prioritisation by global institutions and some national governments.
Demand for greater political action on MHPSS looks set to continue as a result of the short- and
long-term impacts of COVID-19 and as the stigma surrounding MHPSS is addressed (particularly
by young people and the courageous work of people with lived experience). Civil society groups,
UN agencies and other visionary leaders are mobilising to respond.
This year the focus of World Mental Health Day is Mental Health in an Unequal World. it is not
enough for mental health to rise up the political agenda. These political efforts need to be sus-
tained through strong leadership combined with the necessary policy reforms and targeted nanc-
ing that will be galvanised through a mix of advocacy, campaigning and communications across
sectors. Achieving progress needs to be underpinned by mental health and psychosocial support
professionals - including members of the World Federation for Mental Health - who are able and
willing to advocate themselves for change, working fully in partnership with people with lived expe-
rience.
A signicant gap remains in nancing for MHPSS. The World Bank, regional development banks,
the Global Fund to Fight AIDS, TB and Malaria and a host of other international organisations will
need to better prioritise mental health. However, ultimately MHPSS has to be a funded priority of
national authorities and services and support provided free at the point of care if Universal Health
Coverage is to be achieved. Efforts to develop and use investment cases for MHPSS that demon-
strate the return on investment beyond the mental health programmes and systems are a key part
of this work along with advocacy aimed at national parliaments as well as local authority budget
holders, and international donors.
Adopting a Rights-Based Approach
The Convention on the Rights of Persons with Disabilities (CRPD) has created renewed awareness
on the need to uphold human rights standards in the provision of MHPSS for adults, children, fami-
lies, and communities. There has been some momentum in achieving the adoption and implemen-
tation of a rights-based approach to MHPSS since 2017, driven by people with lived experience, but
far more action is needed. To uphold the right to optimal MHPSS as well as the rights of women,
men, girls and boys with psychosocial disabilities on equal basis with others, mental health legis-
lation, policies and practice require urgent reform around the world to ensure a rights-based ap-
proach. While increased investment and more services are needed, the problems of mental health
provision cannot be addressed by simply increasing resources. Instead, it requires - as WHO high-
lighted in its recent guidelines - a move towards more balanced, community-based, person-centred,
holistic, and recovery-oriented practices that respect people’s will and preferences, are free from
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 91
coercion, and promote people’s right to participation and community inclusion.
Progress has been seen at international, regional and national level. The Human Rights Council
has issued various resolutions urging States to take active steps to fully integrate a human rights
perspective into mental health and community services. WHO Quality Rights launched new guid-
ance on rights-based community level services in an event that was incredibly well attended by key
stakeholders and has received signicant attention both in social and traditional media. In June a
virtual meeting on Mental Health and Psychosocial Support in Francophone Africa concluded with
a commitment to create an international french speaking community of practice. Various countries
have also committed to prioritising rights-based approaches, e.g., Victoria, Australia, has embarked
on a reform process which includes the immediate reduction of seclusion and restraint in mental
health, with the aim of eliminating these practices within ten years. But there remains considerably
more work to be done from low-income to high-income countries. A major concern is the decision
of the Council of Europe’s Committee on Bioethics to adopt a draft Additional Protocol to the Ovie-
do Convention, which would allow for the continued use of coercive measures.
Addressing the underlying social determinants
The impact of COVID-19, alongside wars, famines and natural disasters, shows that, in the context
of mental health, there is a need to heal not just individuals but whole societies. COVID-19 has
impacted peoples’ livelihoods, education and social infrastructure across the lifespan; all these
factors contribute to poor mental health.
To address this requires the integration and prioritisation of the social determinants of mental
health including social, political, economic and environmental factors in national and sub-national
plans. This means fully involving people of all ages with lived experience in the development and
implementation of these initiatives. They often face disproportionate barriers to accessing educa-
tion, employment, housing, and social protection. It is accelerating momentum in these areas that
will result in better mental health for all at all ages and stages.
There has been a dramatic rise in the numbers of people reporting mental ill health – partially
linked to COVID-19 but more generally linked to poverty, inequality, discrimination and violence. The
WHO has reported substantial impacts on mental health services due to the impact of COVID-19.
A lack of prioritisation of mental health nationally and locally, combined with poor services and in-
fringements in human rights, have led civil society, particularly youth-led groups, to increasingly use
social media to demand change and provide their own peer to peer support. Action needs to now
take place to develop cross-sectoral strategies for the integration of mental health that prioritise
social and economic interventions to prevent poverty, inequality, discrimination and violence, and
promote more tolerant, peaceful and just societies. This will help redress the challenge of improv-
ing mental health in an unequal world.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 92
Transparent and independent monitoring and
accountability
Monitoring and accountability are essential to driving and sustaining momentum. The personal
advocacy and the detailed reports of the Special Rapporteur on the Right to Physical and Mental
Health, and the Special Rapporteur on the Rights of Persons with Disabilities have been key to
providing detailed analysis and holding individual countries to account. Indicators and benchmarks
are needed to monitor progress towards all aspects of the right to health, not just access. Mean-
ingful participation of persons with lived experience is an important aspect of accountability.
The lack of a global monitoring, evaluation and accountability framework that can be used by a
range of actors - grassroots CSO to global institutions - to hold governments to account has been a
critical gap in global mental health. A partnership between Harvard University, the WHO, The Global
Mental Health Peer Network, Unicef and UnitedGMH has been formed to deliver this framework,
called the Countdown Global Mental Health 2030 (‘Countdown 2030’). The rst interactive dash-
board and annual report was published in September 2021. It demonstrates how social and eco-
nomic determinants impact MHPSS and in future it can contribute to efforts to drive independent
monitoring and accountability for progress on mental health.
Recommendations
1. All stakeholders must work towards the integration and prioritisation of mental health in:
• The COVID-19 response and recovery plans; and future pandemic preparedness
• MHPSS implementation and advocacy across sectors such as Social Welfare, Education, Gen-
der and Health
• Universal Health Coverage plans nationally and internationally to ensure better outcomes for
physical and mental health
• Communicable disease plans and programmes including the Global Fund Strategy 2023-2028
and its implementation
2. A rights-based approach must be championed and upheld through the development of commu-
nity-based services that respect and promote human rights; the reform of national legislation and
policies in line with the Convention on the Rights of Persons with Disabilities and other interna-
tional human rights standards; and the active and meaningful participation of persons of all age
groups with lived experience in policy decision-making.
3. Efforts to address the social determinants of mental health should be prioritised in all sectors
and levels of government as a cross-cutting issue and in a concrete manner, ensuring that MHPSS
and social inclusion interventions are systematically designed and implemented to foster participa-
tion and provide holistic support.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 93
4. Independent monitoring and accountability mechanisms and reports, such as those of the
Special Rapporteurs for the Right to Health and for the Rights of Persons with Disabilities, and the
Mental Health Countdown 2030 dashboard and report, should be used by all stakeholders to help
ensure political momentum delivers better mental health for all.
For more information see:
• www.unitedgmh.org
• www.hi.org
• www.sodisperu.org
• www.unicef.org
SECTION D
Regional Position Statements
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 95
“In search for the missing
link”: Equality and Equity
in mental healthcare in
the Asia-Pacic
ROY ABRAHAM KALLIVAYALIL
Department of Psychiatry, Pushpagiri Medical College and Hospital, Thiruvalla, Kerala, India; Past
President, World Association of Social Psychiatry (WASP)
DEBANJAN BANERJEE
Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Ban-
galore, Karnataka, India
HARIPRASAD GANAPATHY VIJAYAKUMAR
Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Ban-
galore, Karnataka, India
SHU-JEN LU
President, Mental Health Association in Taiwan; Consultant, Department of Psychiatry, Taipei Tzu
Chi Hospital, New Taipei City, Taiwan; Regional Vice President, Asia Pacic Region, World Federa-
tion for Mental Health
Corresponding author:
Professor Roy Abraham Kallivayalil - roykalli@gmail.com
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 96
Introduction: The context of global mental health
inequalities
“The future depends on what you do today.” ―Mahatma Gandhi
Mental health has never been a priority in most countries of the Asia Pacic region. It has long
been ignored resulting in poor mental health infrastructure and poor resource allocation. In many
countries of the region, mental health budget constitutes less than 1% of the health budget. Sim-
ilarly mental health has been ignored in medical and higher education. There are fewer oppor-
tunities for mental health professionals in most of Asia Pacic. Thus, there has been cascading
adverse effects on the mental health of the population. But as Mahatma Gandhi had said, the
future of mental health in the region depends on what we do today. The World Federation of Mental
Health (WFMH) has a paramount role in achieving this mission.
The world has never been an equal place at any time in history. But globalization and neo-liberal-
isation appear to have deepened this inequity in various regions of the world in a diverse manner
over the last few decades. The impact has been particularly negative among populations within the
labour markets in the low-and-middle-income countries (LMIC) [1]. The change in labour markets
has contributed to work intensication, long working hours, increased workload, work pressure and
poor work-life balance [2]. Work life balance has been reported to play a crucial role in promoting
satisfaction and better mental health in employees [3, 4]. Individuals and professionals who work
for a longer duration have been associated to have increased disability-adjusted life years (DALYs)
and years lost to disability (YLD) [5, 6, 7]
Coincidentally stress related illnesses are also predicted to become the leading causes of the
global disease burden within the next decade [8]. While it can be argued that globalization has led
to this poor work-life balance, it doesn’t appear to be the only cause of stress-related illnesses. The
differences in the work environment in different countries can often specially be attributed to their
social welfare policies, psychosocial safety climate and labour market policies. Countries with a
high social expenditure and where the social policy superseded the economic policy appeared to
have a better psychosocial safety climate. The other indicator of the psychosocial safety climate
was union density, which was also related to worker health, life expectancy, income equality and
gross domestic product (GDP) at the national level [9, 10]. Lack of awareness of worker psychoso-
cial well-being has also hindered the development of policies in certain regions of the world.
Social stratication in various societies appears to result in inequalities in capabilities, which in
turn leads to unequal empowerment and access to resources, thereby contributing to inequalities
in health. Hence, relative poverty and socio-economic position may play a major role in the inequi-
ties in health. Income inequality may also maintain and increase the social divisions and inequal-
ity to resources, by its negative effects on one’s health [11]. Inequities are particularly high with
respect to mental health. One of the reasons for high mental health inequality is setbacks in the
understanding of the relationship between mental health and the other existing inequalities in the
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 97
society [12, 13].
In addition, psychiatry as a discipline, tends to limit itself to the eld of medicine and not beyond,
by its classication of mental illnesses in such a way that only individuals who require medical or
psychological management are identied. This approach might also inuence the popular ‘bio-psy-
cho-social’ model in a negative way such that the psycho-social interventions in the model are
reduced to predominantly helping an individual in understanding the biological model of the illness
and getting treatment for the illness. This might unjustly medicalize the distress that the individual
undergoes because of their social identity, deprivation and various other psycho-social factors, and
subsume it under the illness or completely negate the plausibility of its correlation with the illness.
Such an approach might also oversimplify these psycho-social issues as functional diculties in
individuals, and thereby trivialize and maintain these factors.
While it can be debated that it is beyond the scope of psychiatry to deal with these issues, an ap-
proach to ignore them might only help the individuals cope in environments which are unjust and
even cruel to them. While the above lies in the context of ‘social causation’, the concept of ‘social
drift’ is also to be noted [14]. Persons with mental illness also get displaced and disempowered in
society and may face inequality in their lives. Due to the above factors and many more explained
below, addressal of inequality has become quintessential in improving population mental health
and overall wellbeing. This warrants a thorough understanding of the inequalities, their association
with mental health, and the challenges in tackling them. Aptly enough, the World Federation for
Mental Health (WFMH) has set the theme “Mental Health in an Unequal World” for this year’s World
Mental Health Day (2021).
Mental health in the Asia-Pacic: A strategic and
economic area of importance
Even though there is some ambiguity on what constitutes Asia-Pacic (APAC), the term has gained
popularity since the late 1980s in political relations, climate change, socio-economics and com-
merce [15]. In spite of the inter-nation heterogeneity, most countries are emerging as markets expe-
riencing rapid growth and the consequent urbanization has marked effects on psychosocial health.
The APAC generally includes South Asia, East Asia, Southeast Asia, Oceania and Australasia, and is
home to around 2.6 billion people, being considered one of the most dynamic global regions. APAC
contributes 47% of global trade and 60% of world’s GDP [16]. Besides the rapid industrialisation,
economic growth and scientic expansion, this region also has certain unique challenges. Some
of them are vulnerability to climate change, frequent natural calamities, increasing rural-to-urban
migration and ever-widening socio-economic and health inequality.
Epidemiological and socio-demographic transitions are leading to an increased focus on non-com-
municable disorders (including psychiatric illnesses), population ageing and healthcare equity. The
proportion of the budget dedicated to healthcare in this region is low compared to the Western
countries [17]. Even though all of these have direct and indirect implications for mental health, and
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 98
related research has increased over the last few decades, mental health systems, service delivery,
policies and legislations still have a long way to go to address these growing challenges. Some
of these common challenges with regards to mental health in the APAC region are highlighted in
Table 1. Some or all of the countries in this region face challenges as the quality and standard of
mental healthcare varies widely across and within the countries.
• Low mental healthcare budget expenditure
• Vulnerability to disasters and rapid climatic changes
• Mental health funding mainly by government resources with low involvement of private agen-
cies and insurance companies
• Lack of trained mental health workforce
• Limited availability of funding, service provisions and medications
• Barriers to mental health research
• Most nations have mental health policies or plans, few have legislations
• Stigma and discrimination related to psychiatric care, medical misinformation and lack of com-
munity acceptance
Discourse on mental health assumes a renewed signicance as APAC is predominantly an eco-
nomic forum, in terms of identity. According to the UK All-Party Parliamentary Group on mental
health [18] the total nancial burden of chronic diseases worldwide (including mental disorders) is
an estimated USD 47 trillion. APAC leaders have also highlighted that “continued neglect of mental
health constitutes a brake on economic and social development.” Even though this region shel-
ters nearly half of the estimated population of individuals experiencing mental illness worldwide,
community mental healthcare continues to be an ongoing challenge [19]. The diculties include
inadequate funding and trained workforce as well as lack of integration among various levels of
healthcare and limited public-private collaboration [20]. Most importantly, the shortage of trained
mental health professionals is a critical limiting factor.
The World Mental Health Day theme of 2021 “Mental Health in an Unequal World” aptly puts to
light the concerns of the APAC region and the need to implement changes right from the individ-
ual to structural level. This position statement thus calls for action to reduce the mental disorder
burden in this region and to promote psychological health and wellbeing. This includes principles
of preventive psychiatry, rehabilitation for disabilities, social inclusion of people who are mentally
ill, human rights-based approach, and poverty reduction measures. These measures are not limit-
ed to just the health sector but cut across the domains of education, employment, housing, food
security, sanitation, and fundamental rights. The measures discussed here are both in line with the
FundaMentalSDG (a global initiative for aligning the sustainable development goals (SDG) with
mental health priorities and target indicators) [21] as well as the WHO Mental Health Action Plan
2013 – 2020 (which resonates with the national noncommunicable diseases strategy) [22]. The
core principles of both these action plans need to be considered for interventions in the APAC re-
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 99
gion. These include human rights protection, dignied mental healthcare, community engagement,
psychological rst-aid, universal mental health coverage, life-course based multisectoral approach,
developing national mental health laws/policies and evidence-informed service delivery. The vari-
ous intersecting dimensions of mental healthcare in the APAC are depicted in Figure 1.
Figure 1: Various inter-related dimensions of mental health in the Asia-Pacic region.
Existing community models of care in the Asia-
Pacic region
As mentioned above, the APAC nations are geo-politically and socio-culturally unique. As a result,
Western community-based mental healthcare models cannot be directly adopted for interventions
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 100
in these areas. While a commonality is desired, it will be reductionistic to create rigid recommenda-
tions based on a singular community care model, that cannot be translated to reect the diversity
of this region. As [19] mentions, “for constructive change to occur in the region, innovative, culturally
appropriate and economically sustainable pathways for community treatment models need to be
explored, developed and shared.” Besides the regional mental health organizations and their strate-
gies within the APAC such as South-Asian Association for Regional Cooperation (SAARC) Psychi-
atric Foundation, Asian Federation of Psychiatric Associations (AFPA) and the Australasian Feder-
ation, there is the Asia-Pacic Community Mental Health development (APCMHD) project, which
comprises of 14 nations/regions in the area.
The APCMHD works in collaboration with the WHO Western Pacic Regional Oce and is led by
Asia-Australia Mental Health (a consortium of the Department of Psychiatry, University of Mel-
bourne) and St. Vincent’s Health (part of the WHO Collaborating Centre for Mental Health, Mel-
bourne) [19, 23] The project aims to promote evidence-based practice of community mental health
in the APAC region with cross-national collaboration and sharing of knowledge. A network of key
representatives from the ministries of health and mental health bodies in various participating
nations are involved to jointly develop best practice guidelines.
Some of the key principles of community-mental health care models in the APAC region based on
this project and examples of best practice from the component nations are highlighted in Table 2.
be used to address mental health inequalities [11, 19, 24, 36-39]
NO. PRINCIPLE FEATURES EXAMPLES
1 Community-based
care in hospital
system
Community outreach teams
Primary-tertiary collaboration (hub-spoke model)
Facilitate early discharge and social integration
Liaison with general hospital and primary care
Day care services, rehabilitation and community education
• Bahagia Ulu (Perak, Malaysia)
• Kyonggi Provincial Mental
Health Program (Korea)
• The Regional Psychiatric Ser-
vice Network (Taiwan)
2Equitable mental
healthcare access
Access to basic level of psychiatric care, medication and
family support
Curative, preventive, promotive, vocational services
Stigma reduction, nancial support, social welfare benets
Target vulnerable groups (older people, homeless, low SES,
etc.)
• National Mental Health Service
Model Reform Program / 686
Program (China)
• Community Mental Health
Nursing (CMHN) (Indonesia)
3Continuity of care Prevent chronic institutionalisation
Strengthen self-ecacy, personal abilities and quality of life
Social skills training, housing support, supported employ-
ment
Telephonic review
• The Extended-Care Patients
Intensive Treatment, Early
Diversion and Rehabilitation
Stepping Stone (EXITERS)
(Hong Kong)
• Fight from the Nest Group
(Sudachi-kai) (Japan)
• Ger Project – WHO and SOROS
Foundation (Mongolia)
• Long-term Care Services for
Psychiatric Patients Pilot Pro-
ject (Taiwan)
4Empowering ser-
vice-users/carers
Enable joint decision-making in treatment
Patient autonomy and independence
Patients and carers as sources of experience and advocacy
Self-help groups
• House of Bethel (Japan)
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 101
5Networking Partnerships with NGOs, community groups, volunteers, etc.
Collaboration with all involved stakeholders
• Mental Health Care model
(Cambodia)
• Community-based Mental
Health (CSSKTT) (Vietnam)
6Integration into
public healthcare
system
Cost-effective model of care in settings with limited
resources
Training healthcare workers in community/primary care in
basic mental health
Tele-training
• District Mental Health Pro-
gramme (DMHP) / National
Mental Health Programme
(NMHP) (India)
• Taipei Model, Taipei City Psy-
chiatric Center (TCPC), Taiwan
7Mental health
education and
promotion
Improve knowledge-attitude-practice
Stigma reduction
Community mental health awareness programs
Create mental resilience and mind literacy
• DMHP (India)
• Community Based Mental
Health Program (CMHP)
(Thailand)
• Mental Health Promotion
Project (Mongolia)
• Mental Health Literacy Pro-
gram, Mental Health Associa-
tion (Taiwan)
8Dealing with psy-
chiatric emergen-
cies
Adequate and timely crisis interventions (emergencies,
homelessness, during disasters, etc.)
Tele-psychiatric practice and monitoring
Suicide prevention
• Seoul Metropolitan Mental
Health Centre (SMM-HC)
(Korea)
• Crisis Mental Health Interven-
tion (CMHI) (Thailand)
9Early psychiatric
interventions
Disability and relapse reduction
Attention to education, social skills and social participation
Chronic mental illnesses
• Early Psychosis Intervention
Programme (EPIP) (Singapore)
• Early Assessment Service for
Young People (EASY) (Hong
Kong)
• Early Assessment and Inter-
vention Service for Develop-
mental Delay Children (Taiwan)
10 Patient-centred
and rights-based
approach
Recovery oriented services
Socio-culturally sensitive interventions
Comprehensive and exible models of care (in-patient, com-
munity, outpatient and home-based)
Multidisciplinary care (GP, psychiatrist, CP, PSW, psychiatric
nurse, allied professionals)
• Prevention and Recovery Care
(PARC), Victoria (Australia)
• Community Psycho-Geriatric
Programme (CPGP) (Singa-
pore)
• National Mental Health Service
Model reform program / 686
Program (China)
Challenges and the need for Action
Mental health is inuenced by numerous factors including genetic constituency, parenting, perina-
tal factors, adverse childhood experiences, quality of life, stressful events, income equality, acces-
sibility to education and mental health services, social stratication, culture, labor market policies,
human rights perspective, and economic policies. Hence, the presentation of mental health issues
and the challenges that are associated with their management differs from one region to another.
But the approach to mental illnesses has almost always utilised or adapted the western classi-
catory systems to dene and manage mental illnesses. While there is no doubt that it is by far the
best system available to dene mental illnesses in a categorical way, and is in turn a valuable tool
for the diagnosis and treatment of the respective mental disorders, it does not take into account
the cultural and social factors of the various regions and cannot be regarded as an universal sys-
tem. This becomes especially important as distress may be experienced and expressed in different
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 102
ways, depending upon the culture and practices of a region. More importantly, it has the potential
to universalize the socio-economic positions of individuals in the western countries, which may not
be the case worldwide. This might especially be detrimental in addressing the sociogenic causes
of distress and disability, which are more prevalent in the LMIC and often invisible in nature. Hence,
there is a need to make region specic plans and actionable goals.
The current understanding of the relationship between inequality and mental illness appears to be
reductionistic in reducing the same to a bidirectional relationship between poverty, and increased
incidence of mental illness and disability. The generic measures of poverty may not be sensitive
or specic enough to detect, dene and determine the inequalities in the society [14]. Hence, there
is a need to dene these inequalities and social determinants as warranted in different regions
through validated instruments. Social inequalities are multi-dimensional and cut across various
aspects of living. How each of these attributes can potentially affect psychosocial wellbeing is
summarized in Table 3. Likewise, the denitions of mental illnesses need to be modied to be
more holistic to include these parameters. These two changes might help in more accurately
dening the above relationship and providing appropriate data. Besides the shortcomings of the
available measures, there is a severe lack of data related to mental healthcare inequalities in most
LMIC, affecting the policy making [25]. There is an incognizance towards mental health at various
levels in the government; social determinants among the psychiatrists; psychiatric illnesses and
treatment among the population. Although there are efforts being made worldwide to address few
of these issues, they have not been able to make any drastic changes in reducing the mental health
gap or attenuating the existing inequality. One major reason for the above, especially in LMIC is
that the minimum spending on mental health from their total health expenditure is less than the
recommended minimum [25]. This can again be attributed to the above factor of incognizance at
various levels, especially when aggravated by disasters or pandemics such as COVID-19 making it
a vicious cycle (Figure 2).
Table 3: Different dimensions of social inequalities and how they affect psychosocial well-being
[14] [with permission from Routledge]
DIMENSIONS OF SOCIAL INEQUALITY ATTRIBUTES AFFECTING MENTAL HEALTH
Poverty • Debt
• Income inequality
• Substance abuse
• Marital breakdown
• Increased rates of crimes
Unemployment • Impaired autonomy and condence
• Reduced social networks
• Compromised social status
• Relative poverty
Poor quality of workplaces • Lack of job security
• Insucient pay
• Social exclusion
• Absenteeism
• Inexible work environment / poor physical work environment
• Lack of safety at workplace (especially for women)
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 103
Low levels of education • Decreased emotional and cognitive skills
• Risk of substance abuse
• Trauma and bullying
• Reduced mental health awareness
• Accentuates income inequality
Cultural/group-based discrimination
(age, sex, gender, ethnicity-based; BAME
communities; LGBTQI+)
• Racism and violence
• Social discrimination/prejudice
• Othering
• Bullying and hate crimes
Migration • Heightened income inequality in migrant workforce
• Social identity crisis
• Social injustice
• Lack of policies/crisis interventions
• Societal apathy
• Increased mental health problems in asylum seekers, refugees, immigrants (de-
pression, post-traumatic stress disorders, existential threats, eviction)
Social stigma • Lack of knowledge (ignorance)
• Maladaptive attitudes (prejudice)
• Self-stigma and discrimination
• Social isolation
• Reduced access to mental healthcare
Adverse childhood and adulthood expe-
riences
• Socio-economic disadvantage
• Any form of abuse
• Familial discord
• Parental substance abuse
• Substance use disorders
• All the dimensions mentioned above
Disability and aging • Social drift
• Frailty
• Sensory and cognitive impairment
• Loneliness
• Ageism
• Elder abuse and institutionalization
Ecological • Urbanization
• Lack of adequate housing/transport facilities
• Homelessness
• Maladaptive neighborhood environments
• Pollution
• Lack of public space/greenery
Figure 2: The vicious cycle of poverty and social inequality amplied by disasters or pandemics
such as COVID-19.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 104
There is a need to conduct research on, publish and advocate for studies on health economics,
especially cost-effective studies for a better understanding of the same, enabling adequate allo-
cation of resources to mental health to attain the targets. There is also a need to ensure proper
distribution of the allotted resources, taking into account the various decits in the health and
social infrastructure as these decits might hinder the accessibility of resources. Hence, it is
important to strategize the means and modes of distribution accordingly. For instance, allocation
of more resources to inaccessible communities might reduce the stigma associated with mental
illnesses and would help in moving towards universal access. There is a need to re-examine the
correspondence of psychiatry to mental health, and to include and promote other human sciences
such as sociology and anthropology in the context of mental health. This would not only provide
more workforce to the cause of mental health, but also encourage collaboration. Another known
is for the branch of mental health to lay more emphasis on positive psychology and the concept
of functional recovery. Both of these concepts may be more associated with disability rather than
psychopathology; and are likely to be more inclusive of sociogenic factors of distress. To summa-
rize, addressing social inequalities in mental health can achieve benets beyond the health sector
alone (Table 4). This assumes socio-economic and political importance in the context of the APAC
region.
• Budget savings in mental health and allied sectors
• Better social functioning and productivity
• More employment and income
• Better educational attainment
• Improved physical health and quality of life
• Reduced crime rates, violence and substance abuse
• More affordability and access to mental healthcare for vulnerable groups
• Reduced hospitalizations
• Decreased health-damaging behaviours
• Reduced all-cause morbidity and mortality
• Mitigate stigma and discrimination
There are a few challenges that might be associated with any steps in addressing the above needs
as follows. The effects of globalization might need addressal at an international level; work-life
balance might be dicult to address merely through a change in labour policies, given the demand
for jobs, unemployment and cultural factors; cultural factors might be deep rooted and may be a
hindrance at many levels of interventions; disparities within a region due to socio-economic posi-
tion of an individual or a community might require specic interventions that may differ from one
region to another; addressal of sociogenic causes might require multiple sectors to coordinate ac-
tively; the same might be required for the support of an individual when he is ill and on the path to
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 105
recovery; an adequate budget to mental health would be essential; distribution of the resources in
population-dense and diverse APAC countries might need an intricate approach; due to poor social
capital, a huge proportion of the population is subjected to detrimental effects of climate change,
disasters, and pandemics, and preparedness for the same is essential.
Eects of the COVID-19 pandemic
The crevices of mental health inequalities have widened during the ongoing COVID-19 crisis. The
COVID-19 pandemic has not only exposed the social and structural inequities in the Asia Pacic
region, but also accentuated it [26]. The economic and social impacts of the pandemic have been
severe such that the cost incurred in various responses to the pandemic may not be within the
capacity of many countries in the region [27]. With two-thirds of the population in the Asia Pacic
region informally employed, a huge proportion of this population have lost their jobs, and many
nd themselves socially insecure. This is especially true with the international and internal migrant
workers, who lost their employment and had to return to their home countries and towns. This
unprecedented reverse migration has caused many individuals to lose their livelihoods, be exposed
to the virus, be stigmatized, and also not receive adequate care due to the lack of health insurance.
The households which were below poverty line are at risk of adopting various destructive coping
strategies, leading to further decrease in their economic status. The pandemic is also likely to re-
verse the gains in poverty reduction which the region has attained in the past few years. Many who
are employed in low-skilled services and whose alternative livelihoods are limited due to various
reasons such as lack of digital literacy or internet access might fall below the poverty line. Women
in the region have also been disproportionately affected by the COVID-19 pandemic, with closure of
schools and the amount of unpaid work increasing drastically; domestic violence at home; dis-
crimination at the workplace as being less competitive due to their dual role of domestic work and
employment. This has led to women losing their jobs and also their engagement in socio-political
activities and decision making, which in itself is very poor in the region, leading to further inequali-
ties [28]. The COVID-19 pandemic has signicantly impacted the economic conditions of the APAC
countries, resulting in the likelihood of further decreases in the budget allotted to health and the
concomitant setbacks in welfare policies and increased inequalities. In addition, the likelihood of
stringent economic policies in the coming years might lead to further poor work-life balance and a
downward spiral of mental health. All these factors have led to increased psychosocial problems
throughout the APAC region (Figure 3).
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 106
Figure 3: Various intersections between the COVID-19 pandemic and psychosocial wellbeing.
Region specic actions needed in the Asia-Pacic
A multifaceted problem necessitates a multifaceted approach. Region specic strategies for
addressing mental health inequalities should be multi-layered and should involve the active partic-
ipation of all relevant sectors in the community and cross-nation collaboration. The best practice
models in Table 2 depicted above are examples of how the same principle can be modied and
adapted in different areas based on culturally relevant settings. Exchange of knowledge about
regional practices and policies can help reduce mental health inequalities in various regions of the
APAC, but that strongly involves strengthening community-based care. Ideally, the mental health
issues prevailing and that which are predicted to happen in the next few years require a response
similar to the COVID-19 pandemic.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 107
The concept of disaster preparedness must be integrated into the objectives of mental health
prevention and promotion. This is especially important to countries in the Asia Pacic, consid-
ering how they were disproportionately affected by the pandemic and the reasons for the same.
Although the SARS-CoV2 virus affected the whole world in the same way, the consequences faced,
and the measures taken to contain the virus were not the same for everyone. APAC contains re-
gions which have inequities in wealth, limited accessibility to health care services, social security,
social capital and poor welfare policies. Some countries have struggled to handle the situation, and
the effects of the pandemic on the inequities and overall well-being of these individuals have been
deleterious [27, 28, 29] Various mental health priorities that have emerged in the region during this
pandemic crisis are listed in Table 5.
• Economic empowerment of people who are under-privileged
• Address structural inequalities (gender, sexual, race, ethnicity, religion, migration, socio-eco-
nomic)
• Psychological rst aid (evidence-based)
• Prevention and management of abuse (children, domestic, elder)
• Disaster appropriate behaviours for betterment of public health
• Besides the rst responders, mental health promotion of other public (especially the population
with lack of resources) also need to be prioritised
• Mental health promotion and education
• Improving knowledge-attitude-practice (KAP) gap in general public
• Involving lay counsellors, primary level health-workers and general physicians in screening and
treatment of common mental health disorders
• Community engagement
• Involvement of media for mental health promotion
• Target high-risk groups
• Capacity building of existing mental health systems and helplines
• Optimising tele-psychiatric services and guidelines
• Psychosocial wellbeing geared policies
• Cross-nation collaboration and research
If not for the semantics of the denition of a pandemic [30], psychiatric illnesses like depression
warrant to be named as a pandemic or at least require a response equivalent to the same. The
management of mental illnesses are as challenging (if not, more) as the COVID-19 pandemic, due
to the factors listed above and how they require a multisectoral and parallel response. Like the
COVID-19 pandemic, an early, adequate, equity-centric and evidence-based strategy at various
levels is required to manage mental illnesses, without which the consequences of the same in the
upcoming years on the psycho-social and economic conditions might be severe. The following
multi-level strategies to address mental health inequities are proposed to give a framework of the
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 108
actionable goals that could be adopted in the region. Figure 4 is a summary and schematic rep-
resentation of the same.
Figure 4: Multi-levelled strategies for addressing mental health inequalities and inequity.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 109
Structural
• In spite of the cultural and region-specic differences, economic status, welfare policies and
political approaches might be similar among some countries within APAC.
• Suitable collaborations can be made on this front, for exchange of research, workforce and
training that can drastically increase the eciency of the interventions.
• If the detrimental effects of the economic policies are found to outweigh the benets, feedback
can be given regarding such adverse effects from a mental health perspective.
• Research on mental health should include addressal of the mental health inequalities (and
inequity) and needs to be actively promoted by the government.
• Suitable modules for individuals at various levels of administration and the general population
should be designed in an easily understandable manner and advocacy activities for accessibili-
ty of the modules
• Mental health is everyone’s concern, and all sectors and services in government should create
a ‘mental health wing’, thereby actively improving community participation.
• Administrators should be continually educated about the need to improve the social factors
such as psycho-social-safety climate, income inequality, etc from a mental health perspective.
• Although it might be dicult and cumbersome to make region specic classicatory systems,
region specic criticisms of the classicatory systems can be made.
• The social determinants of mental health can also be region specic, given the varied institu-
tional structures, social hierarchies, relative poverty, etc in different regions.
• Labour market policies need to be discussed, and the positive effects of welfare-oriented poli-
cies on the long term need to be emphasised.
• Existing policies are not fully utilized due to poor integration of data across various sectors.
• Technology can be adopted as much as possible to bridge the gaps in workforce as much as
possible [25, 26].
• Technology can not only help in linking data across elds like psychiatry, legal services, educa-
tional and administrative services, but can also help in transparency and armative action.
• The integration of data across various services will also help in the statistical analysis of the
inequalities and its contribution to mental health, and best strategies can be framed based on
the nature and extent of mental health inequalities.
• A dedicated programme needs to be framed in each region with consumers, carers and health-
care professionals to collaborate, actively research, design and develop or make amendments
to policies and strategize action plans.
• Primary prevention should be the heart and soul of the mental health policies and programmes
created.
• Mental health programmes should not merely focus on mental illnesses alone but should
include indices of mental health and overall well-being, at least with respect to high-risk regions
and communities. This may also help to elucidate the relationship between the social factors
and overall well-being in the regions.
• Mental Health Promotion into Action is necessary. In the view of ‘Mental Health for All’, it is
essential ‘that’ the governments and organizations integrate mental health into all policies, to
develop local empowerment models, focus on the mental health promotion and primary pre-
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 110
vention, build community resilience and social support, and pay close attention to the needs of
population across different age groups, economic classes, regions, etc.) [31].
• In addition, mental health promotion education should be the key strategy to tackle inequity
and inequality.
Ecological
• Ecological factors are also major inuencers of mental health, given their ability to disrupt
social support and threaten personal safety. Hence, preparedness and action plans to face the
same should be devised and prompt in deployment to reduce the impact to minimum possible
[24].
• Poor social security and its perilous effects on mental health were clearly exposed during the
COVID-19 pandemic. Measures to improve the social security of all citizens need to be ensured
to face such situations, lest they should accentuate the already existing disparities, worsen the
well-being, and mental health gap [28].
• The main idea of disaster preparedness includes strengthening mental construction. In particu-
lar, implementing mental health promotion education to improve self-care and emotional skills,
to build community networks and support, and to create a community resilience model [32].
• Clear strategies also need to be advised for such mental health issues arising due to inade-
quate social security or capital, lest these issues should be treated like any other mental health
disorder neglecting the sociogenic causes and associations.
Community
• Accessibility to mental health care should be ensured by tying both ends of the same - making
resources available in the community and promoting health seeking behaviour and awareness
among individuals in the community [17, 19, 24].
• Active community participation will help to modify the strategies and agenda in real-time and
tailor it to the most suitable action approach for a particular region or community.
• Social stigma and discrimination need to be addressed through public health campaigns, ad-
vertisements in mass media and social media. The adoption of mass media by the government
can promote collaboration between various individuals and organisations [17].
• Region specic social determinants like racism and institutional structures, and their perilous
effects need to be studied.
• There are inequities that are accentuated in certain communities within the region/ country
such as women, migrant workers, homeless people, etc.
• These individuals appear to have an even lesser social capital, accessibility and affordability
within the society. They are also at a high risk for violence, adverse childhood events and high
risk behaviours [33].
• Work-life balance and the overall well-being also appear to be worse in individuals experiencing
inequality and inequity, contributing to deterioration in their mental health, irrespective of them
developing mental illnesses.
• The differences in the mental health of these individuals need to be identied. Valid scales and
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 111
measures have to be developed that can be applied in the community, which would acknowl-
edge these issues and promote action.
• Wherever possible, sociogenic associations of poor mental health outcomes need to be docu-
mented and acknowledged, so that they are not avoided as an exception and recognised as a
norm.
• Multisectoral coordination is of prime importance in LMIC, as the social expenditure in these
countries are less, and individuals are more reliant on their families and individual selves for
their expenses.
• Persons with disabling mental illnesses need to be supported by the government in as many
services as possible for their fast and best recovery, which might in turn contribute to the over-
all welfare of the state.
Individual
• Positive psychology approach might be benecial, given the high risk of adverse events in re-
gions with poor socio-economic conditions [34].
• This might require an increased enrolment of individuals in schools and colleges, which can
serve as the locus for psychological interventions.
• Mental health and psychological rst aid can be incorporated into most curricula and all sec-
tors can appoint a key-informant, who might support and monitor the mental health issues of
individuals.
• More resources should be allotted to individuals who have been socially deprived and who are
disempowered, given their higher risk to undergo adverse experiences, and to develop mental
illnesses.
• Additional resources should not be restricted to only medical interventions, but should also
include psychological and sociological interventions
• Treatment for mental illness without any consideration of the social factors might accentuate
the inequities and lead to poor outcomes, due to issues in accessibility and compliance.
• Adverse childhood experiences need to be identied promptly, followed by appropriate early
management and intervention. This calls for dedication from mental health professionals and
non-mental health professionals with specic role designs.
Implementing change: Strategies in the Asia-
Pacic
Implementing the above changes might require strong principles of mental health and social wel-
fare to be laid down in a succinct manner, so that everyone involved in the delivery of the service
is clear regarding the same. Principles which might be universally applicable are a strong mental
health policy, sustainable integration of various sectors that includes [17, 24, 25]:
• Diverse perspectives in the responses
• Increasing community participation
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 112
• Capacity building and preparedness for disasters
• Adoption of technology to bridge the gap in workforces
• Cognizance of mental health impacts of climate change and in high-risk groups
• A social determinants approach with emphasis on women’s mental health
• Early childhood development and substance use disorders
• Social welfare policies
• Setting attainable and achievable targets
• Consistent and progressive monitoring of the efforts made
• Strengthening information systems and promoting evidence-based practices
Culturally sensitive research needs to be conducted to identify specic interventions through which
these can be implemented. Table 6 below shows some of the evidence-based approaches to ad-
dress the mental health inequalities that can be potentially attempted in the APAC region.
Cost- effective models and best practices for community mental health care in the Asia pacic
region have also been identied. Establishing community mental health centres; resourcing the
community from a tertiary hospital; improving the access to mental health care; community reinte-
gration programmes including social skills training, housing stability and vocational rehabilitation;
empowering patients as consumers through focused-group meetings; partnerships with NGOs in
improving the community networks; integration into existing services and decentralization of the
resources; mental health promotion and stigma reduction paving way for acceptance and active
help seeking behaviours; early crisis intervention and preparedness for the same; early detection
and management of psychiatric illnesses; and adopting the approach based on the patient’s needs
have been some of the best identied practices in the Asia Pacic [19].
There are studies reporting that the Asia Pacic region has committed itself to the cause of im-
proving community mental health, has been advocating the human rights perspective and estab-
lishing intersectoral links for better outcomes in this domain [35]. But, this can only be considered
as the beginning of a great leap that is required to bridge the gap in inequities of mental health
services, and improve overall well-being. There are several domains which require relentless efforts
such as adoption of local and culture appropriate models, health economics, information strength-
ening, use of technology, recovery models of management, positive psychology, work-life balance
and social welfare expenditure. Also, there are domains which need improvement like community
participation, capacity building, evidence-based strategies and public-health campaigns. But what
is evident is that this requires a systematic, coordinated and dedicated effort from the specic
regions or countries, which clear short term and long-term targets. These targets should also be
validated measures of mental health, overall wellbeing, and social security rather than mere pres-
ence or absence of a disease. Special targets should be set for the population subjected to undue
distress due to their gender, caste, race or religion, which can serve as a measure of improvement
of the inequalities, and thereby the welfare of the society by large. Consistent monitoring of the
efforts and persevering amendments are expected to keep such a huge endeavour in check. To
conclude, mental health in the APAC should broaden its horizons to include the other services and
sectors, which have been neglected due to the reication of the concept of mental health to only a
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 113
few branches of science. Recognition of mental health as everyone’s province, and the synergistic
effect of everyone in improving the same shall be the next big step in tackling the inequalities to
promote positive mental health and overall well-being in a society.
Table 6: Evidence-based approaches to address mental health inequalities and psychological well
being
Reducing adverse childhood
experiences
• Community education
• Ensure compulsory education for all age-groups
• Reduce bullying and violence
• Substance abuse interventions
• Parental support
• Family reunication
• Child security and child-friendly spaces
• Relevant legislations
Address basic needs • Safe housing, prevent overcrowding
• Ensure adequate nutrition
• Employment
• Promote healthy population ageing
• Social welfare and social security benets
Mental healthcare access • Primary-secondary-tertiary collaboration
• Improvise tele-psychiatric and tele-psychotherapy services
• Mental health insurance
• Public-private partnerships
• Disability benets
Strengthening community
engagement
• Involve public gures and key stakeholders (youth, elders, local faith leaders, indige-
nous communities, community groups)
• Utilizing community resources
• Capacity building
• Accessible, acceptable, affordable and culturally appropriate intervention models
• Building intergenerational bonds and family support systems
• Citizen-led groups for homelessness, SUD, etc.
Tackling inequalities • Screen and prioritize high-risk groups (age, sexual minorities, homeless, migrants,
refugees, low SES, chronic mental illness)
• Anti-stigma interventions and community education
• Social inclusion and participation among the minority groups
• Involvement of media
• Prevention of children and elder abuse
• Improvise mental health services for the poorer populations
Suicide prevention • Reducing access to means (policies)
• TOT approach / Gatekeeper training
• Early identication and management of psychiatric disorders
• Life-course approach
Disaster response • Training and supervision in psychological rst aid
• Long-term sustainability of services
• Trauma-focused research and services
• Optimize digital mental health interventions, ensure access to technology
• Community outreach
• Mental health education
• Address mental health impacts of climate change
• Collaborative networks (ex: Asia Pacic Disaster Mental Health Network)
• Post-pandemic preparation
Policies and legislations • Target mental health of high-risk groups
• Prevent stereotyping and abuse
• Prioritize psychological wellbeing and allied areas
• Funding for mental health research and training
• Workforce building (psychiatrist, CP, PSW, psychiatric nursing, GP, etc.)
• Implementation and evaluation of mental health interventions and networks
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 114
Collaboration • Cross-nation training, resource building and research
• Sub-region mental health task forces (like South-East Asia, SAARC, etc.)
• Leadership and capacity building
• Incorporate mental health agenda in national and international policies
• Liaise with global public health agencies (such as WHO, CDC, etc.)
SUD: Substance use disorders; SES: Socio-economic status; TOT: Train-the-trainers approach; CP:
Clinical Psychologist; PSW: Psychiatric Social Worker; GP: General Physician; SAARC: South Asian
Association for Regional Cooperation; WHO: World Health Organization; CDC: Centre for Disease
Control and Prevention
Conclusion
The Covid-19 pandemic has posed challenges as never before, to the whole world. Economies
have been badly hit leading to job loss for individuals and nancial breakdown for many families.
People are living in highly stressful times. This must lead to a paradigm shift, not only on how we
see our own countries but also the whole world. If there is any one message, it is of global co-oper-
ation and collaborative work to rebuild societies and economies across the world. The Asia Pacic
region plays an important role in the global economy and is developing rapidly. It faces unique chal-
lenges related to urbanization and mental health, and the social inequalities prevalent within the
region have been specically exacerbated by the COVID-19 pandemic. Many countries, especially in
the South Asian region are among the worst-hit and continue to face signicant challenges in con-
taining the pandemic. During the pandemic and in the post-pandemic aftermath, legislation, service
standards and government policies need to be established to ensure equal access and delivery of
mental healthcare for better psychological wellbeing and quality of life. Community-based mental
health care, involvement of primary healthcare workers, mental health education, tele-psychiat-
ric guidelines and use of technological innovations, and nally multi-disciplinary exible mental
healthcare delivery models are the essential keys. This also involves inter and intra-nation collab-
oration, resource sharing and research for mutual and global gains in mental health. Sectors such
as housing, education, social welfare, and employment also need alignment with mental healthcare
reforms if poverty and health inequality are to be targeted. This position statement is in no way
absolute but provides a framework of various principles, approaches and strategies of rights-based
psychological care in the APAC region. These factors can be adapted in various settings based on
the regional socio-cultural context. The process has just begun and there is still a long way to go in
restoring equity of mental health in “an unequal world”.
Funding: None
Acknowledgement: None
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 115
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WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 117
Tackling Social and
Health Inequalities to
Promote Mental Well-
being – A Call to Action
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
of KwaZulu-Natal, South Africa
MICHAEL KARIUKI
Vice President, Constituency Development World Federation for Mental Health
CHARLENE SUNKEL
Founder & CEO:Global Mental Health Peer Network
1. Introduction
Africa is the second-largest continent and the second most populated in the world with a pop-
ulation of 1.4 billion people in 55 countries. Most countries are characterised by low income,
high prevalence of communicable diseases, malnutrition, low life expectancy and poorly staffed
services. [1] Despite its vast natural resources, Africa remains one of the least developed and
economically underprivileged continent [2] Most of Africa was colonised by European countries
during 1400–1960 due to its vast natural resources. The scramble for Africa was largely driven by
industrialisation and the need to access raw materials of which there were plenty on the continent.
According to Ocheni and Nwankwo, this situation necessitated the quest for direct takeover and
control of the economy and administration of the African enclaves and states. [3].
Colonisation accounts for many countries on the continent falling into under-developed or low and
middle-income groups and has had a particularly devastating impact on mental health. It is, there-
fore, no surprise that mental health remains a low priority in the region, which has contributed to
grave injustices and human rights violations experienced by people with lived experience. Many
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 118
African countries have no mental health policies or clear targets to achieve optimal mental health
service delivery. [4]
Under-development on the continent has resulted in high poverty levels and economic inequalities.
People living with mental illness experience gross mental health inequalities across the continent.
Mental health remains a low national health priority in many African countries. The dominant
bio-medical approach to mental health interventions with low nancial investment remains the pre-
ferred option of care and limits holistic person-centred recovery approaches to care within commu-
nities. Traditional African tribal or ethnic specic customs and belief systems have often reinforced
stigma and discrimination against the most vulnerable. In South Africa, traditional healers are still
the rst port of call for many who espouse tribal customs. [5] Traditional healers and religious lead-
ers (such as priests) provide a signicant proportion of the care received by persons with mental
illness. For example, in Ethiopia, about 85% of emotionally disturbed people were estimated to
seek help from traditional healers. [6]
Eaton states that on average 90% of people with mental illnesses have no access to treatment,
especially in poor and rural areas in Africa [7] In Sierra Leone, for example the treatment gap for
mental health services is estimated at over 98%. [8]. The limited access to professional mental
health care, in addition to prevailing cultural beliefs, means that there is frequent recourse to care
by spiritual and traditional medicine practitioners, some of whom employ abusive practices such
as physical restraint, physical abuse and food deprivation.[9]. Treatment remains largely inacces-
sible and mostly provided in outdated dilapidated buildings. Many countries in the African region
are engulfed in conict and civil strife, with the attendant adverse impact on the mental health and
well-being of the affected populations, foremost being post-traumatic stress disorder. [10]
Global recognition of the importance of the role of persons with lived experience of mental health
conditions in research, policy reform, co-design of services and its implementation and monitoring
and evaluation, as well as service delivery as peer support workers, has gained momentum – plac-
ing an emphasis on improving the status quo. However, the role of peer-led interventions in many
countries in Africa is seldom integrated into mental health service delivery. Inequality, combined
with stigma, discrimination and paternalistic approaches to mental health service provision, cre-
ates barriers for people with lived experience to live fully integrated lives with dignity and respect.
2. Mental Health Policy and Legislation in Africa
The effect of mental health being a low priority on the continent has led to most countries having
no mental health policy or mental health legislation to regulate care and safeguard the human
rights of persons with lived experience. Faydi and colleagues stated that “Approximately half of
the countries in the African Region had a mental health policy by 2005, but little is known about
quality of mental health policies.” [11]. This raises signicant concerns as policy and legislation in
mental health reinforces a country’s commitment to ensure that mental health is prioritised – and
the absence thereof creates gaps in services, poor resourcing and nancial investment, and fails
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 119
to take into account human rights protection instruments for this vulnerable group. They noted six
gaps that could impact on the policies’ effect on countries’ mental health systems: lack of internal
consistency of structure and content of policies, the superciality of key international concepts,
lack of evidence on which to base policy directions, inadequate political support, poor integration
of mental health policies within the overall national policy and legislative framework, and lack of
nancial specicity [12]. They added that “Mental health policies and plans are essential tools for
setting strategic priorities, coordinating action and reducing fragmentation of services and resourc-
es. Mental health policies are more likely to achieve the desired effect when they reect a clear
commitment from governments, are consistent with the existing evidence base, and international
standards, and reect a broad consensus among key stakeholders. [13]
Daniels concurs and added that a mental health policy is an instrument aimed at facilitating trans-
formation in mental health. The success of this policy cannot be measured unless mental health
professionals and service users actively engage and monitor the implementation. It is recommend-
ed that this policy be used as a powerful tool to lobby and advocate for improved funding, collab-
oration and deployment of non-specialist mental health human resources to decrease the number
of individuals who currently have no access to mental health. Formal institutional structures and
capacity have been established through a Mental Health Ministerial Advisory Committee to ensure
that a coordinated and less hospital-centric approach to mental health is devolved to communities.
[14]
Gureje and Alem state that “The development of health policies are critical to maximize scarce
public resources and support families in the provision of the best possible care for the mentally ill.
The goals must recognize the need for clear strategies to reduce the disablement associated with
mental illness and to promote research on mental illnesses and how to prevent or treat them.” [15]
3. Mental Health Stigma and Discrimination
Daniels stated that mental illness remains one of the most stigmatised health conditions, which
created barriers to treatment and limits full integration into work, education, communities and fam-
ilies. [16] She noted further that the greatest barrier that people with mental illness face is society’s
attitude towards them.
Stigma takes many forms in communities in Africa, often involving extreme prejudice anddiscrimi-
nation. Within more traditional African communities, these may relate to the perceived reason why
people have diculties and are inuenced by forces, witchcraft and supernatural powers beyond
their control. For people with lived experience suffering is made worse by the attitudes and preju-
dices of people around them and the larger community. Stigmatisation often leads to community
prejudice that impacts on the whole family.
Prejudice towards people with mental illness in Africa can take extreme forms, affecting multiple
aspects of people’s lives, including their self-esteem and condence. In such instances, people
may be accused of witchcraft, they may be deniedmarriageopportunities, and the explanations
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 120
for their behaviour may extend to all areas of their lives and in some instances lead to a process of
exclusion. [17]
Kenya, for example has multi-sectoral promotion and prevention programmes on mental health at
national and county levels that include strategic objectives and priority actions related to promot-
ing “mental health literacy and stigma reduction” [18]
According to Corrigan and Watson, “Many people with serious mental illness are challenged dou-
bly. On one hand, they struggle with the symptoms and disabilities that result from the disease. On
the other, they are challenged by the stereotypes and prejudice that result from misconceptions
about mental illness. As a result of both, people with mental illness are robbed of the opportunities
that dene a quality life: good jobs, safe housing, satisfactory health care, and aliation with a
diverse group of people.” [19]
Lived Experience Narrative – Godfrey Kagaayi (Uganda)
In 2005, I was diagnosed with depression after going through a chain of traumatic ex-
periences as a child. In my community, people with lived experience with mental health
conditions are believed to be wasted, unproductive and violent. Because of these damag-
ing beliefs and attitudes, in many ways, I was isolated and excluded in almost all spheres
of life by friends, family and the community at large. Once a family member told me that
nothing good will ever come out of me. This statement affected my self-esteem for many
years. I was convinced that I am capable of doing nothing with my life to an extent of
attempting to end my own life. I am lucky enough that I survived the suicide attempt.
Because of this experience, I founded Twogere, a registered community-based organisa-
tion that is on a mission to change the way how people think and behave towards per-
sons with mental health conditions in Uganda. Furthermore, my advocacy work in mental
health is being fuelled by the Global Mental Health Peer Network, where I can freely
interact with a bunch of really compassionate and understanding friends.
4. Mental Health and Human Rights in Africa
The inclusion of mental health as a priority area among the Sustainable Development Goals (SDGs)
has heightened the need to address mental health concerns globally. Certainly, the impact of the
COVID-19 pandemic has highlighted the importance of paying special attention to mental health,
not least because one of the main symptoms associated with the disease is depression. In Africa,
evidence indicates that mental health has been largely neglected as a health concern and noting
that less than 1% of national health budgetary allocations are apportioned to mental health infra-
structure and resources, which is signicantly less than the minimum percentage health budget
spend for mental health that the World Health Organization (WHO) recommends which is 5%. [20]
Between the years 2000 and 2015 the number of years lost to disability as a result of mental and
substance use disorders increased by 52% in Africa with 17·9 million years reportedly lost to disa-
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 121
bility as a result of mental health problems. [21-22]. As the disease burden has increased, resourc-
es and infrastructure to adequately address mental illness have either stagnated or declined, point-
ing to systematic neglect of mental health in Africa. In the context of COVID-19 pandemic, human
rights protection and mental health needs have not been adequately integrated into the pandemic
emergency response policies and management. [23] Various reports have highlighted widespread
undermining of mental health and violations of individual civil liberties and fundamental human
rights including mobility rights, access to accurate information, access to proper protection for
health workers, right to education, and discrimination against including individuals living with men-
tal and neurological disorders [24]
Optimal mental health is a fundamental human right. The intersection between mental health and
human rights (and, in turn, development) is acknowledged most recently through the Sustainable
Development Goal Three [25].
The legally binding basis is however expressed in Article 12 of the International Covenant on
Economic, Social and Cultural Rights, which protects “the right of everyone to the enjoyment of
the highest attainable standard of physical and mental health.” [26].This provision is mirrored in
the African Charter on Human and Peoples Rights’ Article 16 and various other UN human rights
instruments that contain the right to health provision. Additionally, the UN Convention on the Rights
of Persons with Disabilities (CRPD) imposes obligations on State Parties to address both physical
and mental disabilities (Article 25). [27]
Several UN resolutions and reports on the right to health arm mental health as a basic ‘human
right’. Moreover, the WHO Mental Health Action Plan (MHAP) provides policy imperatives to facil-
itate efforts of State Parties to address mental health. [28] One of its underpinning principles is
human rights and it states that “mental health strategies, actions and interventions for treatment,
prevention and promotion must be compliant with the CRPD and other international and regional
human rights instruments.” [29]
Therefore, a human rights framework for mental health exists. Certainly, the need to adopt a ho-
listic, human rights-based approach to mental health is required and is armed by WHO’s recent
guidance on community mental health care. [30] The challenge is that the shift to addressing men-
tal health as a human rights concern has been slow [31]
Lived Experience Narrative - Sandra Ferreira (South Africa)
Having had the experience on more than one occasion of being gagged and restrained
feels like the perfect irony and metaphor of human rights violations within my mental
health journey. Admittedly, I realise that when someone is in a state of psychosis and
irrationality that it is a dicult situation to manage and that there is no ‘one size ts all’
solution. However, looking back at my experiences, what I can say is that ‘muting’ or dis-
qualifying me as a human being had no positive effects on my recovery or understanding
of my rights or condition. If anything, it angered me and agitated my state further. What
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 122
is happening to me? I do not understand why I am here. Quite simply… I was scared.
Unfortunately, these are not questions that are easily answered in the current models of
treatment. Medication is often the rst port of call, but treatment should be practised
as multi-dimensional and person-centred from the start. Over the years, I have taken the
time to learn as much about my condition, medication and my rights through reading,
research and through my physical experiences. I however continued to experience a
response where my voice, my being, was boxed into a category and my knowledge was
disregarded. Without a doubt, compassion, empathy, understanding, education and relat-
ability should be core values and foundations of treatment. All humankind is equal and
should be treated as such. Recovery is not linear but human rights and dignity should be
a priority.
5. Multi-dimensional Determinants of Mental Health
Mental health is an integral and essential component of the health of African societies. It is more
than just the absence of mental disorders or disabilities. Mental health is a state of well-being in
which an individual realizes his or her abilities, can cope with the normal stresses of life, can work
productively and can contribute to his or her community. [32] In Africa, optimal mental health and
well-being are fundamental to interpersonal and family relationships, emotions, social life and liveli-
hoods.
Mental health and well-being in Africa are largely determined by biological factors (e.g. physi-
cal health, genetic vulnerabilities, disabilities, temperament); psychological factors (e.g. trauma,
self-esteem, coping skills); and social factors (e.g. interpersonal skills, family relations and circum-
stances, peers, substance use). In Africa persistent socio-economic pressures (e.g. poverty, level
of education) have been identied as among the key social determinants of poor mental health
among individuals and communities. [33] Other known determinants of mental health in Africa
include protracted conict and violence, gender discrimination, social exclusion, stressful work
conditions, and human rights violations. All of the aforementioned factors are deeply rooted in
persistent poverty and income inequality that are the realities of most communities on the African
continent. [34]
The provision of mental health services in Africa is a developmental and human rights issue that
requires urgent redress. Africans with mental disorders are faced with multiple levels of discrim-
ination at structural, economic and social levels with limited access to appropriate mental health
services. Context-specic interventions will full the constitutional obligations and imperatives of
nation-States in Africa, as well as signicantly reduce the burden of mental and neurological disor-
ders in Africa. [35]
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 123
Lived Experience Narrative – Tivania Moodley (South Africa)
As a suicide attempt survivor, my lived experience with depression emanated from years
of a lack of self-worth, living a lie, having to conform to society’s expectations of me,
exacerbated by harsh life experiences such as rape and intimate partner violence. I could
not express my truth, and suffocated in silence, eventually considering suicide as an op-
tion. I survived my suicide attempt, and since spent many years trying to understand the
correlation between mental health and gender-based violence and I have come to under-
stand keenly the relationship between acts of violence and men’s mental health. I rmly
believe, that when we address mental health in men and boys, we inadvertently save girls
and women against gender-based violence.
Lived Experience Narrative – Marcos Tabule Alex (South Sudan)
I am a 42-year-old person living with disabilities. In 1992 during my intermediate class
of senior two, I experienced an Antinov aerial bomb in my school where I lost twelve of
my colleagues in the incident. I was a top performer in my class and with this incident, I
became less able to concentrate, started withdrawing from my colleagues, feeling body
fatigue, and headaches were the order of my day and sometimes I had less appetite for
food. I was referred to an organisation known as HealthNet TPO who provided me with
anti-psychotic drugs that enabled me to regain my life...
Since then I have worked with HealthNet TPO to help people who have witnessed similar
situations. This was my rst job in a humanitarian organisation and my role as Commu-
nity Mental Health and Psychosocial Ocer was to identify people who have witnessed
and experienced Mental Health and Psychosocial issues and refer them to access ser-
vices. As a Mental Health and Psychosocial Support Practitioner, I have a dream that we
Leave No one with Mental Health and Psychosocial problems behind.
6. Refugee Mental Health in Africa
Africa currently hosts an estimated 37 per cent of the world’s 19·7 million refugee population, (36)
calling for an urgent need for the early and ongoing provision of mental health services in refugee
communities in Africa that extends beyond the period of displacement to resettlement in a host
country, particularly for refugee women and girls. In Africa, the term refugee applies to “every per-
son who, owing to external aggression, occupation, foreign domination or events seriously disturb-
ing public order in either part or the whole of his country of origin or nationality, is compelled to
leave his place of habitual residence in order to seek refuge in another place outside his country of
origin or nationality”. [37] Refugees are one of the most vulnerable populations in the world. Their
vulnerability stems from their experiences of forced migration, including exposure to traumatic
events such as war and conict, loss or separation from family, arduous journeys to safety and
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 124
exposure to violence including sexual violence, abuse and exploitation. These experiences make
them highly susceptible to mental disorders that persist for many years after displacement. [38]
While key policy documents related to refugee mental health have been developed, the mental
health needs of refugees have not been addressed in a systematic, and coordinated manner in
Africa despite epidemiological evidence pointing to the need for targeted intervention. [39] A
multi-country study that analysed refugee health records in 90 refugee camps indicates a very
low uptake of mental health services among refugees despite a high prevalence of post-traumatic
stress disorder (PTSD), anxiety and depression[40]. Gender differences in mental health-seeking
behaviour have also been reported among refugees, with female refugees more likely than males
to report emotional disorders, medically unexplained somatic complaints and other psychological
complaints. [41]
Lived Experience Narrative - Tendai Chisirimunhu Kathemba (South
Africa)
South Africa has been the country l sought protection as a refugee. l left my home and
birth country Zimbabwe at the height of social, political, and economic turmoil. Losing a
brother and witnessing politically motivated violence towards me (as a youth back then),
crushed my hope and l realised l no longer had a life and future living in Zimbabwe, so l
ed to South Africa.
Living as a refugee in South Africa was one of the most dicult challenges I encountered
in my life. I have struggled with depression and anxiety but had to be ‘strong’. The sys-
tem is stacked against you from day one and you must ght hard. I had a huge cognitive
dissonance being African and realising for the rst time the hostility and contempt a
migrant or refugee faces daily in South Africa, yet Africa is my home.
You are labelled and stigmatised as a ‘refugee’, and this can be quite disorienting when
you know your worth and value as well as contributions to society.
As much as I have had a tough time living in SA as a refugee, in a twisted way it has
become my home away from home. I have been exposed and had opportunities that l be-
lieve that my country would still not and cannot offer me or the young people growing up
there. I have established friendships that have become family and have plugged myself
(albeit sometimes forcefully) within communities, actively participating and have been
warmly embraced and treated with kindness by many South Africans. This is the narra-
tive l mostly chose to carry in my head so l can remain ‘sane’ and because it is true. The
bad has come with a lot of good.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 125
7. Access to Mental Health Care in Africa
Africa is one of the regions in the world with the lowest mental health public expenditure rates,
with an estimated per capita expenditure of less than US$ 10 cents. it is not surprising that the
proportion of Africans who receive treatment for mental health problems continues to be extreme-
ly low compared to other regions of the world [42; 43]. According to Sankoh, Sevalie and Weston
(2018), Africa can only account for an estimated 1·4 mental health workers per 100 000 popula-
tion, compared with a global average of 9·0 mental health worker per 100 000 and the rate of visits
to mental health outpatient facilities per year is 14 per 100 000 in Africa compared to the global
annual rate of 1051 visits per 100 000 population [44].
Notwithstanding relatively poor access to mental health services, the COVID-19 pandemic
is also reportedly halting crucial mental health services in Africa. According to WHO (2021)
“critical funding gaps are halting and disrupting crucial mental health services in Africa, as
demand for these services rise amid the COVID-19 pandemic”. In the context of the COVID-19
pandemic in Africa, there is an urgent call for increased funding for mental health services. The
WHO Regional Director stated that “COVID-19 is adding to a long-simmering mental health care
crisis in Africa” [45]
In Africa “we also need more action to provide better mental health information and education,
to boost and expand services, and to enhance social and nancial protection for people with
mental disorders, including laws to ensure human rights for everyone.” [46]
Lived Experience Narrative – Marie Angele Abanga (Cameroon)
Mental health has for several years been considered a taboo subject in my country, be-
cause anything to do with the mind is mysterious or spiritual. It, therefore, hasn’t mat-
tered enough for conversations about mental health to be normalized.
While I struggled with my mental health in my teenage years, I was largely ignored,
blamed and even punished for being selsh, reckless and a ‘good-for-nothing child’.
There was and still is little information about mental health care services available for
people struggling with their mental health, and this meant people like myself dealt with
a lot of stigma – in my case self-stigma and some from my family who thought I was
reckless or seeking attention.
I struggled with my mental health and self-medicated in my own way until I attempted
suicide and had a lightbulb moment; had I died it would have been my loss, not socie-
ties. I decided to leave my abusive marriage that was the source of tremendous trauma
and settled abroad, where I went to see a psychiatrist and a psychotherapist– services I
would never have been easily accessible in my country.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 126
8. COVID-19 and Mental Health
The COVID-19 pandemic has had an unprecedented and rampant impact on societies across the
world, leaving health, social and mental health devastation in its tracks.
The global health pandemic has impacted on the mental health of millions of people across all na-
tions. This virus not only impacts on health outcomes but its negative symbiotic relationship with
mental health compromises millions infected and affected.
The United Nations (2020) stated that “Although the COVID-19 crisis is, in the rst instance, a phys-
ical health crisis, it has the seeds of a major mental health crisis as well if action is not taken. Good
mental health is critical to the functioning of society at the best of times. It must be front and cen-
tre of every country’s response to and recovery from the COVID-19 pandemic. The mental health
and wellbeing of whole societies have been severely impacted by this crisis and are a priority to be
addressed urgently.” [47]
COVID -19 lockdown measures came at a heavy social and economic cost to many countries but
its impact was specically evident in under-resourced and poverty-stricken communities across
the world including Africa where pre-existing inequalities were already alarming. The total number
of COVID-19 infections on the continent have remained lower than expected compared to Europe.
South Africa remains the epicentre of the pandemic in Africa with the highest infection and death
rates. The vaccine programmes across Africa were slow to start and continues to lag behind devel-
oped nations while affordability also pose challenges.
“Disadvantaged groups will suffer disproportionately from the adverse effects of COVID-19. Low-in-
come earners performing jobs in precarious, informal sectors of the economy without unemploy-
ment insurance, limited access to healthcare, and no back-up savings, are especially at risk.” [48].
He added that “The COVID-19 pandemic may not only present a temporary shock, but have lasting
implications for poverty rates in South Africa through its effects on people’s health, education, and
employment prospects, as well as potential knock-on effects from increasing rates of crime and
domestic abuse.
Despite this bleak situation, “High-income countries have reserved more than half of the world’s
coronavirus disease (COVID-19) vaccine doses despite representing just 14% of the world’s popula-
tion, according to an analysis of publicly available data on premarket purchase agreements.” [49]
“The successful, equitable implementation of COVID-19 vaccination programmes requires unprec-
edented global coordination and a sustained commitment of resources—nancial, logistical, and
technical—from high-income countries.” [50]
Most of Africa continues to battle with their purchasing disadvantage and demand-and-supply
challenges. The global vaccine access inequalities have a direct impact on Africa’s ability to reduce
infection rates and deaths. Yet we know no one is safe unless everyone has access to vaccines.
Population immunity on the continent will without a doubt reduce the devastating mental health as
well as social consequences of mental health.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 127
Lived Experience Narrative - Wariimi Karingi (Kenya)
The COVID-19 pandemic has had adverse effects on the global economy and disrupted
social interactions. It has caused a considerable degree of fear and worry. I am not an
exception to this, and the fact that I am living with depression and anxiety disorder has
been extremely hard.
From the onset of the pandemic, l have experienced numerous relapses due to the ‘new
normal’. I had a morbid fear of the virus. My anxiety levels skyrocketed because of the
thought of losing family members, friends, and my own life. I was initially afraid of speak-
ing up because at the time everyone was experiencing the same challenges, both those
with lived experience and without lived experience; we were all trying to survive.
After about four months, I eventually opened up to my psychiatrist who recommended
we increase the dosage of my anti-anxiety drugs and have therapy sessions weekly for a
couple of months. My health has greatly improved over the past few months. I still have
my fears, however; thanks to the correct treatment, I have been able to cope better with-
out my life getting disrupted.
9. Mental Health Intervention – Innovative Practice
Despite the challenges in mental health service provision and specically the lack of resources,
many NGOs have designed and developed innovative practices to ensure greater access to mental
health services at a community level.
The Zimbabwean Friendship Bench Project, a mental health innovation provided by lay “grandmoth-
er counsellors” also known as “gogos”, has 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.
Evidence on the value of Peer Support Work (PSW) has indicated that peer support workers
achieve similar outcomes and are even better than professional services at reducing inpatient
service use and enhanced engagement with care, and resulted in a variety of recovery-related
outcomes (empowerment, behavioural activation, hopefulness for recovery). Despite the evidence
of the benets (from mostly high-income settings), PSW as a formal service in the African Region
has not yet been fully recognised and incorporated into mental health systems. PSW can add value
in community-based settings where a continuum of care sets the foundation for recovery, whilst it
aligns with human rights and person-centred approaches and ensures that the person is at the cen-
tre of decision-making and decides what their specic and unique needs are in terms of facilitating
recovery and overall wellbeing.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 128
Lived Experience Narrative – Dixoni Emmanuel (Tanzania)
Going to school was dicult for me; it was too noisy and boisterous. I tried hard to avoid
attention and became ‘invisible’. In secondary school, I was bullied for a while. I then
started to do sports and was pretty good at it. Yet, I found it dicult to move out into the
world and I did not know what was happening to me. My college years were dicult but
I survived; though I felt small and inferior, I had a big ego like any young man. For years, I
was very unwell. One week down, then high for a while, anxious for a few days, then not
sleeping. My emotions were ‘all over the place’ as the phrase goes. My soul was in pain.
What has turned my life around, has been a combination of medication, psychotherapy
and peer support.
GROW, the self-help peer group that I am involved in, means a lot to me, I made friends
and get ongoing support.
In an unparalleled, never-before-seen strategy, South Africa’s COVID-19 State of Disaster regula-
tions identied psycho-social support and interventions as essential while dealing with the devas-
tating consequences of the pandemic. Even though mental health COVID-19 provincial plans were
often fragmented, pockets of best practices were identied. Mental health non-prot organisations
who pre-empted the lockdown were better prepared and able to reorganise their services while oth-
ers experienced the lockdown as a barrier and limitation to provide accessible mental health care
during the emergency and extended lockdown periods.
Cape Mental Health (CMH) was one such organisation that maximised the lockdown advance no-
tice to design its remote mental health service. The oldest community-based non-prot organisa-
tion in South Africa with a proud history spanning 107 years, CMH is committed to providing com-
prehensive, proactive and enabling mental health services to persons with intellectual disability
and those with mental illnesses in the Western Cape Province. The organisation has a track record
of mental health service excellence in poor, under-resourced and densely populated communities.
The Western Cape Province, in which it operates, is currently the epicentre of the third wave of the
pandemic in South Africa, a country that remains the epicentre with the largest infection and death
rates seen on the African continent.
The pandemic created the opportunity for CMH to shift, reinvent, reorganise and adapt the way
the organisation provides mental health care from facility to home, and face-to-face counselling to
virtual interventions and, most importantly, to retain contact, reduce isolation and continue virtual
interactions with beneciaries and all who required mental health support. In the planning stage of
this model, the organisation recognised that approximately 98% of their beneciaries had cellular
phones that became a vital tool for migrating the mental health service remotely.
Despite the lockdown restrictions, the organisation was able to keep its ‘doors open’ by maintaining
and building relationships and communicating with those in need about the services using remote
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 129
technology such as cellular phone applications, virtual IT technology, Skype, telephonic counselling
and assessments, social media engagement, as well as video-conferencing where possible.
The entire switchboard and telephony system of the organisation migrated to a cellular phone. All
telephone calls to any of the organisation’s programmes were automatically diverted to one cellular
phone operated by the receptionist at her home to relay all messages. Data management to render
the service was centralised within our Administration Department.
A comprehensive basket of mental health services was offered during the lockdown period to
ensure regular contact with service users and their families or caregivers to lessen their isolation,
nurture their mental health and offer messages of hope. For example, online counselling services,
mental health support, COVID-19 crisis and case management, were provided by a dedicated team
of social workers through their preferred means of communication (cellular phone applications,
SMS messages, telephone calls or e-mails) to service-users with emotional adjustment problems,
psychosocial disability/mental illness, intellectual disability and anyone requiring support during
this time.
Activities were shared remotely across all Special Education and Care Centres for children with
severe and profound intellectual disability, and youth and adults with moderate and mild intellec-
tual disability and those with severe and profound intellectual disability at Training Workshops
Unlimited. The intervention at the Special Education and Care Centres was identied as a best
practice mental health innovation during the COVID-19 pandemic by the Mental Health Innovations
Network. [51]
10. Financial Investment in Mental Health
Under-resourced and inadequate mental health services have a devastating impact on the lives of
many people in Africa.
Eaton et al. noted that Africa, in particular, struggles to meet a number of the key parameters. [52]
In many sub-Saharan countries, less than 1% of already small health budgets is spent on mental
health, and much of this is used wastefully on institutional care. However, we see a similar picture
at an international level, where about the same 1% of Ocial Development Assistance for health
is spent on mental health [53]. In South Africa the vast majority of mental health expenditure
was spent on inpatient and outpatient mental health services - approximately 86% of these costs
were attributed to inpatient services, while the remaining 14% were attributed to outpatient care.
They found that the mental health budget allocations varied signicantly across provinces. These
ndings highlight the signicant lack of investment in community-based mental health investment
despite the long history of deinstitutionalization and devolvement of primary health level and com-
munity mental health. [54] Patel et al. noted that mental disorders are on the rise in every country
in the world and will cost the global economy $16 trillion by 2030 if no substantial commitment is
made to reverse this situation. [55]
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 130
The estimated costs of scaling up treatment, primarily psychosocial counselling and antidepres-
sant medication, amounted to US$ 147 billion. Yet the returns far outweigh the costs.
The WHO reported that national governments spend on average 2% of their health budgets on men-
tal health, ranging from less than 1% in low-income countries to 5% in high-income countries. [56]
The President of the World Bank Group, Jim Yong Kim, stated that “Despite hundreds of millions
of people around the world living with mental disorders, mental health has remained in the shad-
ows.” [57] According to the WHO, for every US$ 1 put into scaled up treatment for common mental
disorders, there is a return of US$ 4 in improved health and productivity. This is a strong motivation
and justication for investing in mental health that has remained the Cinderella of health services
on the continent. [58]
The inadequate response to invest and increase access to mental health has resulted in gross fail-
ure to ensure that all global citizens can live fully integrated lives. The United Nations Policy Brief:
COVID-19 and the Need for Action on Mental Health states that “this historic underinvestment in
mental health needs to be redressed without delay to reduce immense suffering among hundreds
of millions of people and mitigate long-term social and economic costs to society.” [59]
The value of investment needed over the period 2016‒2030 for scaling up treatment, primarily
psychosocial counselling and antidepressant medication, amounted to US$ 147 billion. (60) Mental
health is an investment and not an expense and should be prioritised now more than ever across
all African nations.
11. Proposed Regional and Sub-regional Specic
Actions
The recommended region and sub-regional actions to address the inequalities are as follows:
• Regional and sub-regional structures using their oversight function to ensure that all countries
on the continent have mental health policies and legislation with clearly identied targets for
implementation and ring-fenced budgets; these national mental health policies that are multi-
sectoral involve education, labour, justice, transport, environment, housing, social welfare and
civil society sectors
• Promoting a “Recovery-oriented Mental Health System” in which each essential service is ana-
lysed with respect to its capacity to ameliorate people’s impairment, dysfunction, disability, and
disadvantage.
• Promoting and protecting the centrality of community-based care in the national response to
mental health.
• Addressing the mental health of refugees; African nations should promote a climate that
respects and protects basic civil, political, socio-economic and cultural rights fundamental to
mental health promotion.
• Integrating trained Peer Support Workers into the mental health workforce.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 131
• Integrating people with lived experience into higher education and curricula of health and men-
tal health-related professional training.
• Ensuring meaningful and authentic engagement with people with lived experience in policy and
practice.
• Forming partnerships with existing lived experience organisations to ensure lived experience
engagement/consultation is included from the outset in decision-making processes.
• Establishing empowerment programmes for persons with lived experience, and ensuring ac-
cess to information about mental health, mental health conditions and human rights.
• Aligning mental health services with the recovery model – where services integrate the medi-
cal, social and human rights models.
• The region working in unison using the existing platforms: viz. the Africa Union and regional
policy subdivisions like the East Africa Community, IGAD, ECOWAS, among others, and always
having mental health on the various regional congregations’ agenda.
12. Proposed Country-Specic Actions
Countries have a responsibility to ensure equality and care for the most vulnerable. The following
are proposed actions that governments can take to address the inequities:
• The development and implementation of mental health policies and legislation within a human
rights framework with clearly identied targets for implementation and ring-fenced budgets;
these national mental health policies should have a multi-sectoral focus, involving education,
health, labour, justice, transport, environment, housing, social welfare and civil society sectors
• Multi-disciplinary Ministerial Advisory Committees that include people with lived experience
should be established in every country.
• An integrated Community-based Mental Health Care Model that increases access to mental
health services within communities and villages in rural areas that are provided by users of
mental health services, other non-specialists, mental health workers and professionals should
be implemented; these interventions are person-centred, readily accessible and cost-effective.
• Interventions that shift their focus from largely bio-medical to bio-psycho-social and cul-
ture-sensitive interventions.
• Lived Experience Councils or Advisory Committees established to help guide policy reform and
to inform implementation, monitoring and evaluation of service delivery so as to ensure align-
ment with local and international human rights instruments and best practices.
• Existing lived experience organisations to receive additional support and to established these
organisations where they do not exist – to ensure that the lived experience community is in-
cluded in decision-making processes pertaining to policy and practice.
• Countries directing more funds to the mental health sector and using an integrated communi-
ty-based approach in the implementation of mental health services; responding to a high need
for community education awareness programmes to reduce the stigma attached to consumers
of mental health services in the region; enhancing capacity building of mental health profes-
sionals using the MhGAP approach.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 132
13. Proposed actions for individual citizens
Mental health is everyone’s business. It is therefore imperative that everyone every individual con-
tributes the following manner to create an equal society for persons with lived experience in the
following manner:
Individuals could benet from:
• Being informed about mental health conditions, how to identify when someone is experiencing
an emotional crisis, and how to support and help such a person access appropriate services
(where required or expressed by the person seeking help).
• Being part of the solution to destigmatise mental health and mental health conditions by en-
gaging in conversations around mental health and mental health conditions without judgement.
• Being mindful of using language and terminology that is not stigmatising or discriminatory
when talking about mental health and persons living with mental health conditions.
• Encouraging citizens to embrace community ownership of grassroots-based mental health pro-
grammes; faith-based institutions being more inclusive and focusing on universal health care
with a mental health lens.
• Being willing to volunteer and support the work of NGOs in providing mental health interven-
tions.
• Becoming mental health ambassadors and advocating for the human rights of all with lived
experience.
• Gatekeepers in suicide prevention at community level.
14. Conclusion
Decades of poor investment and resourcing in mental health services have disadvantaged many
people, thereby limiting access to mental health services in Africa. This legacy has continued
preventing a signicant proportion of people with lived experience from accessing mental health
care within their communities despite affordable person-centred recovery-orientated interventions.
Fragmentation in the service delivery and lack of political will to ensure a better dispensation for
people with mental illness have been largely responsible for the neglect in policy and legislative
frameworks to protect the most vulnerable of our society.
Many awareness campaigns have made clarion calls for greater equality in mental health care
to ensure social justice and bring about redress but sadly have fallen short in real mental health
actions. The theme of this World Mental Health Day 2021, “Mental Health in an Unequal World:
Together we can make a difference”, places the responsibility to address stigma, discrimination, in-
vestment in mental health and address social determinants of mental health at our doorstep, mak-
ing it everyone’s business. Silence endorses injustices and makes us complicit when no advocacy
and action is realised. The calls for real action and prioritisation of mental health particularly during
the COVID-19 pandemic can no longer be ignored. In this position statement we call for regional,
country-specic and individual actions aimed at addressing the scourge of non-delivery in mental
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 133
health care.
Mental health can no longer continue to operate in an unequal world in which people’s rights are
disregarded. Every stakeholder needs to be involved in addressing mental health inequalities
and the multi-dimensional determinants of mental disorders to promote human rights and social
justice for every African. Arundell et al. recommended that “to reduce the disadvantage associated
with these inequalities, meaningful and effective strategies need to be developed.” (61). The COV-
ID-19 pandemic has placed mental health at the forefront of the health emergency - it is everyone’s
responsibility to ensure social justice for all living daily with mental health needs. Every effort to re-
verse the social and health injustices and suffering needs to be prioritised. Africa needs to advance
its strategies to ensure that equality, equity and justice prevail for those with mental health needs.
Of all forms of inequality, injustice in health is the most shocking and inhumane…
Dr Martin Luther King, Jr.
Special Acknowledgement:
We wish to acknowledge the special contributions and Lived Experience Narratives provided by
the members of the Global Mental Health Peer Network on the continent of Africa who graciously
shared their experiences, their pain and their survival despite the inequalities meted out to them
just because they have a mental illness.
Informed consent forms have ocially been signed and given by all lived experience narrative con-
tributors.
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WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 136
Introduction Mental
Health in an Unequal
World- the case of
Latin America and the
Caribbean
GERARD HUTCHINSON
MBBS, MD, MSC- Professor of psychiatry, Faculty of Medical Sciences, Oniversity of the West In-
dies, St Augustine Campus.
Summary
Latin America and the Caribbean is one of the most unequal regions in the world. It is sometimes
divided into the subregions of South America, Central America and the Latin Caribbean and the
non-Latin Caribbean and they all share in the marked inequality in the region. There are longstand-
ing health, social, economic and racial/ethnic inequalities and it is also the most violent region in
the world with disproportionately high rates of crime and violence (8% of the world’s population but
33% of its murders) (Muggah et al, 2018; Moncada & Franco, 2021). These inequalities are seen
between and within countries in the region ( Mascayano et al, 2021). Wealth and income inequality
especially is one of the more signicant issues in this region that impacts every aspect of life. In a
2020 report from the InterAmerican Development Bank (Moreno, IADB, 2020), it was noted that the
richest tenth of the population in this region captures twenty- two times the wealth of the lowest
tenth. This disparity affects moreso women, those of African descent and indigenous peoples.
These inequalities begin at birth and widen during childhood and adolescence having profound
impacts on growth and development through inequalities in education, opportunity and access to
health care among other social ills. The more disadvantaged are also more likely to be hindered
by climate change, natural disasters and social upheaval inclusive of exposure to and experienc-
ing violent crime and poor nutrition. It is no wonder that these disparities have been highlighted
during the ongoing Covid 19 pandemic with the poor bearing the brunt of both the health effects
and the effects of the mitigation lockdown strategies to combat it (Busso & Messina, IADB,2020).
The report noted that high levels of inequality undermine the commitment to the common good
and result in discouragement, distrust and cynicism which further disrupt social bonds and lead
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 137
to fragmentation and lack of community building. Institutions are also weakened by this distrust.
These features of life in this part of the world make mental health promotion and mental illness
prevention and treatment urgent societal and developmental issues. Improving access to mental
health care and the strategic initiatives to tackle the socioeconomic, gender and ethnic inequalities
remain constantly intersecting priorities.
Introduction
Mental health care is one of the main areas where the inequality that is inherent in the region of
Latin America and the Caribbean manifests itself. In Disability Adjusted Life Years (DALYs) in the
region, a comparison of 1990 and 2017 to review the most common diseases impacting on this
metric, revealed self harm and violence increase from eighth to fourth, mental disorders from tenth
to sixth and neurological disorders from twelfth to seventh (Berlinski et al, IADB, 2020). This sug-
gests that the consequences of compromised mental and neurological health are becoming an
increasingly signicant burden on these societies. The other major shift has been the increased
prevalence of the chronic non - communicable diseases. All of these - from diabetes to hyperten-
sion to obesity and cancer have bidirectional relationships with mental health. The current Covid 19
pandemic has highlighted and exacerbated these inequalities so the timing is right for a focus on
how best to address the disparities in mental health care (Mascayano et al, 2021). The disparities
that arise out of social inequality also affect North America where African Americans and some
Hispanic populations have higher rates of mortality and morbidity for many illnesses and are less
likely to access mental health care (Carratala & Maxwell, 2020). The burden of morbidity and mor-
tality in every area of health is therefore greater for these groups. In societies already congured
in ways that reinforce the inequalities that exist through unequal access to educational and em-
ployment opportunities, the effects of the disparities are worsening over time. Health disparities in
Latin America are thought to be a consequence of disparities in living conditions so that the poor
and disadvantaged are disadvantaged in this area also (Davila-Cervantes & Agudelo-Botero, 2019).
These disparities are generally derived from income inequality and this has been found to be as-
sociated with poorer mental health at the subnational level and social, economic and public health
policies should be developed to address this in a coordinated manner (Tibber et al, 2021).
An acknowledgment that these gross inequalities in the social system are reected in the health
system can be measured and quantied through the ease of access to care, availability of appropri-
ate treatments and relevant health promotion and prevention efforts. It is also reected in the way
health systems are managed and governed with institutional systems that are inclined to restrict
and inhibit diversity and equity of access. There has been a renewed interest in the health effects
of inequality. The association of these inequalities with race remains one of the greatest health
problems in the world. This is especially pointed with regard to mental health and studies in the
United States have repeatedly shown this ( Williams et al, 2019). Even in Columbia, ethnic- racial
inequity has been identied as a structural component of inequities in access to health services
and contributed to the disadvantages for those so affected in the population (Viafara- Lopez et al,
2021).
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 138
Mental Health Systems in the Region
Dealing specically with mental health, the World Health Organisation has developed 10 overall
recommendations for mental health care (WHO-AIMS, 2013)
1. Treatment in primary care of mental disorders
2. Availability of psychotropic drugs
3. Develop national policies, programmes and legislation
4. Development of human resources
5. Public education
6. Give care in the community
7. Monitor community mental health
8. Involve communities, families and consumers
9. Links with other sectors
10. Support more research
These recommendations are further grouped into six domains in the assessment instrument for
mental health care systems (AIMS) through which the issues related to inequality and mental
health can be discussed. The domains are 1. Policy and legislative framework. 2. Mental health
services. 3. Mental health in primary care. 4. Human Resources in mental health care. 5. Public
education and links with other sectors. 6. Monitoring and research. The following is a review of the
last published report on mental health in Latin America and the Caribbean published by the Pan
American Health Organisation (PAHO) in conjunction with the World Health Organisation (WHO) in
2013 (WHO-AIMS, 2013). All statistics quoted come from the text of the report.
Domain 1 – Policy and Legislative Framework
While most countries in the region now have mental health policies and plans the degree to which
these have been implemented vary widely and in turn affect how equitably the services available to
the mentally ill can be accessed. Human rights, community- based care, legislation governing the
treatment of the mentally ill are in various stages of evolution throughout the region and the nanc-
ing of mental health services tends to be in the range of 1-3% of the national budget on average
in the region. This combined with the absence of social security benets, diculties with housing
and employment all contribute to the lived inequality of those disadvantaged by the socioeconomic
and other societal inequalities. In this way, protection of the most vulnerable is unattainable. The
inability to afford medication and low minimum wage levels mean that those at the lower end of
the social spectrum are subject to the likelihood of unaffordable medicines especially as the public
sector services are not consistently accessible or consistently stock all of the necessary medica-
tion. Many countries in the region do not have updated legislative frameworks for mental health
and this indeed is an urgent priority to provide protection for those who are already disadvantaged
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 139
by their lack of economic and social status.
Domain 2 – Mental Health Services
Most of the services are based on tradition and history based on the systems developed by the
former European colonisers in the region and generally function around a centralized mental hospi-
tal/s with outpatient services in the community. Many of the hospitals serve a residential function
as well as an acute care function and there are an average of 12 beds /100000 population in the re-
gion. Day care facilities are lacking as are forensic units though generally the non - Latin Caribbean
have the most evolved services. Many of the countries have free public sector services but these
function at varying levels of ecacy and effectiveness. Private care is also available in most coun-
tries but since these must be individually funded, they are only accessible to those with available
economic resources. It generally creates a two-tiered system where the public services are availa-
ble to the poorer classes and the private services to those better off nancially. This reinforces the
inequality in the society and mean that those who use the public sector are less likely to challenge
for their rights if these rights are being abused. Another gaping absence is services for children
and adolescents particularly in the non latin Caribbean where only 7.5% of the service allocation
is for this age group compared to 21% and 23% for Central and Latin America (WHO-AIMS, 2013).
The elderly and those with co-morbid chronic non-communicable illnesses are also underserved.
There are few dedicated services for these populations and their care is subsumed in to the gener-
al services on an as needed or as requested basis.
Domain 3 – Mental Health in Primary Care
The provision of mental health care in primary care has been identied as a means of addressing
the gaps in treatment that leave many mental disorders unrecognized and therefore undiagnosed
and untreated. Having the facility to treat mental health problems at this level also decreases the
burden on the more specialized services and also contributes to reduced stigma. However, the
uptake from this approach has been fairly limited in the region, as training in mental health and the
absence of practice guidelines have hampered primary care health professionals from engaging
in this process more comprehensively. This may in turn lead them to seek help from more tradi-
tional sources such as healers, people who claim to deal in the supernatural or churches and other
religious practice. Belief systems regarding the cause of mental illness while pervasively embrace
the supernatural and the spiritual also inuence the decreased engagement with services that are
thought to be oriented toward physical health. This further underserves the population who are
likely to be those who are already disadvantaged and diminishes the quality of the mental health
care that they may be able to access. Cuba is an exception to this situation and here members of
the Comprehensive Family Health Care teams regularly interact with mental health and social work
professionals to offer an integrated model of care.
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Domain 4 – Human Resources in Mental Health Care
In the region, there is wide variation in the availability of mental health professionals – 6-79 per
100,000 in Central America and the Latin Caribbean; 4 – 173 in South America and 9.6-182 in the
non -Latin Caribbean. The number of psychiatrists also varies with South America and the non-Lat-
in Caribbean being as much as twice that available in Central America. Apart from the non-Latin
Caribbean, the availability of nurses working in mental health is relatively low. Another problem
is that the psychiatrists tend to be concentrated in urban areas making mental health care in the
rural areas much less accessible. In addition, the psychiatrists and some of the other mental
health professionals share their time between the private and the public sector making them less
available to meet social need. They are also then compromised in advocating for improvements
to public health care services or indeed to develop new ones that are adapting to the needs of the
population. Training in mental health related disciplines is available throughout the region but the
availability of mental health professionals in allied disciplines such as Psychology , Occupational
Therapy and the creative therapies such as Music and Art Therapy remains less than optimum.
Social work is perhaps the one discipline where the numbers reect the needs of the population
and compare favorably to the developed world. Because of these limitations and the demands
placed on limited human resources, burnout among these mental health professionals is common
and again in the absence of mental health plans and policies, their services are utilized in private
practice and the benets are denied to the masses particularly those who are socially displaced
and indigent. User and family associations are also mostly non-existent and their absence means
that the needs of those most disadvantaged may not be identied and addressed particularly with
regard to human rights and the improvement of services.
Domain 5 Public Education and Links to Other Sectors
There has been a growing appreciation and implementation of education and awareness cam-
paigns for mental health which target various sectors in the society. Most of the countries in the
region have coordinating bodies that manage these campaigns. The absence of user and family
groups and perhaps stigma against the mentally ill, is reected in the consistent lack across the
region of legislative or systematic mechanisms to facilitate housing, employment and non-discrim-
inatory practices for people living with mental illness. Formal interdisciplinary links with other sec-
tors for example the legal and judicial system mean that services do not always meet the holistic
needs of the population being served. This is particularly seen in South America, where in only half
the countries of this subregion 1-20% of prisons offer services for the mentally ill. Interestingly in
the non- Latin Caribbean most of the prisons have some form of mental health service in the larger
islands. Still, the links with the judicial and law enforcement systems are not so developed as
there are few training provisions for these ocers involved in discharging these services in mental
health. Similarly links with the education sector are patchy as are those with social services and
services for populations such as the homeless and the street dwellers.
There are usually established links within the health sector however there may also be gaps when
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individuals need multiple inputs such as those provided by primary care and substance abuse ser-
vices or indeed more specialized medical or surgical services
Domain 6 – Monitoring and Research
Provision of data and information systems reporting on the utilization of the mental health services
is inconsistent, information systems in most of the countries do not have the tools or technology to
report effectively on the utilization of mental health services. Most countries report on the number
of beds being occupied, the length of stay and the range of diagnoses of the admissions but very
little is reported on the kinds of admissions – involuntary compared to voluntary and the patterns
of utilization. This means that an understanding of the epidemiology of mental illness over time
is not easy to engage. This hinders an appreciation of the effectiveness of the services and the
direction in which they should adapt to suit the particular needs of their population. It also serves
to disguise possible human rights violations and/or treatment biases particularly in already disen-
franchised groups (Almanzar et al, 2015). Information generally ows to the Ministries of Health to
justify funding and allocations of staff but there is little critical analysis.
Research is also limited particularly in mental health though there is now greater attention being
paid to this area. In most of the region, only 10-15% of the health papers published do report on or
include some aspect of mental health. A possible reason for this is the lack of funding for research
in general except in the larger countries of the region such as Brazil, Argentina and Mexico. A lot
of funding comes from the pharmaceutical industry which would be interested in developing their
agenda rather than meeting the developmental needs of the country. In addition, dissemination of
information derived from research tends to have limited impact because there is limited exposure
to the population through public engagement.
The WHO-AIMS report concluded that while there was cause for optimism and some major ad-
vances had occurred over the previous decade (2001-2010), a lot needed to be done to address the
many disparities within and between countries. Mental health legislation, more equitable nancing,
decentralizing mental health care, greater integration with primary care services, greater intersec-
toral links, protection of human rights of those with mental illness and improvements in informa-
tion systems and research activity are all required to address the decits identied.
Discussion/Conclusion
Inequities in access to mental health care, social vulnerability, and an absence of social inclusion
all inuence the generation of mental health distress and the capacity to seek and receive appro-
priate help for this distress (Blucacz et al, 2020). The treatment gap in mental health is a major
concern in the region and a high proportion of adults, children and indigenous people remain
untreated and therefore unable to fully engage in productive optimum lives (Kohn et al, 2018). This
has implications for human and social development in the region and must be addressed as an
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 142
area of special concern. The marked difference in access to services in rural compared to urban
communities, the lack of mental health in patient beds and specic services remain obstacles to
ensure equity of mental health care in this region.
The Jamaican model of treating mentally ill patients in a general hospital setting on beds in the
medical ward (Abel et al, 2011) has been one strategy to overcome this rural-urban divide by reduc-
ing the need for dedicated psychiatric beds in a specic location.
Other diculties in the region include insucient services, poor integration of related services,
fragile crisis management and inconsistent family and social support because of inherent limi-
tations in psychosocial resources and lack of strong structural networks for crisis management
(Sampaio & Bispo Jnr, 2021).
In the Americas, there are specic geo-political issues such as migrant refugees, crime and vio-
lence, mental health support during this ongoing Covid 19 pandemic, drug use and treatment and
rehabilitation of those socially displaced and mentally ill warrant great attention. Migration and un-
regulated movement of populations seeking a better life or escaping from conicts or persecution
remains a feature and this also creates inequities as these groups have additional mental health
needs related to managing trauma for example that are rarely met. The recent crisis in Venezuela
and the many citizens of Central and South America who attempt to enter other countries in the
Americas illegally bears witness to this (Derr, 2016 ; Mougenot et al, 2021).
Mental health services in Latin America and the Caribbean have improved over the 21st century.
One of the major inhibiting factors is insucient funding which is a consequence of the parlous
and vulnerable economic state of many countries in this region. Lack of consensus, and inade-
quate and perhaps inappropriate training among the human resources, the lack of family and user
association advocacy and a relatively dormant political will all contribute to the slower develop-
ment of mental health services in this region. Renewed interest in human rights, the development
of research capacity, the psychological impact of natural disasters and now the covid 19 pandemic
and the greater opportunities for international cooperation may also inuence the positive growth
of these services. ( Caldas de Almeida, 2013). One of the major drivers of mental health services
reform was the 49th Directing Council of PAHO/WHO which approved the Strategy and Plan of
Action on Mental Health in the region of the Americas (Rodriguez, 2010). This plan mandated the
Ministries of Health of the region to engage in sectoral reform and provided technical assistance to
achieve the goals. Although insucient funding was a limiting factor, the awareness of the growing
burden of diseases attributable to psychiatric and neurological problems and also a growing treat-
ment gap where the majority of those aicted with these problems were not accessing services
prompted these initiatives which have borne some fruit.
Challenges/Objectives
1. To remove the stigma associated with mental health and treatment.
2. To ensure equitable mental health delivery and access among all socio- demographic groups.
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3. To minimize disability and improve linkages with other sectors to ensure improved social ser-
vices for those with mental health problems and other underserved populations eg prisoners
4. To increase funding for mental health
5. To improve prevention and mental health promotion efforts
6. To improve mental health delivery in maternal health.
7. To integrate primary care services with mental health services.
8. To have improved liaison services between mental health and other medical services eg mater-
nal health and child health.
9. To improve research activity and ensure appropriate dissemination.
10. To improve advocacy through facilitation of user groups and caregiver support strategies
Closing Comments
Public health, and primary care must be intimately involved in the expansion and development
of mental health services to reach more people and reduce the number of unrecognized mental
health problems. Improved access to educational opportunity is also another pivotal factor as is
maternal and child health care. Child and adolescent mental health services in the region lag far
behind other more developed countries. At the other end of the age spectrum, the region’s demo-
graphic shift is also well underway and is already demanding a greater range of geriatric mental
health services for the growing elderly population (WHO-AIMS, 2013). Again, here the inequalities
of the region will determine the effectiveness of these responses within populations.
The incorporation and alignment of faith based services with mental health services may be help-
ful in addressing mental health literacy and antistigma interventions as beliefs related to super-
natural causation of mental illness and prayer and faith as a means to overcome psychological
distress are common in the region (Caplan, 2019). More general efforts to improve mental health
literacy, thereby diminishing the stigma of mental illness and encouraging and facilitating help
seeking are urgent priorities
Workplace wellness and mental health, improved disaster management plans incorporating men-
tal health emergencies that are inevitable a part of these disasters is needed. Specic services
for populations like the incarcerated, substance use disorder programs, mitigating the roles of
pollution and climate change are all components of the strategies to combat the likely mental
health needs of the region in the coming decades and address the inequalities that now exist in the
region that are amplied by the socioeconomic inequalities. Devising preventive and early access
facilities for intimate partner and interpersonal violence are also priorities as these disproportion-
ately affect the region’s disadvantaged. Training of mental health professionals in all areas from
psychiatry to nursing to the various physical occupational and creative therapies would all help to
decrease inequality and mental health support and treatment.
Intersectoral academic and service linkages with maternal and paediatric health services will
serve to anticipate some of the problems that begin in childhood but only express themselves in
adolescence and young adulthood including those of poor nutrition and bullying. Multisectoral
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 144
approaches marrying economics, education, social services and mental health alongside the provi-
sion of services to address issues such as housing, employment and discrimination. Working with
Making the links between the social problems such as interpersonal violence and social inequality
with mental health problems is also needed given the regions unfortunate tag as the most dan-
gerous in the world. Finally, recognition that inequality has a direct and powerful effect on mental
health and contributes to many of the region’s problems and requires political and social will to be
overcome if the region’s development is not to be permanently stunted. Equity of access to men-
tal health services is one of the ways in which the social inequalities that affect the region can be
addressed.
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WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 146
Pediatric Racial/Ethnic
Mental Health Disparities
in North America
ANDRES J. PUMARIEGA M.D.
Professor and Chief, Division of Child and Adolescent Psychiatry. University of Florida College of
Medicine.
Purpose of this Position Statement
• To highlight the signicance of racial/ethnic disparities in pediatric mental health in North
America, particularly the United States
• To outline the various types and levels of racial/ethnic disparities in clinical care, as well as sys-
temic disparities related to structural racism and discrimination in the mental health and health
system
• To outline recommendations for addressing racial/ethic disparities that encompass provider,
health and social service systems, and population level interventions and reforms
Introduction
North America, particularly the United States, has undergone a major growth of non-European pop-
ulations over the past 50 years. This has been both a result of demographic changes (aging of the
European origin populations and relative grrater growth of African American, Latinix, Asian origin,
and American Indian populations) and signicant immigration from Latin America, Southeast and
East Asia, the Middle East, and Africa. As a result, by last year (2020) the majority of children and
youth in the U.S. are from non-European backgrounds (this will be the case for the overall popu-
lation by 2045). These populations face higher rates of psychosocial disparities such as poverty,
lack of education, and barriers to health and mental health services, as well as dealing with multi-
ple stressors such as traumatic stress, community violence exposure, immigration stresses, and
acculgturation stress from pressure to assimilate to mainstream American culture. These are
placing greater stressors on these populations than on their European-origin cohorts, and starting
to result in increasing rates of mental health morbidity, such as suicidality, stress related disorders,
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 147
school disciplinary actions, and rates of incarceration and placement in state custody. At the same
time, the children’s mental health service system in the U.S. is a largely fragmented system geared
to middle class Caucasian norms of family independence and self-suciency. In spite of some
efforts, this system lacks the necessary skills and capacity to address the special cultural and psy-
chosocial needs of these growing populations. This mental health system has inherent structural
racism and discrimination as a result where Black Indigenous and Populations of Color (BIPOC)
lack access to care and experience lack of effective services and outcomes, adversely affecting
their quality of life and potentially adversely affecting the overall mental health of the nation. (Ref
here)
The challenges and the need
The increasing need for and utilization of child mental health services in the United States has
spurred their rapid growth. Recent studies suggest that approximately 20 percent of children and
adolescents have a diagnosable mental, emotional, or behavioral disorder, with 5 percent having
serious mental illness and emotional disturbance and over US $ 247 billion being spent annually on
children’s mental health services (Perou et al, 2013). Several morbidities have been associated with
childhood emotional disturbance and mental illness, including suicide, homicide, substance abuse,
child abuse, teenage pregnancy, school dropout, youth crime, and associated institutionalization
and incarceration. However, less than 1 percent of children in the United States receive mental
health treatment in hospital or residential settings, with another 5 percent receiving treatment in
outpatient or community-based settings; greater than two-thirds of children in need still receive
insucient or no mental health services whatsoever. There is evidence that the recent COVID-19
pandemic has signicantly increased levels of mental health need and rates of morbidities as well
as rates of mental health utilization among children and youth, aggravating these gaps in services
even more (FAIR Health, 2021).
BIPOC children and families have been traditionally served by public community-based mental
health and human services agencies. Children from these populations experience higher levels
of stressors, such as poverty, discrimination, immigration, acculturation stress, and exposure to
violence and trauma, and they are likely to have higher levels of need for services. It has become
clearer that these populations suffer from major disparities in access to care as well access to
quality and effective care, particularly African American and Latinix youth. A growing awareness
and recent reckoning with the long-term impact of racism and discrimination in the United States
racism has pointed to inherent structural racism in societal institutions, including mental health,
health, education, and social services, which are now recognized as resulting in such disparities
and the lack of cultural competence of such services. The cost of effectively serving BIPOC chil-
dren and adolescents is in stark contrast to the much higher cost of psychosocial morbidities of
racial/ ethnic disparities, including lost human potential and the costs of welfare dependency and
institutionalization. The United States continues to have the highest youth incarceration rates in
the world, the highest levels of out-of-home or community residential placement for youth, and a
high rate of children in state custody (Alegria, et al. 2015; Youth.gov, 2021), both disproportionate-
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 148
ly impacting youth of color. Due to lack of funding for effective community-based mental health
services, a health and human service agencies (schools, social welfare agencies, child protective
agencies, juvenile justice, and public health) have shouldered the increasing burden of psychoso-
cial morbidity experienced by these children and youth. These agencies typically address pieces of
the service system puzzle, with little to no coordination with other agencies serving the same youth
resulting in increasing care fragmentation. (Abram et al, 2015; Alegria et al, 2015).
These trends have increased pressures on public child mental health and social service agencies
to demonstrate improved clinical and cost-effectiveness, increasingly turning to managed care
approaches to nance and organize mental health and social services. Most children covered by
Medicaid (the public insurance system in the US) are under managed care plans, including for
behavioral health services. Most managed care approaches were developed with private sector
populations in mind, relying on a priori benet restrictions based on actuarial data on middle-class
populations with adequate social supports, who are traditionally lower users of services. When ap-
plied to public child mental health services, these approaches deprive children at high risk of effec-
tive intervention and preventive services. They also contribute to fragmentation of care and burden
shifting to other child-serving agencies and systems, signicantly increasing morbidity and acute
need. Some state Medicaid programs have successfully implemented community-systems-of-care
approaches and integrated them with managed care methods through its home and community
based behavioral health services waivers (Medicaid and CHIP Payment and Access Commission.
Report to Congress on Medicaid and CHIP, 2021), but so far, no state in the United States has been
successful at statewide implementation of system of care in spite of an extensive number of sys-
tems of care pilots (U.S. Department of Health and Human Services, 2015).
Services research literature with underserved minority youth has been sparse, and initially was
focused on documenting racial differences in services provided. African American children tend
to remain in foster care for longer periods of time and to have more foster care placements than
white children. Studies have shown culturally diverse children to be underrepresented in mental
health institutions and overrepresented in child welfare and juvenile justice settings and place-
ments compared to nonminority youth, even when they are equally psychiatrically impaired. Ethnic
and racial differences in the diagnoses of culturally diverse adolescents have been identied by
some investigators, including overdiagnosis of conduct disorder and psychoses and underdiag-
nosis of affective, personality, and substance abuse disorders. Signicantly lower rates for overall
services utilization persist over a number of years, and specically for the treatment of depression
among African Americans and Latinos have been documented (Alegria et al, 2015). Signicant
amongst them, the SAMHSA Comprehensive Community Mental Health Services for Children and
their Families initiative has demonstrated not only signicantly improved access by BIPOC children
and families, but also equivalent outcomes that are correlated to cultural competence program
measures.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 149
Proposed region specic actions
This position statement is written in the context of a well recognized global crisis in children’s men-
tal health, highlighted by the COVID pandemic. Therefore, it is important to note that most nations
fall short in addressing these important and growing needs (Benton, Boyd, and Njoroge, 2021).
The main recommendations outlined below in the country section are more specic to the United
States. However, the proposals and models are also a goog t for thhe children’s mental health
needs experienced by the rest of North America, particularly Mexico and Canada.
Mexico has signicant racial/ethnic disparities that parallel regional disparities due to its dearth of
chidlren’s mental health services but also their concentration in urban centers and academic insti-
tutions. Mexico lacks a community-based children’s mental health infrastrcutre that reaches down
to smaller towns and rural areas, where the majority of its indigenous populations resides. , which
is a very young popoulation. Only 200 psychiatrists are licensed to see children, so there is not only
an extreme shortage of child/ adolesdcnet psychiatrists, but also similar shortages of other mental
health disciplines.
Sixty percent of Mexicans have national health insurance, so 40 % are uninsured. A combination
of state and federal funding supports the country’s 32 states in administering their health care
systems. States also differ substantially in their health investment since they differ substantially in
their tax base and other resources as well as the degree of social need. Child and adolescent men-
tal health services in Mexico are delivered through an underfunded, and uncoordinated network
of institutional providers (many psychiatric hospitals) isolated from the larger health care system.
Some localities have consulting psychiatrists and psychologists serving schools as a means of
providing some access to services. The natioinal child welfare system, Desarrollo Integral de la
Familia (DIF), under the federal Secretariat of Health, has some family preservation service that at
times can be mobilized for chidlren with behavioral and mental health problems. (Espinola-Naduril-
le et al, 2010; Sistema Nacional para el Desarrollo Integral de la Familia (DIF), 2021).
The Canadian system is socialized and organized at the levelof provinces with prpovincial and fed-
eral funding. The Canadian system is organized around primary care, with specialty care provided
by referral to specialist and specialty centers Canada has signicantly greater access to childen’s
menta health services and much higher numbers of mental health professinoals, with some ties to
schools and other local institutions but largely based in clinics and hospitals. Canada still faces a
shortage of intensive community-based services for children and families and lack of coordination
across child serving agencies. The challenge for Canada is that provinces outside of Ontario and
Quebec face many of the similar issues as in the U.S. due to their more Euro-centric orientation in
spite of growing Native and non European immigrant populations. Mexico has challenges around
implementation of many of these recommendations given their relatively resource poor environ-
ment and less developed mental helth system. (Mental Health Commission of Canada, 2021).
Both Mexico and Canada could benet from a more systematicinter-agency approach to children’s
behavioral health services that alsoexpanded community-based services in local commumnities.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 150
Given their signicant diversity due to its high percentate of indigenous and growing immigrant
populations, both nations can also benet from culturally competent approaches. Though Canada
has recentl focued more attention to the needs of First Nation populations, Mexico’s mental health
system could benet from a more comprehensive culturally competent approach that leveraged
non-professional indigenous lay mental health workers and cultural healers to provide an outreach
basic behairal workforce. In fact, in the U.S. a model for this approach, the Promotas de Salud mo-
del, is used along the US-Mexico border for publis health and behaviiral health promotion (Grames,
2006).
Proposed country specic actions
A. Implementation of cultural competence mental health training for all US
mental health providers, both at the pre-practice training level and tied to
their on-going licensure maintenance
Cultural competence is an integral element of community-based systems of care. It implies that
practitioners in systems of care develop the necessary attitudes, skill, and knowledge base to serve
minority and culturally diverse children and families in their communities, as well as having service
systems that develop policies and practices to remove barriers for access to services and make
these more responsive to the needs and values of diverse communities. Studies have also shown
higher engagement in treatment by minority youth and families if the clinician is of a similar ethnic/
racial background, though the impact on outcomes is less signicant (Cabral and Smith, 2011).
These ndings have led to a focus to address disparities through recruitment of greater number of
BIPOC providers into the mental health professions. Though such efforts are very much needed,
less attention has been paid to the effectiveness of cultural competence training of mainstream
providers to equip them to better serve BIPOC children and families, as well as well as training on
the implementation of many evidence-based psychotherapy and community treatment programs
that are effective in serving BIPOC children and families (Pumariega et al, 2013).
The community-based systems-of-care approach is congruent with the cultural values of ethnic
minority populations, which emphasize strong extended family involvement in the life and upbring-
ing of children and the use of natural community resources rst in dealing with the emotional and
physical problems of family members. These factors have been shown to be protective from some
of the morbidities associated with emotional disturbance, such as substance abuse and suicidality.
National guidelines for cultural competence for managed Medicaid services have been published
by the CMHS, and the Practice Parameter adopted by the American Academy of Child and Adoles-
cent Psychiatry (AACAP) operationalizes elements of cultural competence at both the clinical and
systems levels. Building on this work, more recent efforts by various professional organizations
and researchers on children’s mental health has focused on the impact of structural racism on
racial/ ethnic disparities, such as the rising prevalence of psychiatric morbidities such as suicide
in BIPOC children and the barriers to access to effective mental health and social services (Four
Racial Ethnic Panels, 1999; Pumariega et al, 2013; Alegria et al, 2015).
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 151
B. Statewide and nationwide systematic implementation of the community
systems of care model as the overall structure for children’s mental health
services
Over the last 35 years, the community-based system of care model and principles have been devel-
oped in response to similar problems with fragmentation of care and lack of appropriate access in
child mental health, particularly for children and families with multiple problems and needs. These
principles are based on a exible and individualized approach to service delivery for the child and
family within the home and community as an alternative to treatment in out-of-home settings, while
attending to family and systems issues that impact such care. The key principles include: access
to a comprehensive array of services, treatment individualized to the child’s needs, treatment in the
least restrictive environment possible, full utilization of family and community resources, full partic-
ipation of families and youth as partners in services planning and delivery, interagency coordina-
tion, the use of case management for services coordination, no ejection or rejection from services
due to lack of “treatability” or “cooperation” with interventions, early identication and intervention,
smooth transition of youth into the adult service system, effective advocacy efforts, and non-dis-
criminating, culturally sensitive services (Winters and Pumariega, 2007).
Family-driven care is a cornerstone of the system-of-care model and has had a signicant inuence
on national policy for both child and adult mental health. The child and family drive the clinical
planning process through determining the goals and desired outcomes of services, selecting the
composition of the interagency service planning team, evaluating the effectiveness of services,
and having a meaningful role in all decisions, including those that impact funding of services. The
interagency planning team typically has representatives from all the agencies and sectors involved
with the child, and the team process facilitates interagency and interdisciplinary collaboration. The
complementary contributions of various team members function synergistically in identifying sys-
tem and community resources to promote better outcomes (Stroul and Freedman, 1986; Winters
and Pumariega, 2007).
For children with complex problems involved in multiple child-serving agencies, assessment and
treatment planning are primarily accomplished through interdisciplinary clinical teams. These
teams bring together different clinical and support resources to address the child’s needs to
supporting him/ her and their family in their community environment. Teams use the wraparound
process, a specic model of a child- and family-driven team planning process that has been em-
pirically tested within systems of care. Wraparound is a denable, integrated planning process
that results in a unique set of community services and natural supports that are individualized for
a child and family to achieve a set of positive outcomes. The wraparound process builds on the
strengths of the child and family, is community-based (using a balance of formal and informal
supports), is outcome-driven, and provides unconditional care. Use of a strength-based orientation
and discussion of needs rather than problems promote more active engagement by families in ser-
vice planning activities. Interventions designed to reinforce strengths of the child and family may
include nontraditional therapies such as specic skills training or mentored work experiences that
remediate or offset decits. These interventions generally are not included in traditional categorical
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 152
funding and may require exible funds that are not assigned to specic service types. Care man-
agement is key for the wraparound process so that different services and different interventions
can be well coordinated and integrated for greatest effectiveness, and not duplicated (Winters and
Pumariega, 2007).
Family participation is also facilitated through the parallel development of child and family teams
(CFT’s). CFT’s are composed primarily of nonprofessional members led by the consumer family,
usually a parent. In cases of older youth as consumers, the youth may serve as team leader. Em-
powering youth and families to assume a central role in outlining treatment goals and planning
requires the involvement of specially trained individuals who can guide such families to develop
such goals. CFT’s collaborate with interdisciplinary teams and professionals in agencies providing
services. The CFT creates an overall care plan, including a crisis plan. The clinical team then nego-
tiates their role in the crisis and care plans. This negotiation further educates families about how
their child’s needs could be addressed through treatment and enables professionals to learn about
the realities faced by the family (Winters and Pumariega, 2007).
More recently, services quality, cost-effectiveness, and outcomes and integration of evi-
dence-based practices have received greater emphasis within community-based systems of care
programs. An example of such emphasis has been the multisite national evaluation of the Compre-
hensive Mental Health Services Program for Children and Their Families. This program, which has
funded over 170 local and regional systems of care programs, has had national evaluations with
methodology measuring symptom, functionality, and strength change over baseline ratings at the
start of the programs and matched control evaluations The most recent report to Congress (U.S.
Department of Health and Human Services, 2015) on the evaluation of this program as well as
previous reports outlined signicant improvement in internalizing and externalizing symptoms and
child/family function using objective measures, increased stability of living situation with reduced
caregiver strain, improved educational function, reduced hospitalizations, reduced law enforcement
contacts, and reduced cost of care in other service sectors such as education, juvenile justice, child
welfare, and general health, and more recently cost reductions in mental health costs. Other results
from the program evaluation have demonstrated correlations of clinical and functional outcomes
to program site delity to system of care principles, including cultural competence domain mea-
sures (Stephens, Holden, and Hernandez, 2004). Additionally, these programs have demonstrated
equivalent access and outcomes for BIPOC children, youth, and their families (U.S. Department of
Health and Human Services, 2015).
Despite this signicant Federal investment in the Communities of Care program (by now over one
billion dollars) and their signicant outcomes, there has been few efforts at bringing the program
up to scale for statewide or national implementation, especially through the Medicaid public in-
surance program. This program would address not only the need of BIPOC children and families,
but also all children and families, and would be more cost effective than the current fragmented
approach. This is the main second recommendation within this position statement, which could be
enacted at rst through Federal legislation granting nancial incentives for state system reform to
interested states, but eventually making Medicaid funding contingent on a system of care frame-
work and model for all regions of each state.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 153
The ideal application of the system of care model at a state-wide level would have basic medical,
developmental, and behavioral health services coordinated through a collaboration of school-
based mental health programs and Pediatric Medical Homes. School-based mental health pro-
grams have been a cornerstone of most of the programs under the Comprehensive Mental Health
Services Program for Children and Their Families. Schools are the ideal setting for the “base” for
a comprehensive mental health system of care program given the signicant time that children
spend in school, the access to evaluation of children’s functionality, how behavioural/ mental
health disorders adversely impact academic and social function evident in schools, access to the
observations of multiple observers (teachers, counsellors, staff) and high level of family engage-
ment to schools. Many schools already provide a certain level of mental health services, but in this
proposed structure all ambulatory services (including even middle intensity services such as par-
tial programs or intensive community teams) would be based out of schools (Stephan et al, 2007).
The Pediatric Medical Home is another important cornerstone for this system. These share many
principles and elements with the community-based mental health systems model (Arsanow, et al,
2017). Adjunctive entities that have recently surfaced nationally and are closely tied to pediatric
medical homes are Pediatric Behavioral Health Collaborative Programs. These provide the sup-
ports that are often necessary for pediatric primary care providers to address entry level behavioral
health (and often developmental) services, including consultation (telephonic or televideo) with
child and adolescent psychiatrists, psychologists, and licensed social workers, assistance with
care coordination services to assist families in accessing community resources, ongoing training
and skill building support, and technical assistance for practices to integrate behavioral health ser-
vices within the practice’s care processes. This collaboration can also identify children and youth
with complex needs who require a more interdisciplinary coordinated care approach. (Pumariega,
2017; Arsanow et al, 2015; Grimes et al, 2018).
For children, youth, and families who have more complex mental health needs, more intensive care
could be coordinated at the local level using interdisciplinary teams and child and family teams
which would interface with school-based mental health programs and Pediatric Medical Homes,
in conjunction with Pediatric Behavioral Health Collaborative Programs. These could pursue com-
prehensive assessment and treatment planning, bring in the necessary medical and behavioral
specialists/ disciplines from their respective sectors (private, public, academic, non-prot, etc.) to
negotiate service/ treatment plans across school, home, and community with families and affected
persons, implement such plans, address arbitrary barriers to access to care and care coordination
(for example, between private/academic and public providers, across schools and mental health
providers, and blended funding sources for different types and levels of services. Such interdisci-
plinary teams would be signicantly more clinically effective and cost effective. State entities that
currently provide limited support and referral services could provide the oversight, structure, and
case management support, and serve a convening function for such teams, with incentives from
enhanced funding for team participation (as opposed to solo treatment in silos) and empower
such teams by streamlining eligibility and access procedures. More uniform standards around the
qualications of service providers and application of evidence-based interventions to delity by
such care coordinating entities could also greatly enhance such approaches. The primary care pro-
vider within the Pediatric Medical Home and the pediatric behavioral health collaborative program
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 154
would continue to be central and engaged within these teams.
Proposed actions for individual citizens
Individual citizens can take up more active advocacy for children’s mental health services, particu-
larly for BIPOC children and families, and for children’s system of care reform in general. This will
require public education campaigns that inform citizens on the impact of racial/ ethnic mental
health disparities on communities and the ineffectiveness of the currently fragmentad chidlren’s
mental health system. Individual citizen advocates, outsode of the professional ranks, coudl inu-
ence legilators (rst at the Federal level and later at the state level) on holding hearing and investi-
gations on systematic children’s mental health services reform and reasons wy a auccfessul model
has not been taken to larger scale. This might also reqjuire efforts at stigma reduction so the
parents of affeccted children can speak out and give input to legislators on how the current system
fails their children.
Implementing change
Strategies that could be used to advocate these change steps include public stigma reduction
campaigns, advocacy organizations approaching friendly Federal legislators about investigations
and hearings as proposed above, and to address BIPOC communites ad enlist them in joining
advoacy efforts. The two main advocachy organizations that could be motivated to take on this
effort are the Federation of Families for Chidlren’s Mental Health and the National Alliance for the
Mentally Ill. The Federation was actualy very involved in the advocacy for the initiation and sustain-
ability of the Federal Communities of Care program. National advocacy organizations for BIPOC
populations such as the NAACAP, Urban League, League of Latin American Voters (LULAC) and
Federal legislative caucuses such as the Congressinlal Black Caucus and the Congreressional
Hispanic Caucus would be natural allies. Professinla organizations such as the American Academy
of Child and Adolescent Psychiatry, the American Psychological and Psychiatric Associations, and
others are also key in advocating for this change. The outcome of these advocacy efforts could be
a system of care that is culturaly responsive, anti-racist, clinically effective, and cost accountable.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 155
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WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 157
Urgent action needed to
scale-up mental health
services in an unequal
world
DR WAFAA EL SAWY
Technical ocer. Mental Health and Substance Use Programme. Department of Noncommunica-
ble Diseases and Mental Health. World Health Organization Regional Oce for the Eastern Mediter-
ranean. elsawyw@who.int
DR. SUHAILA GHULOUM
Mental Health Services. Hamad Medical Corporation. Weill Cornell Medicine. sghuloum@hamad.
qa
DR. UNAIZA NIAZ
Adjunct Professor of Behavioral Sciences & Psychiatry, University of Health Sciences, Lahore, Paki-
stan. Faculty of Psychiatry, Dow University of Health Sciences, Karachi, Pakistan, WFMH Director at
large 2021—2023. drunaiza@gmail.com
JASMEEN UL-HAQUE
Assistant Executive Director of Corporate Communications. Hamad bin Khalifa Medical City. Ham-
ad Medical Corporation. julhaque@hamad.qa
MS NISREEN ABDEL LATIF
Communications Lead. Department of Noncommunicable Diseases and Mental Health. World
Health Organization Regional Oce for the Eastern Mediterranean. abdellatifn@who.int
DR. NASSER LOZA
President-Elect World Federation for Mental Health (WFMH). nasser.loza@wfmh.global
DR KHALID SAEED
Regional Adviser. Mental Health and Substance Use Programme. Department of Noncommunica-
ble Diseases and Mental Health. World Health Organization Regional Oce for the Eastern Mediter-
ranean. saeedk@who.int
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 158
Equity is at the heart of the 2030 Agenda for Sustainable Development, with a particular aim
to “promote physical and mental health and well-being, and to extend life expectancy for all, by
achieving universal health coverage and access to quality health care [so] no one [is] left behind”
(WHO SDGs, paragraph 26 of the 2030 Agenda)[1]. However, action on achieving both universal
health care and promotion of mental health and well-being remains patchy and uneven in the East-
ern Mediterranean Region (EMRO) of WHO and globally.
The burden of mental disorders continues to grow with a signicant impact on nation states, de-
velopmental and security trajectories and their ability to deliver on their commitments to promote
and protect the rights of their citizens. This includes impacting on their right to enjoy the highest
attainable standards of health, and to achieve their true potential as individuals contributing to their
families and communities.
The EMRO has the highest rates of mental disorders among the WHO regions. This is primarily
accounted for by prevailing protracted humanitarian emergencies in several countries in the re-
gion, which on one hand increases the need and demand for mental health services, while on the
other results in attrition of the capacities of health and social care systems to deliver the needed
care. The mental health care systems continue to suffer from neglect and apathy with the inade-
quate allocation of human, structural, institutional, and nancial resources. The situation is further
compounded by the stigma, discrimination, and human rights abuses to which people with mental
disorders are exposed (United Nations, 2020)[2].
This Position Statement aims to outline the risks and challenges relating to mental health in an un-
equal world; providing practical and inclusive recommendations designed to correct the apathy and
neglect of the past decades to support bringing mental health into the mainstream of public health.
Background
The Eastern Mediterranean Region stretches from Morocco in the West to Pakistan in the East and
consists of 21 WHO Member States and the Occupied Palestinian territories (West Bank and Gaza
Strip). It is home to 731 million people characterized by marked disparities between and within
countries, complex, protracted humanitarian emergencies, and a growing youth population with
large-scale internal displacement and migration. While some countries have experienced growth
and development, others have witnessed extreme adversity with subsequent deterioration in health
parameters in general and mental health in particular. Furthermore, the social, religious, and cul-
tural norms are also amongst the important determinants of mental health in the Region. While
contributing to the high levels of social cohesion and support for people with mental health prob-
lems, they also contribute to some damaging beliefs and practices that lead to stigmatization of
and discrimination against people with mental health disorders. All these issues can have serious
consequences on accessibility, availability, affordability, and acceptability of health and social care
services for persons with mental health disorders.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 159
Introduction
Mental, neurological, and substance use disorders (MNS) affect 1 in 10 persons around the world
at any given time (Mental Health Atlas, 2017)[3]. The Lancet Commission on Global Mental Health
(2018) reported a rise in mental disorders in every country in the world over the last three decades,
which is expected to cost the global economy $16 trillion by 2030. The economic cost is attributed
to lost productivity due to mental illness based on an estimated 12 billion working days predicted
to be lost every year. The report showed that poor mental health not only has an impact on the
individual level but also on the social, cultural, and economic level that could result in inequality in
matters such as education, income, nutrition, housing, and social support (Policy Brief, 2018)[4].
In the past couple of decades, Eastern mediterranen Region countries have experienced rapid
social, political, and economic change that has resulted in widespread civil unrest and violence and
exposed the majority of the population to stress. These factors have especially adversely impacted
vulnerable groups such as women, children, the elderly, migrants, and persons with MNS disorders
(Eaton et al., 2020)[5]. This has contributed to the gradual rise in the rates of MNS disorders in
countries of the Eastern Mediterranean Region, from 7% in 2000 to 9.8% in 2019 (WHO, 2021)[6].
The rise in rates of MNS disorders has not been matched with a commensurate increase in the
traditionally low allocations for mental health in countries of the Region. This translates into a
paucity of the mental health workforce, with 7.5 mental health professionals per 100 000 people
on average for the Region (compared with the world average of 24·3 per 100 000) and 5.2 inpatient
beds per 100 000 people in short-stay facilities; as well as a lack of treatment options and services
(Eaton et al., 2020). This not only reduces availability and access to treatment but also results in
an unfair distribution of resources as mental health services become concentrated in capital cities
and available for those who could afford them, leading to the yawning treatment gap. Among the
vulnerable population groups, children, women, older adults, refugees, people with disabilities, and
those in institutions such as prisoners are particularly adversely affected. (IASC, 2020)[7]. For the
purpose of this document, we are focusing on four of these vulnerable groups: women, children,
older adults and refugees.
Given that 75% of mental disorders occur before the age of 25, the lack of investment in young
people’s mental health further exacerbates the burden on the individual and communities due to
loss in productivity (Eaton et al., 2020).
With the onset of the global COVID-19 pandemic, countries of the Eastern Mediterranean Region
like elsewhere have seen an intensication of mental health crises fueled by a widespread sense
of uncertainty, nancial stress, social isolation and bereavement. The resulting increase in rates
of mental illness is exacerbated by decreased access to treatment, alongside the challenges of
particular health consequences of COVID-19 (Dong & Bouey, 2020; Torales et al., 2020; Eaton et al.,
2020)[8, 9, 5].
The COVID-19 pandemic will have signicant long-term consequences that need to be tackled by
governments, communities and individuals. However, it has also brought to the fore the urgency
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 160
to have mental health at the front and center of the policies that address poverty, access to health,
employment, and inequities in education (Eaton et al., 2020).
The challenges and the need
More than two-thirds of the world’s total Refugees (17.5 million) (including Palestinians) are from
the Region, of which almost 67.0% (11.7 million) remain in the Region (UNESCWA, 2019)[10].
Despite the high burden of mental, neurological, and substance use disorders, support for mental
health and well-being remains one of the most neglected areas of public health. This is evidenced
by the low level of public investment made in mental health, with a median spending of 3% of the
health budget on mental health. It is important to contextualize that the EMRO is a low investor in
health care compared to other regions.
Most countries spent under 5% of GDP on health care and all countries spend below the world
average for expenditure on health care. Additionally, despite the fact that currently 59% of the
EMR countries have a national policy/plan for mental health in line with international human rights
instruments (IHRI), only 7 (32%) of the EMR countries have implemented this (50% of high-income
countries versus only 17% of countries in fragile and conict settings).
The situation is compounded by ineciencies in the allocation of these meagre resources, which
is reected in the relative paucity of community-based services and patchy integration of mental
health components in primary health care settings with limited service coverage (only 5 regional
countries reported that they meet the criteria for integration of mental health in primary health
care) (Table 1).
Table 1: Mental health component integrated into primary health care (Mental Health Atlas, 2020)
Guide-
lines
Phar-
ma-col-
ogy
Psy-
cho-so-
cial
Training
Su-
per-vi-
sion
Total
Score
Score
4 or 5
Eastern Mediterranean Region
(N=22)
86% 29% 11% 82% 71% 2.8 23%
Rest of the World (N=172) 62% 33% 19% 75% 70% 3.0 26%
EMRO Country Group 1 (N=6) 100% 23% 9% 100% 68% 3.5 50%
EMRO Country Group 2 (N=10) 100% 25% 11% 90% 70% 2.9 20%
EMRO Country Group 3 (N=5) 60% 0% 0% 60% 60% 1.8 0%
The issue of scant human resources available for mental health is compounded by the fact that the
majority of professionals are deployed in large institutions mostly located in major urban centers
and therefore accessible to only a fraction of the population who need them. The result is high
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 161
treatment gaps for mental, neurological and substance use disorders differentially affecting the
most vulnerable groups of the population.
On top of the deciency in several mental health professionals, specialised training for addressing
the mental health needs of children, women, older adults and the institutionalized, such as prison
inmates, is even more decient.
Since March 2020, the COVID-19 pandemic has exacerbated the already fraught situation. A rap-
id assessment of the impact of COVID-19 carried out by WHO in June 2020 shows high levels of
disruption of essential mental, neurological, and substance use services in countries of the Region
(Figure 1). (WHO, 2020)[11]
However, the analysis also highlights the fact that emergencies often provide opportunities in that
multiple innovative interventions and approaches were instituted to overcome service disruptions.
The extraordinary situation helped galvanize many countries to provide mental health and psycho-
social support (MHPSS) through establishing helplines for MHPSS (85%), resorting to telemedicine
and teletherapy to replace in-person consultations (80%) and setting up self-help or digital psycho-
logical interventions (65%).
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 162
3.1 Vulnerable group: Women
The most prevalent mental health conditions, such as depression and anxiety disorders, are more
common in women who suffer disproportionately at the prime of their lives. Perinatal mental
health conditions, especially depression, are common around the world, yet likely to be missed with
limitations in specialised resources in the Eastern Mediterranean Region. The effects on the un-
born child and families are well documented in the literature.
In the rst study to quantify the burden of mental disorders in the Region 1990-2019, the Global
Burden of Diseases, Injuries, and Risk Factors Study (GBD), the Institute for Health Metrics and
Evaluation (IHME) showed how women suffer a higher mental health burden across the Region.
Women lost 3.3 million total DALYs to depression, compared to men’s nearly 2.1 million DALYs, in
2019. Similarly, women in the Region lost more than 1.9 million DALYs due to anxiety, compared to
1.3 million DALYs in men. (GBD, 2021)[12]
3.2 Vulnerable group: Children
The Region is also home to a growing youth population with 50% of the population being under the
age of 25 years. This is signicant given that 75% of all mental conditions commence before the
age of 25.
While specialized services for children and adolescents are gradually increasing in the Region,
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 163
these remain insucient to meet the demand. Only 6 countries of the 22 in the Region have child
and adolescent mental health beds and only 12 have some form of outpatient facilities for this
group. Staff working in these facilities are considerably fewer than the global median. Limited
efforts exist towards education and prevention of mental illness that target the younger population,
specically children and adolescents.
3.3 Vulnerable group: Older Adults
Overall, older adults are highly revered in the Region and they are typically looked after by members
of their family within their household. However, older people are also susceptible to MNS disorders.
Depression is the most common mental illness in this age group. In those with pre-existing mental
illness, chronicity will have its toll on their cognition, functioning and physical health. Loneliness,
perceived loss of role and frailty are all factors contributing to mental health disorders in this popu-
lation. More education for healthcare professionals and research is needed to address the issue of
paucity of service availability and data on the extent of the problem for this section of the popula-
tion.
In 2020, a regional survey assessing the status of implementation of the global action plan on the
public health response to dementia showed that the majority (71%) of EMR countries do not have
a dementia-specic national policy, strategy, plan or framework. Community-based services provid-
ing health and social care for people with dementia existed in around two-thirds (65%) of countries
in the EMR; these services were most prevalent in countries with high-income and abundant re-
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 164
sources (83.3%) (GDO, 2021)[13].
3.4 Vulnerable group: Refugees
Many countries in the Region are experiencing civil unrest, political turmoil and natural or man-
made disasters. Ten of the 22 countries in the Region are designated as fragile and conict-affect-
ed states and levels of conict in the Region have increased since 2010. 419 million (57%) people
lived in nine countries with graded emergencies (Afghanistan, Iraq, Libya, Pakistan, Palestine,
Somalia, Sudan, Syria and Yemen). Internally displaced persons (IDPs) in the Region have been
growing steadily during the past decades rising to 19.5 million (2020), 45.0% of the world’s total
number.
Protracted emergencies and vulnerabilities to natural disasters with their attendant destruction and
disruption of socio-cultural, political and economic institutions and activities, can leave people –
particularly the most vulnerable people – susceptible to poverty, destitution, violence, social ex-
clusion, internal displacement and migration; all of which lead directly to poor and unequal mental
health.
According to the WHO estimates, at least 1 in 5 people living in areas affected by conict is likely to
have a mental health disorder and these rates are likely to go up further in the long run (Charlson et
al., 2019) [14]. The United Nations High Commissioner for Refugees (UNHCR), states that “Women
and girls make up around 50% of any refugee — internally displaced or stateless — population and
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 165
those who are unaccompanied, pregnant, heads of household, disabled or elderly are especially
vulnerable”. The promotion of mental health and well-being was recognized as a health priority for
the rst time by world leaders through the Sustainable Development Goal 2, Target 3.4. Specically,
paragraphs four and 23 provide a strong basis for inclusion by calling upon nations to leave no one
behind, including refugees, internally displaced persons, and migrants. (United Nations, 2015)[15]
The New York Declaration for Refugees and Migrants, adopted in 2016, commits to refugee
children and outlines plans for working on those commitments. Points 26, 29 and 32 stress the
importance of addressing the needs of refugee children who have been exposed to physical or
psychological abuse and focusing on their psychosocial development. To this date, mental health
professionals in countries receiving refugees are struggling to deal with the issues related to refu-
gee and asylum-seeking children.
Capitalizing on Opportunities
The adoption of the Global Mental Health Action Plan 2013–2020 by the World Health Assembly
represents a paradigm shift from institutional to an integrated, person-centered, community-based
model of mental health care. In 2021 this Plan was endorsed for an extension until 2030 to ensure
its alignment with the 2030 Agenda for Sustainable Development. This is in line with the provisions
of the UN Convention on the Rights of Persons with Disabilities [16] which calls for active involve-
ment of people with mental health problems in all policy dialogues, development of services and
their delivery as well as all decisions about their own.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 166
One of the watershed developments at the global level has been the inclusion of mental health-re-
lated targets and indicators as part of the health-related Sustainable Development Goals, which
has broadened the remit from ‘No health without mental health” articulated in the global action
plan to “No sustainable development without mental health”.
Universal health coverage is identied as the overarching target for the health goal of the UN 2030
Agenda for Sustainable Development, which has led to a reinvigoration of the “health for all” com-
mitment rst made during the Alma-Ata Declaration (1978). Thus, the inclusion of specic indica-
tors related to mental well-being and substance use disorders provides an opportunity to integrate
mental health across all populations, communities and health platforms. The Disease Control
Priorities (third edition), Department of Global Health © 2018 also identies the most cost-effec-
tive interventions to be included in the universal health coverage benet packages, with the goal of
inuencing program design and resource allocation at country level to address the MNS disorders
equitably.
The other key developments include the Sendai Framework for Disaster Risk Reduction 2015 –
2030, which outlines four priorities for action to prevent new and reduce existing disaster risks: (i)
Understanding disaster risk; (ii) Strengthening disaster risk governance to manage disaster risk;
(iii) Investing in disaster reduction for resilience and; (iv) Enhancing disaster preparedness for
effective response, and to “Build Back Better” in recovery, rehabilitation and reconstruction. The
Sendai Framework’s fourth priority explicitly urges countries to provide for MHPSS services for all
people in need to promote resilience and building back better. It highlights the need to empower
“women and persons with disabilities to publicly lead and promote gender equitable and universal-
ly accessible response, recovery, rehabilitation and reconstruction approaches”.[17] That has been
backed up at the World Humanitarian Summit in 2016, where Member States, UN organizations,
non-governmental organizations and other relevant actors committed to advancing the Agenda for
Humanity centralizing the “Leaving No One Behind” approach.
Building on these developments, the Regional Framework for scaling up action on mental health
was adopted in 2015 by the member states at the regional committee to align the regional agen-
da with the global Mental Health Agenda for improving the mental health and wellbeing of whole
populations. The framework provides countries of the Region with a roadmap of specic, evi-
dence-based strategic interventions and indicators to monitor progress. The measures included in
the framework are high-impact, evidence-based, cost-effective, and affordable, and can be imple-
mented by all countries irrespective of income. The framework consists of 13 strategic interven-
tions for countries to implement and 19 progress indicators to monitor implementation (WHO,
2021) [18].
The framework, together with other documents, tools and technical packages, will help countries
to bridge the treatment gap through not only increasing the resources for mental health care but,
more importantly, utilizing the available human and material resources eciently to deliver integrat-
ed, community-centered care in an equitable fashion.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 167
Proposed region-specic actions
The last decade has witnessed some increase in investment in mental health and expansion of ser-
vices, with a focus on community outreach programs. Such expansions are a major step towards
service improvements, though they remain insucient to meet the demands.
Mental health should be an essential component of universal health coverage benet packages to
ensure sustainable investment and prioritized nancing.
Emergencies often result in increased focus and commitment for MHPSS which needs to be lever-
aged to ensure building back better of the mental health systems and services. This can be done
by incorporating mental health and psychosocial support as an essential part of emergency prepar-
edness, response and recovery plans.
Targeted health-related research remains an important area for development. While regional re-
search output has increased ve-fold in the decade from 2004–2013, however, the regional share
of global research production remains small and progress is not distributed evenly with a few
countries claiming a high share of publications (WHO, 2019)[19].
Proposed country-specic actions
Mental health should be reected in the national development agendas and policies as well as
health policies, where mental health should be formulated as a universal right and appropriately
resourced for achieving the 2030 Agenda for Sustainable Development.
A concerted effort has to be made to integrate mental health across the national emergency pre-
paredness, response and recovery plans to ensure the availability of multi-layered multi-dimension-
al MHPSS to the population(s) in need, including the most vulnerable population groups such as
women, children and adolescents, older adults, persons with disabilities, migrants and refugees.
Mental health-related policies and legislations should be reviewed and reformed to be aligned with
existing international human rights covenants/tools, such as the UN Convention on the Rights of
Persons with Disabilities.
Strengthening workforce capacity must be undertaken across health, social and educational sec-
tors for a collaborative multi-sectoral approach to promote mental health, prevent mental, neuro-
logical and substance use disorders, provide care and promote recovery.
Build mental healthcare capacity by expanding a qualied mental health and social care workforce
to provide MHPSS interventions to the population in a timely manner using the emerging technolo-
gies to deliver evidence-informed interventions across the spectrum of care and needs.
Investing in strengthening programs for mental health promotion and prevention of mental dis-
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 168
orders, such as adopting a life-course approach with a special focus on early child development,
parenting skills, life skills education for children and adolescents (Life Skills Education School
Handbook, WHO 2020)[20]. Promoting maternal mental health, suicide prevention and workplace
interventions are equally important, including support for health care workers and for caregivers of
persons with dementia.
Promoting mental health literacy to counter stigma and discrimination is essential and requires
national and community-based efforts to develop and implement targeted programs.
Urgent investment is needed to explore and develop the rational and prudent use of technology to
build and deliver mental health psychosocial support services; building on the experience gained
over the years in different settings, especially during the current COVID-19 pandemic, which has
seen the rapid deployment of technology to support healthcare delivery.
Countries must strengthen their health information systems to generate real-time data by ensur-
ing that mental health indicators are present in national health information systems. In addition,
mental health indicators must be included in national systems to monitor key developmental and
humanitarian targets.
More targeted investment is needed to generate and use new evidence to help guide policy and
legislative review and the resulting development of services responsive to the needs of the popula-
tion.
Empower mental health service users and carers through the involvement of people with lived ex-
perience in the design and monitoring of policies on a national level and service delivery in commu-
nities. Governments and policy makers should consider involving the individual in policy making,
service delivery and mental health promotion/awareness activities, etc.
Allocate resources to encourage the gradual shift away from institutional to a more integrated
community-based model of care delivery. This should include psychological interventions as a
major tool to help people in need in less rich countries.
Inpatient mental health facilities should be designed in a manner that clearly separates between
long-stay and short-stay wards to overcome the blockage of facilities by long-term patients.
Proposed actions for individuals
Develop personal skills: Health promotion supports personal and social development through
providing information and education for health and enhancing life skills. It increases the options
available to people to exercise more control over their own health and over their environments and
to make choices conducive to health (source: WHO, 1986)[21].
Due to the continuing stigma of mental illness, engaging those with lived experience is often chal-
lenging. People with mental illness should be encouraged to participate in public mental health
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 169
initiatives while efforts are made to protect them from vulnerable exposure. In the Region, family
plays a very important role in the management of people with mental illness and promotion of
their recovery. Families therefore must also be actively engaged in planning to ensure successful
outcomes. For instance, in comparison to Western mental health laws, in several countries in the
Region the family’s role in the mental health law is highly emphasised, acknowledging their crucial
role/participation.
Implementing change
In order to implement change and provide equal opportunities for all citizens in the EMR region,
the required interventions necessitate a whole of society and whole of government approach, with
active engagement and ownership from all the stakeholders across the public, private sectors, civil
society and academia. The priority interventions should ensure the inclusion of evidence-based
mental health interventions in the UHC-BPs of the countries across population, community and
health system platforms and delivery channels, to ensure all individuals have equal access to men-
tal health services without discrimination. It is also important to set up a well-resourced mental
health department within the Ministry of Health that coordinates and oversees implementations
and monitors these policies using an equity and human rights lens
Special considerations should be made to protect vulnerable groups such as women, children,
refugees, prison inmates, as well as people from different ethnic and cultural groups who are more
likely to experience stigma and discrimination (IASC, 2020)[6]. Such groups might have diculty
accessing mental health services due to lack of support from the community and professionals. A
key implementation concern should be around strengthening capacities for MHPSS service pro-
vision through the incorporation of the MHPSS component in emergency preparedness, response
and recovery plans with specied resources.
Counselling and psychotherapy are becoming increasingly more popular and accepted across the
globe for many people with certain mental health conditions and should be considered by the WHO
and individual countries as cost-effective and ecient options for a broad range of mental health
disorders.
The American Psychological Association state that many people prefer psychotherapy to phar-
macological treatments because of medication side-effects and individual differences and people
tend to be more adherent if the treatment modality is preferred (Deacon & Abramowitz, 2005; Paris,
2008; Patterson, 2008; Solomon et al., 2008; Vocks et al., 2010). Research suggests that there are
very high economic costs associated with high rates of antidepressant termination and non-adher-
ence (Tournier, et al., 2009), and psychotherapy is likely to be a more cost effective intervention in
the long term (Cuijpers, et al., 2010; Hollon, et al., 2005; Pyne, et al., 2005)[23].
Key to promoting mental health and well-being is strengthening mental health literacy programmes
to empower persons with mental health problems and combatting stigma and discrimination.
This includes focusing on universal, targeted and indicated prevention programmes with special
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 170
reference to parenting skills, maternal mental health, school and workplace mental health, suicide
prevention and life skills education with the active involvement of the persons and families with
mental health problems.
Another key intervention is increasing and prioritizing the budget for scaling up integration of
mental health in general health care especially in Primary health care. This intervention should
be supported by capacity enhancement of general and family physicians and staff to provide
evidence-informed mental health and psychosocial support interventions (WHO, 2016)[22] It also
needs to be linked with establishing community-based mental health services, including establish-
ing specialized mental health services in general hospitals for both outpatient and inpatient care
(WHO, 2016)[18].
These interventions support establishing a stepped care model of service delivery ensuring con-
tinuity of care and increased service utilization. It will also help minimize the stigma attached to
psychiatric facilities, where service users are more likely to accept services provided in ‘neutral’
environments, such as general hospitals and community settings (Eaton et al., 2020). This would
involve reorienting the current service delivery models through allocating specied budgets for the
development of such services.
Summary and Conclusion
Overall, there has been progress across the EMR, especially in areas related to policy and legis-
lation. However, there is a need for countries in the EMR to commit afresh to deliver on existing
commitments, articulated in the Regional Framework, for scaling up action of mental health. This
is also crucial in realizing the World Health Organization’s (WHO) ambitious ‘triple billion target’ (1
billion more people benetting from UHC, 1 billion more people better protected from health emer-
gencies and 1 billion more people enjoying better health and well-being).
As EMR countries emerge from the pandemic, the need to foster a commitment to build back econ-
omies and systems not just better but also fairer is hugely important. This is the time and ideal
opportunity to work towards ensuring that a “mental health lens” is used by national governments,
Ministries of Health, local governments, civil society, faith-based organizations and developmental
agencies in their decision making processes using the best evidence-based interventions to cre-
ate fairer and healthier societies. This will help to ensure the sustainable commitment of political,
social, human and nancial resources for developing mental health systems designed to deliver
equitable, person-centered care in an inclusive, decentralized and integrated fashion.
While the pandemic has highlighted the profound challenges and hugely inequitable health impacts
in every country in the Region, it has also identied signicant potential for action. Putting mental
health at the heart of policy action is an essential step forward towards equitable development and
meeting the needs of citizens.
The opportunity to act is now, as COVID-19 has brought home to us the importance of mental
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 171
health as a resource and investment which is crucial for individuals to achieve their full potential,
communities to be resilient in adversity, supporting its vulnerable members, countries to build back
better and nations to fulll their compact with their own citizens and help citizens of other nations
so that no one is left behind.
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WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 172
Socioeconomic
Inequalities and mental
health - proposed actions.
The European
perspective.
ROBERTO MEZZINA
MD, International Mental Health Collaborating Network, World Federation for Mental Health (Vice
President – Europe).
SP SASHIDHARAN
MB BS; MRCPsych; MPhil; PhD, University of Glasgow
Introduction
We live in a world with unprecedented opulence for some and remarkable deprivation, destitution
and oppression for others. .Health and health care across the world reect this, with pronounced
differences in the status of people’s health, in the care they receive and the opportunities they have
to lead healthy lives. This applies to all health, including mental health and is true not only across
middle and low-income countries but also within relatively auent societies such as across Eu-
rope.
Health inequalities and systematic differences in health between different groups of people are
unfair and avoidable [2]. Much of these are created by structural and political processes that affect
the everyday living conditions of individuals and populations (WHO) [3]. Health inequalities repre-
sent a very serious social injustice in modern societies.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 173
Health inequalities in Europe
Inequalities in health and health care are patterned by a variety of socio-economic factors, income
geography (for example, region or whether urban or rural) specic characteristics such as sex,
ethnicity, disability or socially excluded groups (for example, people experiencing homelessness).
There is a positive association between income inequality and mortality rates among countries
within the Organisation for Economic Cooperation and Development (OECD) [4]. More generally,
all health indices are strongly inuenced by income inequality [5, 6]. Europe has some of the high-
est level of unequal distribution of income across the world, with countries like Russia, Lithuania,
Bulgaria, Greece, Spain, Italy at the bottom of the list according to the classication using the Gini
coecient. Major differences in terms of health status and socio-economic categories can be
observed not only between European countries but also within countries, demonstrating the strong
link between socio-economic situation and health status [8, 9]. While life expectancy and mortali-
ty rates are better in Western European countries than in Eastern Europe stark social gradients in
morbidity, mortality and life expectancy remain major challenges across all European countries [7].
Societal inequalities have the most adverse impact on the most vulnerable. There are many as-
pects of vulnerability, arising from various physical, social, economic, and environmental factors.
Economic vulnerability, due to the impact of hazards on economic assets and processes (business
interruption, secondary effects such as increased poverty and job loss), is strongly connected to
social vulnerability, that is the potential impact of events on people who are poor, single parent
households, pregnant or lactating women, people with disabilities, children, elderly etc.. Vulnera-
bility is not just increased risk of exposure, but also reduced resistance (and related measures to
prevent loss) and resilience. Effective coping mechanisms are needed for people, organizations
andsystems, using available skills and resources,to face and manage adverse conditions,emer-
gencies or disasters [10].
Many of the social conditions that increase people’s vulnerability to ill health tend to dene social
groups and target populations. These are not just sociological but also political concepts con-
cerning human rights, as they are associated with inequities in accessing healthcare, services,
treatments, welfare provisions, etc. Health disparities adversely affect groups of people who have
systematically experienced greater social or economic obstacles to health based on their racial or
ethnic group, religion, socioeconomic status, gender, mental health, cognitive, sensory, or physical
disability, sexual orientation, geographic location, or other characteristics historically linked to dis-
crimination or exclusion [3]. Levels of inequality vary considerably even in countries with a similar
level of per capita income. Health and social problems are worse in more unequal countries (Por-
tugal, UK, Italy, Greece vs Scandinavian countries). Income inequality has risen around the world
since 1980 although at different rates in different regions (for example, Europe 34% vs Middle
East 61%). The burden of inequity impacts on the health status gap between the poorest and the
richest income quintiles in 36 European countries. After controlling for age and gender, this gap is
explained by 5 factors (years 2003-2016): (i) income security and social protection (35%) (ii) living
conditions (29%) (iii) social and human capital (19%), (iv) health service (!0%) and (v) employment
and working conditions (7%) [11].
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 174
Primary care is well placed to support health equity. Primary care services cover large populations
and ensure direct contact with patients, often the GP is the rst point of contact with the health
service. Good examples are available in Europe, such as Partnership for Health Equity in Ireland
(www.healthequity.ie) which was established to allow GPs, researchers, educators, health planners
and policy makers to formally collaborate on a number of initiatives with the aim to improve the
health of marginalised groups and those living in deprived areas [12]. Detailed data on social deter-
minants of health can facilitate the identication of inequities in access to health care, for instance
through a sociodemographic data collection tool used in a family medicine clinic [13]. The World
WONCA Health Equity Special Interest Group (SIG) was set up bringing the essential experience,
skills and perspective of interested GPs to address the differences in health that are unfair, unjust,
unnecessary and avoidable [14]. The 2015 WONCA Europe Health Equity Workshop explored the
barriers and facilitators for addressing the social determinants of health in primary care [12].
Mental health inequalities
As with physical health, mental health and wellbeing as well as mental health care are strongly
inuenced by socio-economic factors and individual characteristics such as gender, ethnicity, age.
The world regions with high rates of common mental disorders also have high levels of inequal-
ity, as reported by the WHO [15]. Mental morbidity varies according to social conditions. In most
rich countries (and across Europe) there are also signicant variations in access, experience and
outcomes of mental health care which are driven by social inequalities or differential vulnerabilities
consequent upon economic, social and cultural factors. For example, African Americans are less
likely to have access to mental health care and more likely to poorer quality mental health care
than white Americans. Mental conditions are often misdiagnosed among different minority groups.
In Europe, particularly in the UK, there is strong evidence of signicant ethnic inequalities in mental
health care experiences; black and minority ethnic communities have poorer access to services
and worse clinical and social outcomes than the majority population. Recognition of mental health
problems and diagnosis are strongly inuenced by social status and in particular, belonging to a
minority ethnic group.
One of the earliest and most enduring ndings in psychiatric epidemiology is the strong link be-
tween social status (class) and increased risk of mental disorders [16]. Poverty (lack of socioeco-
nomic resources) increases the risk of exposure to traumatic experiences and stress that increase
the vulnerability to mental disorders. Unemployment can inuence the development of common
mental disorders, such as depression and anxiety. This link between poverty and mental health is
bidirectional. Disparities in access to education and housing due to socioeconomic disadvantage,
can increase the risk of mental illness while long term mental health problems can lead people into
poverty due to discrimination in employment and reduced ability to work. Minority ethnic communi-
ties are exposed to a cumulative experience of microaggressions such as racism that compromise
resilience and autonomy thus increasing their vulnerability to mental ill health. Gender inequality
and gender disparities in mental health are strongly correlated [15]. Several studies indicate that
women suffer mentally more than men particularly in societies with greater levels of gender ine-
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 175
quality and discrimination based on prejudice, creates barriers to accessing community resources
and mental health care.
This ‘social gradient’ means that mental health problems are more common further down the
social ladder. It is now widely accepted that inequalities in health, including mental health, arise
because of inequalities in society – in the conditions in which people are born, grow, live, work and
age. The social determinants of (mental) health act through a cumulative effect of disadvantage
that is associated with increasing stress through the lifespan [17]. “These factors affect each indi-
vidual differently, depending on the presence of buffers such as social support, nancial resources
and emotional resilience, but overall, it is harder to develop this resilience and have access to the
right social support when in a position of disadvantage” [18].
Unequal access to mental healthcare is still a reality in Europe. Mental healthcare remains depend-
ent on high out-of-pocket payments in most European countries, which leads to even greater health
and social inequalities for people living with mental ill health. The report of the European Commis-
sion [19] also showsa lack of investment in preventive and mental health care in more than 10
European countries.
Up to 94% of all mental health care happens in Primary Care. As with physical health, major in-
equalities that impact on mental health are evident in access to primary care and in the recognition
of mental health problems. Mental health literacy is identied as one of the key-factors in address-
ing this. The World Health Organization, as well as WONCA, have recognized this issue through
specic worldwide initiatives, such as the mhGAP Programme for all non-specialized healthcare
settings [20]. Mental health needs assessments do not incorporate discussion about inequalities
in mental health. Frontline professionals tend to dene inequalities as being linked to access to
health services rather than social factors and are “often uncomfortable about discussing inequali-
ties in mental health”[21].
In all western countries, most physical diseases, and severe, ‘psychotic’ psychiatric disorders are
unequally distributed by social position [22]. People of lower socio-economic status are more
affected by mental health problems including higher prevalence of ‘common mental disorders’
(mostly non-psychotic depression and anxiety, either separately or together). These conditions are
associated with poor education, material disadvantage and unemployment [23].
Disadvantaged, vulnerable or marginalised groups are dened by the WHO as those who, ‘due to
factors usually considered outside their control, do not have the same opportunities as other, more
fortunate groups in society’. Examples might include unemployed people, refugees and others who
are socially excluded. Stigma and related discrimination are often inherent to many of these ine-
qualities, especially those related to mental health and socially excluded groups in general.
Experiencing prejudice and discrimination can also compound and hinder recovery from a mental
health condition. This encompasses issues of knowledge (ignorance), attitude (prejudice) and
behaviour (discrimination). As reported by the Mental Health Foundation [18], as many as nine out
of ten people with mental health problems have experienced stigma or discrimination at one time
of their life (at work, in education, from professionals or at home). This has a negative effect on
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 176
people in relation to employment, establishing new and retaining existing friendship, being able to
join groups and take part in activities within the community, having the condence to get out and
about, being able to openly disclose mental health issues and speak up to professionals.
Ecological risk factors for mental ill health such as lack of adequate housing, reduced transport
options, neighbourhood deprivation, adverse built or natural environment and living in an urban en-
vironment are commonly associated with social disadvantage and other social risk factors in most
Western countries. Being homeless or at risk of homelessness is strongly associated with mental
health problems. A 2014 study found that 80% of homeless people in England reported that they
had mental health problems, with 45% having been diagnosed with a mental health problem. Also,
poor-quality housing and housing that is unsafe and insecure, is a risk factor for mental health
problems and may exacerbate existing mental health problems. On the contrary, transitioning from
homelessness to housing, or experiencing housing improvements, has been shown to improve
mental health [18].
These factors can contribute to social fragmentation and increased conict within communities
as well as neighbourhood problems, which in turn impact on health outcomes independently of
socioeconomic status. Emerging evidence suggests that increase in social cohesion may reduce
the negative effects of neighbourhood deprivation on mental health. Societal segregation can
also have an adverse impact on mental health. For example, people with learning disabilities,
experiencing segregated schools and activities, live a separate existence to the general commu-
nity, and the consequent lack of community connections make them vulnerable to hate crime and
discrimination, leading, in turn, to an increased risk of mental health problems. Urbanisation and
urban living are risk factors for depression and anxiety as they are linked to socioeconomic dep-
rivation, low social support, social segregation and environmental conditions such as air, water
and noise pollution, as well as exposure to physical threats (accidents and violence) [18]. Lack of
public spaces prevent community cohesion and increase isolation and loneliness. The report by
the Mental Health Foundation shows the impact of the built environment across the life course,
with school-age children’s attitudes and behaviours affected by the quality of the built environment
and local neighbourhoods. Poor physical condition in neighbourhoods adversely affecting schools.
The lack of outdoor play space has been found to be a causative factor in increased mental health
problems among children and young people [18]. Spending time in natural environments reduces
levels of stress and/or improves attention fatigue and mood more than the built environment. By
making green and blue spaces more available for people, levels could potentially decrease anxiety
and distress, though this requires further research [18]. In the context of the global climate crisis,
it is important to note that the natural environment can be both a positive and a negative inuence
on mental health, depending on the type of environment. Individual distress in the wake of a natural
disaster due to climate change can increase the risk of mental health problems.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 177
Health inequalities uncovered by the Covid
pandemic
The Covid pandemic has exposed and exacerbated health inequalities between countries as well
as within countries. According to Joseph Stigliz, Covid-19 is not an ‘equal opportunity’ virus [24].
The virus has had an unequal impact in all societies and countries. The poor, marginalised, physi-
cally ill and those with long term mental health problems and those in institutional care have been
disproportionately affected by the pandemic. The post-pandemic world could experience even
greater inequalities unless governments take action.
The European Region has been affected by the pandemic the most in the rst phase. A WHO Eu-
rope survey of institutions has shown increasing violation of human rights in the rst wave of the
pandemic [25]. The Technical Advisory Group (TAG) on the Mental Health Impacts of COVID-19 in
the WHO European Region, issued a set of recommendations on the 30 June 2021 [26]. The TAG
agreed to frame the recommendations across three key areas of impact: 1)general population and
communities 2)vulnerable groups and 3)public mental health services.It focused on vulnerable
groups such as those who have less personal and social instruments and resources to cope with
the pandemic and in particular its mental health consequences. The range of these ‘vulnerable
groups’ is wide and cannot be dened by strict criteria, as it is evolving and open to further contri-
butions. There are many aspects of vulnerability, arising from various physical, social, economic,
and environmental factors. The concept of social vulnerability is the one that probably can better t
these issues. Social vulnerability refers tothe potential negative effects on communities caused by
external stresses on human health. The major threats to mental health are in relation to receiving
care for the pandemic itself (prevention, PPI, appropriate care, vaccination), access to services they
need (it is important to remind the WHO recognition that MHS are essential services) and the treat-
ment gap, as well as the continuity of care, social gap / exclusion (physical body / social body), risk
of self-isolation, stigma (“doubled” when people with mental disorders are also Covid positive or ill
with Covid).
People with pre-existing mental health problems (in particular, those with severe mental illness)
are most vulnerable to Covid and may lack access to proper information and medical care. Their
human rights, safety, protection, and even their environment, are at risk. This group is also likely
to be forgotten, neglected and exposed to additional suffering because of the shortage of mental
health services operating within communities, e.g. restrictions that exacerbate the existing short-
ages in relation to rehabilitation interventions, socialization activities and day-care, job placement,
social enterprise, personal support, home and educational assistance services, mainly carried out
by NGOs.
Diagnosis by itself is a poor predictor of vulnerability. In identifying those at high risk, we need
to consider a range of social factors and determinants of mental health and ill health as well as
individual reactions based on personal narratives [27]. Those living in institutions, such as mental
hospitals, nursing homes, halfway homes, social care homes, correctional facilities etc are particu-
larly at risk. Residential institutions have become intrinsically more unsafe during the pandemic
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 178
and consequent restrictions and, as a result, provide less protection against contracting the virus,
while worsening their mental health. The pandemic showed the health inequalities for people who
live in care homes, not just the elderly, but also the group of patients with Learning disabilities and
neurodevelopment disorders, like Autism Spectrum Disorders.
The poorest, people who are socially marginalized, living alone or conned to restricted spaces
such as migrant and refugee populations, are at greater risk of the mental health consequences of
the pandemic and connected restrictions. They need psychosocial support and health protection
as well as a response to their primary needs. Homeless people living with mental illnesses are
among the most vulnerable, lost in a social nothingness [27] as they have lost many of their natural
support systems. Mental health services need to increase outreach support care for those who
cannot access them. However, the restrictions consequent upon the pandemic appear to have led
to the opposite, with a signicant reduction in outreach support and activities. Improving outreach
support should involve mobilising the available resources of communities, volunteers, neighbour-
hoods, associations and other community assets.
Families have now become the primary carers of their relatives, affected by Covid and those with
severe mental illness, and one of the unintended consequences of this is the increase in caring
responsibilities and burden for women. Women’s experience is further worsened by higher rates of
unemployment than men and the reported increase in domestic violence during the pandemic.
Actions to reduce health inequalities
Policy
• No EU member state has yet made a concerted effort to implement the most radical approach
to TACKLING health inequalities, namely the reduction in the health gradient, whereby health
is related to the position of social groups (and individuals within these groups) at every level
within society. EU member states were advised to consider the potential advantages to society
as a whole that might result from the adoption of this wider frame in 2005 [28] but this has not
resulted in any signicant policy changes in relation to health inequalities.
• Most of the interventions in tackling health inequalities focus on the immediate determinants
of specic inequalities and are aimed at modifying lifestyles and behaviours in the more disad-
vantaged classes. It needs to be also recognised that more funding is required for academic
research on effective universal policies, evaluation of their impact and training policymakers
and ocers on health inequalities [29].
• The Commission on Social Determinants of Health [30] has declared that rising inequality is
not inevitable, and policies and institutions are asked to play a decisive role, where intersec-
toral action and social participation / empowerment are key dimensions. State actions are
recommended at (i) macro level: public policies to reduce exposure of disadvantage people
to health-damaging factors (ii) meso level: community – to reduce vulnerabilities of disad-
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 179
vantaged people (iii) micro level: individual interaction – to reduce unequal consequences of
illness in social, economic and health terms.
• The United Nations increased attention to all these factors in the Sustainable Development
Goals (SDGs) [31]. It would be important to focus on the impact of policies designed to further
equality, in order to address existing mental health disparities and achieve the highest possible
level of health for all people.
• The European Union recently decided to foster and complement national plans via the larg-
est-ever stimulus package of €1.8 Trillion to build a greener, more-digital and more-resilient
post-COVID-19 Europe. The plan was called “Next generation EU”. In some countries like Italy,
part of this spending will be aimed to digital transition, green economy and at strengthening
social cohesion by reducing social inequalities. This should create work opportunities, also
through a welfare community with the involvement of social economy and social enterprises. It
is unclear if there will be any dedicated investment directly to community mental health servic-
es, or to welfare services with an impact on the living conditions of people with mental health
issues, at risk of marginalization and social exclusion.
• Within this context, WHO/Europe has urged a mental health coalition to support system re-
forms and COVID-19 recovery as a new agship initiative. [32] WHO underlines that “mental
health is a key public health concern in the WHO European Region – over 110 million people
are living with some kind of mental health condition, accounting for over 10% of the popula-
tion”, and about 140 000 people die per year by suicide. Therefore “…a more concerted effort
is required to secure better mental health for all, both through intensied country support and
intercountry initiatives at regional and global levels.”
• Some of the core components of the WHO mental health agship will be: challenging stigma
and discrimination by improving mental health awareness and literacy among not only the pub-
lic but also service providers and decision-makers; enhancing access to person-centred, rights-
based mental health care in communities. This will expedite progress towards universal health
coverage for people with mental health conditions and make the case for a parity of esteem
between mental and physical health.
• Since the pandemic has shone a light on the fragility of existing institution-based systems and
the need for community-based support and care (delivered through digital means where nec-
essary or applicable), “the mental health agship will encourage efforts and investments to
relocate care away from institutions and towards community services, including through the
integration of mental health into primary health care and other priority programmes such as
adolescent health and noncommunicable diseases” ref?.
• In the Athens Mental Health Summit Declaration (22-23 July 2021), the ministers of health and
representatives of the Member States of the World Health Organization in the European Region
have welcomed the proposal for a new European Framework for Action on Mental Health and
supported the setting up of a Pan-European Mental Health Coalition. This conrmed the issue
of vulnerability stating: “Population groups who have been identied as being at higher risk of
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 180
experiencing negative mental health impacts will require specic and targeted attention and
support”. Also “the pandemic has exacerbated pre-existing gaps in mental health care pro-
vision due to signicant disruption to mental health services, coinciding with an increase in
mental health needs and an overstretched health workforce”. Ministers have recognized that
“the COVID-19 pandemic has uniquely propelled mental health to the top of the policy agenda.
We call for this to be a redening moment in the history of mental health, with stigma and dis-
crimination being tackled through integration of mental health into the mainstream health-care
agenda”. It calls “for mental health promotion and support to be at the heart of the post-COV-
ID-19 recovery agenda to prevent the emergence of chronic mental health conditions as a result
of the pandemic. We acknowledge the structural and environmental elements that contribute to
poor mental health and well-being and seek to develop appropriate strategies to build resilient
individuals and communities and improve our ability to protect the mental health and well-being
of our populations in future crises and health emergencies” [33].
Service changes and welfare community
• A ‘whole of society approach’ to tackle the social problems thrown up by Covid-19 has been
suggested. [34] This includes new forms of social connections, developed and enhanced as
part of a collective effort. Such an approach will be equally relevant in tackling health inequali-
ties more broadly.
• We need to avoid fragmentation of efforts by building alliances between public mental health-
care, social services and the third sector. This will ensure an effective response to whole life
needs, protecting not only health but also the human rights of people living in institutions,
hospitals, prisons, shelters, nursing homes, group homes and other special facilities, and those
experiencing social deprivation.
• Furthermore, in the community, there is an urgent need for policies to reduce the social disad-
vantage with an impact at the level of services. ‘Social economy’ includes cooperatives, mutual
societies, non-prot associations, foundations and social enterprises, which operate a very
broad number of commercial activities, provide a wide range of products and services across
the European single market and generate millions of jobs. According to the EU Commission
[35], there are 2 million social economy enterprises in Europe (10% of all businesses in the EU,
more than 11 million people – about 6% of the EU’s employees). Their members act in accor-
dance with the principle of solidarity and mutuality and manage their enterprise on the basis
of ‘one man one vote’ principle. They substantially contribute to economic, social and human
development across and beyond Europe and supplement existing welfare regimes in many
member states. They contribute to several key EU objectives, such as sustainable and inclusive
growth, employment, social cohesion, social innovation, local and regional development and
environmental protection, as well as individual well-being.
• In Italy, in recent years, mental health services of some regions, with the help of NGOs such
as social cooperatives and voluntary associations, developed, differentiated strategies aimed
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 181
at multi-sectorality and empowerment. Based on the principles of social and health integra-
tion, these policies and programs provide for integrated social and health paths, basic social
support, the right to independent living, training and job placement. One of the main organiza-
tional-strategic keys has been proved to be the construction of ‘personal budgets’, in which the
suffering individual has an active role and a bargaining power. They provide the person with
support in the exercise of fundamental rights and in access to social opportunities (home,
education, training at work, health management, leisure activities), and for capacity-building
paths in relationship with other services and institutions, towards a higher autonomy. In this
way, social determinants can be directly addressed, both at the individual level and the socially
vulnerable as a group.
• It is important to implement the emergency national plans dedicated to mental health, called
for by the World Health Organization and reiterated by the World Federation for Mental Health
[36] and prompted by the UN [37]. It has never been more urgent to step aside from individualis-
tic notions and embrace the values and practices of sharing and solidarity, both civil and social.
This will enhance our sense of being part of a community. Community mental health services,
which have a long history of community networking and engagement, can act as exemplars
and provide essential bridges to a post-covid, ‘new normal’, with collaboration and shared re-
sponsibilities for each other at its heart. This requires a rights based and person centred – but
also whole community - approach.
• The OECD Mental Health Performance Network set from 2018 [38], recently conrmed [39]
the following principles for the mental health sector: (i) focus on the individual, (ii) accessi-
ble, high-quality services, (iii) an integrated, multi-sectoral approach, (iv) prevention of mental
illness and promotion of mental wellbeing, (v) strong leadership and good governance and (vi)
future focused and innovative. These are in line with the WHO Action Plan cross-cutting princi-
ples and some of the most innovative good practice examples.
• The International Mental Health Collaborating Network (IMHCN) has identied a number of
objectives especially related to the importance of Social Determinants of Mental Health: “This
transformation requires a fundamental change in thinking about mental health through a com-
prehensive review of current services and practices.We need to act upon the clear evidence
that social determinants play a fundamental part in the lives of people with mental health
issues. The dominant clinical response today does not acknowledge or address the importance
of social determinants in the current service model.The consequence of this is that life circum-
stances such as, poverty,inequalities, systemic racism, and discrimination are not systemati-
cally addressed. We must prioritise community service development through our Whole Person,
Whole Life – Whole System strategic Approach.
Fundamental Change in Mental Health - Local and Global Action Plan.
The Covid - 19 pandemic has highlighted major health inequalities and the urgent need to act
now”[40] 19 The Action Plan was developed by organisations representing people with lived experi-
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 182
ence, who use services, family members, mental health professionals, policy makers and research-
ers and it has been adopted by a Coalition of International Organisations:
• International Mental Health Collaborating Network
• World Federation for Mental Health
• World Association for Psychosocial Rehabilitation
• Mental Health Europe
• European Community based Mental Health Service Providers Network (EUCOMS)
• Global Alliance of Mental Illness Advocacy Networks (GAMIAN)
• Human Rights Monitoring Institute (HRMI)
• Italian Society of Psychiatric Epidemiology (SIEP)
• Transforming Australia’s Mental Health Service System, Incorporated
• The Action Plan addresses the need for fundamental change in the approach to mental health
that should prioritise improving mental health by focusing on social determinants and achiev-
ing equity in mental health care for all people, worldwide.These targets are for people and
organisations to use locally within their communities and mental health services. Among the
12 Action points, it is important to note: “4.3 There is a fundamental need to focus on under-
standing the importance of the social determinants of mental health in meeting the whole - life
needs of people”.
• The recommended action points are:
• – To develop local strategic plans to tackle the social determinants of mental health
through a community partnership that acknowledges international frameworks and goals.
• - Mental health providers to prioritise these local strategic plans as they are of equal impor-
tance to the development of clinical services.
• - To apply a co-production methodology: A democratic and inclusive process of develop-
ment that encompasses all local stakeholders as equal partners to create a Whole Life -
Whole System approach.
• - To work with Non-Governmental Organisations and a range of different agencies (public
and private) that provide signicant services in our societies. We especially need to work
with them to meet the whole life needs of people in the community.
• - To increase and sustain the funding of community organisations that provide essential
services not met by statutory organisations.
• - To address inequalities, systemic racism and discrimination, ensuring that the needs and
voices of oppressed, marginalised and vulnerable groups are prioritised, and this injustice is
addressed through specic actions by applying equalities principles.
• The organisations included in this campaign have worldwide networks of thousands of mem-
bers and this gives this campaign the potential to reach decision makers, activists, advocates
and the public at a national and local level. The launch of this campaign will be coordinated by
the coalition partners. “We see this Action Plan working simultaneously internationally, na-
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 183
tionally and locally. We believe that an action that is supported by international mental health
leaders, national organisations and their local branches, mental health providers, service user
groups and family associations have a much greater chance of being adopted and effective.
We place great emphasis on identifying and celebrating good practice founded on human
rights and values. There are many examples of good practice around the world that can be
used to support our Identied big issues and what has already been achieved to address these
[40].”
Acknowledgments
We especially thank Jean-Luc Roelandt, Henk Parmentier, Juan Mendive, Olga E Pazyna for their
useful suggestions to this paper.
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SECTION E
Thanks
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 186
Thanks
PROFESSOR GABRIEL IVBIJARO MBE JP
MBBS MMedSci MA PhD FRCGP FWACPsych IDFAPA
Secretary General WFMH
I would like to thank everybody who has contributed to World Mental Health Day 2021 ‘Mental
Health in an Unequal World: Together we can make a difference’.
I am very grateful to all the people who have contributed to this year’s World Mental Health Day
educational material, and to those people who provided peer reviews. We welcome partnership and
are grateful to all our volunteers.
This year’s educational material has been provided by people with lived experience, carers, health
professionals from many specialities, governments and those who commission services. All our
contributors have volunteered their time and expertise to provide this year’s wonderful material –
thank you. Each of their names will be published on the WFMH World Mental Health Day website. I
am also grateful to the WFMH President Ingrid Daniels for her leadership.
The annual World Mental Health Day established in 1992 through the energies of Dick Hunter, and
supported by the Carter Centre, has been actively supported by the WHO, United Nations and many
individuals, institutions and professional colleges around the world with an interest in promoting
mental health advocacy. I am very grateful to you all.
All our WFMH Secretary Generals and WFMH Past Presidents since 1992 have worked to ensure
that this annual event on October 10th continues to grow with a clear message to ensure that men-
tal health is a priority, and each of use receives the dignity of care that we are entitled to.
WFMH is also grateful to all the donors and volunteers who have ensured that WFMH has had the
resources to continue its mental health advocacy work since it was established in 1948. Your con-
tribution is very valuable and contributes to our continued success. We know that many of you will
be organising a range of activities to celebrate World Mental Health Day and to highlight this year’s
theme. It is important to share our work because together, we can make a difference. Please let
us know what you are doing as we may be able to showcase some of the work on the 2021 World
Mental Health Day website.
My thanks to the WFMH 2019-2021 Executive, Regional Vice Presidents and Board of Directors for
their support and to WFMH voting and non-voting organisational members and WFMH individual
members for their support. I am also very grateful to the Technical Team that have supported the
Oce of the Secretary General for their untiring hard work.
WORLD MENTAL HEALTH DAY 2021 - Mental health in an unequal world. Togetherwe can make a difference. 188
WFMH World Congress
London 2022
PROFESSOR GABRIEL IVBIJARO MBE JP
MBBS MMedSci MA PhD FRCGP FWACPsych IDFAPA
Secretary General WFMH
It gives me great pleasure to invite you
to come to our WFMH World Congress
which takes place on:
28th June 2021 to 1st July 2022 at Cen-
Central Hall Wesminster, the venue of
the 23rd WFMH Congress has a unique
place in the history of WFMH because
it was here that the rst International
Congress on Mental Health was held in
August 1948 leading to the foundation
of WFMH.
At that time the International Preparato-
ry Commission for the congress con-
cluded that:
‘principles of mental health cannot be
successfully furthered in any society
unless there is progressive acceptance
of the concept of world citizenship.
World citizenship can be widely extended
among all peoples through the applica-
tion of principles of mental health.’
We know that the last two years have been very dicult across the world because of the pandemic,
and we are pleased that the recovery has begun so that many of us will be able to come to London
and meet face to face. This will also be a wonderful opportunity for us to prepare for the 75th Anni-
versary of WFMH which takes place in 2023.
