Establishing political priority for global mental health: a qualitative policy analysis.

Mental disorders represent the leading cause of disability worldwide, yet they remain a low global health priority. This paper uses a case study methodology and different data sources (35 interviews and documents) to analyse factors that have shaped the generation of political priority for global mental health over the past three decades (1990-2020) and their changes over time. The Shiffman and Smith framework on determinants of political priority for global health issues is used to organize data into themes: actor power, ideas, political context and issue characteristics. Global mental health has gained political attention, especially over the past decade, yet support remains limited. Findings reveal that actor power is undermined by a fragmented policy community, the absence of one guiding institution or coordination mechanism and little civil society mobilization. Public portrayal of the issue is divided, hampered by the absence of a common understanding by the community and by stigma. Some policy windows have been missed and a strong global governance structure is lacking. Credible indicators and evidence on simple cost-effective solutions, especially in low- and middle-income countries, are scarce. However, opportunities are arising, including an increasing number of leaders and grassroots organizations, multiple arguments for action and integrated solutions resonating with broader audiences, widening political support at the national level, an emerging global governance structure and an expanding evidence base on the scale of the problem and available solutions. The results point to three technical and four political challenges that advocates need to address to increase political support over the next decade.

Global collective action in mental health financing: Allocation of development assistance for mental health in 142 countries, 2000-2015.

Collective action between international donors is central to the mobilisation of global solidarity in global health. This is especially important in mental health where resources remain extremely limited. In this paper I investigate global collective action in mental health financing, looking at the responsiveness of international donors to mental health needs in low- and middle-income countries (LMICs). I analyse factors at the level of recipient countries (needs, interests, policy environment) associated with allocation of development assistance for mental health (DAMH) using a two-part regression model applied to a time series cross-sectional dataset of 142 LMICs between 2000 and 2015. Findings reveal that international donors' disbursements are not well aligned with mental health needs of recipient countries, and, moreover, contextual factors might be playing more prominent roles in resource allocation. Countries are more likely to receive DAMH if they experience significant outbreaks of infectious diseases or have lower gross domestic product (GDP) per capita and lower market openness. Selected recipient countries are more likely to receive higher DAMH amounts per capita if they have lower GDP per capita, higher government health expenditure, or higher mortality rates due to conflicts or natural disasters. Past DAMH recipients are more likely to be selected and, when selected, to receive higher DAMH amounts per capita. My results demonstrate that more holistic collective action amongst international donors is required to address mental health needs in LMICs. Investments should better reflect needs, particularly during and after emergencies such as COVID-19, and could be amplified by leveraging synergies across other health conditions and sectors.

Motivation and methods of external organisations investing in mental health in low-income and middle-income countries: a qualitative study.

Mental disorders (including substance use disorders, dementia, and self-harm) account for a substantial burden of disease and economic costs in low-income and middle-income countries (LMICs), yet they attract little funding. External resources are urgently needed but evidence on investments is scarce. This Health Policy paper uses 35 elite interviews and documentary analyses to examine how and why external organisations have invested in mental health in LMICs over the past three decades, and how this investment has changed over time. Four levels are examined: organisations, source countries, recipient countries, and global landscape. Organisations have invested in numerous internal and external activities. Among the various factors shaping organisational decisions, actors (ie, individuals and organisations concerned with mental health) were the most salient at all four levels. To increase external organisation investments in mental health in LMICs, organisational leadership and understanding are crucial, along with increased political support in source and recipient countries, and a stronger governance structure at the global level.

Philanthropy for global mental health 2000-2015.

BACKGROUND: Mental disorders are the leading cause of years lived with disability worldwide. While over three-quarters of people with mental disorders live in low- and middle-income countries (LMICs) and effective low-cost interventions are available, resource commitments are extremely limited. This paper seeks to understand the role of philanthropy in this area and to inform discussions about how to increase investments. METHODS: Novel analyses of a dataset on development assistance for health were conducted to study philanthropic development assistance for mental health (DAMH) in 156 countries between 2000 and 2015. RESULTS: Philanthropic contributions more than doubled over 16 years, accounting for one-third (US$364.1 million) of total DAMH 2000-2015. However, across health conditions, mental disorders received the lowest amount of philanthropic development assistance for health (0.5%). Thirty-seven of 156 LMICs received no philanthropic DAMH between 2000 and 2015 and just three LMICs (Antigua and Barbuda, Grenada, Saint Vincent and the Grenadines) received more than US$1 philanthropic DAMH per capita over the entire period. Eighty-one percent of philanthropic DAMH was disbursed to unspecified locations. CONCLUSIONS: Philanthropic donors are potentially playing a critical role in DAMH, and the paper identifies challenges and opportunities for increasing their impact in sustainable financing for mental health.

Sustainable development for global mental health: a typology and systematic evidence mapping of external actors in low-income and middle-income countries.

INTRODUCTION: Mental disorders account for a substantial burden of disease and costs in low-income and middle-income countries (LMICs), but attract few resources. With LMIC governments often under economic pressure, an understanding of the external funding landscape is urgently needed. This study develops a new typology of external actors in global health adapted for the sustainable development goals (SDGs) era and uses it to systematically map available evidence on external actors in global mental health. METHODS: The new typology was developed in line with conceptualisation in the literature and the SDGs to include 11 types of external actors for health in LMICs. Five databases (EconLit, Embase, Global Health, MEDLINE, PsycINFO) were searched for manuscripts published in peer-reviewed journals in English, French, Italian, Portuguese or Spanish between 1 January 2000 and 31 July 2018 and reporting information on external actors for mental disorders in LMICs. Records were screened by abstract, then full-text against inclusion criteria. Data were extracted and synthesised using narrative analysis. RESULTS: 79 studies were included in the final review. Five were quantitative studies analysing the resource flow of development assistance for mental health globally over the last two decades. The remainder were qualitative studies providing a description of external actors: the majority of them were published in the last decade, focused on Africa, and on public sector (bilateral and multilateral governmental organisations) and third sector organisations (non-governmental organisations). Evidence was particularly scarce for for-profit organisations and individual households. CONCLUSION: This study reveals opportunities for unlocking additional funding for global mental health in the SDG-era from an ecosystem of external actors, and highlights the need to coordinate efforts and to use sustainable, ethical approaches to disbursements. Further research is needed to understand all external actors and the allocation of their contributions in different settings.

The role of youth mental health services in the treatment of young people with serious mental illness: 2-year outcomes and economic implications.

AIM: This study aims to evaluate the outcomes and economic case for a UK innovative youth-specific mental health service for 16-25 year olds. METHODS: A pre-, during- and post-treatment comparative design for 20 young people at high risk of developing psychosis who received 2 years' treatment with the service, using outcomes that concurred with the service aims: changes in mental health, employment rates and service use. RESULTS: Forty-five percent of those at risk and with symptoms of serious mental illness commencing treatment were not receiving mental health services at baseline. Compared with service use prior to treatment at the youth-specific service, hospital admissions, Accident and Emergency, and criminal justice system use appear to decrease over the 2 years of treatment and the year after treatment, with potential cost differences of £473 000. Mental health improved or stayed the same, compared with baseline. Employment rates improved, although the sample size for this is very small. Potential cost differences associated with service users moving into employment over the 2 years are £148 000. The estimated cost over 2 years of providing the youth-specific mental health service to these young people was £106 000. CONCLUSIONS: Given the extensive long-term negative consequences and high costs of untreated mental illness in the 16-25 age group and the documented problems young people have in receiving appropriate services, this youth-specific, age-appropriate service model appears to be successful, with improved outcomes and cost differences in the short-term, and with encouraging implications for the longer term.

Costs and economic consequences of a help-at-home scheme for older people in England.

Solutions to support older people to live independently and reduce the cost of an ageing population are high on the political agenda of most developed countries. Help-at-home schemes offer a mix of community support with the aim to address a range of well-being needs. However, not much is currently known about the costs, outcomes and economic consequences of such schemes. Understanding their impact on individuals' well-being and the economic consequences for local and central government can contribute to decisions about sustainable long-term care financing. This article presents results from a mixed-methods study of a voluntary sector-provided help-at-home scheme in England for people of 55 years and older. The study followed a participatory approach, which involved staff and volunteers. Data were collected during 2012 and 2013. Social care-related quality of life was measured with the Adult Social Care Outcomes Toolkit for 24 service users (59% response rate) when they started using the scheme and 4-6 months later. A customised questionnaire that captured resource use and well-being information was sent to 1064 service users (63% response rate). The same tool was used in assessment with service users who started using the scheme between November 2012 and April 2013 (100% response rate). Costs of the scheme were established from local budget and activity data. The scheme was likely to achieve a mean net benefit of £1568 per person from a local government and National Health Service (NHS) perspective and £3766 from the perspective of the individual. An expenditure of £2851 per person accrued to central government for the additional redistribution of benefit payments to older people. This article highlights the potential contribution of voluntary sector-run help-at-home schemes to an affordable welfare system for ageing societies.

Suicide and poverty in low-income and middle-income countries: a systematic review.

Suicide is the 15th leading cause of death worldwide, with over 75% of suicides occurring in low-income and middle-income countries. Nonetheless, evidence on the association between suicide and poverty in low-income and middle-income countries is scarce. We did a systematic review to understand the association between suicidal ideations and behaviours and economic poverty in low-income and middle-income countries. We included studies testing the association between suicidal ideations and behaviours and economic poverty in low-income and middle-income countries using bivariate or multivariate analysis and published in English between January, 2004, and April, 2014. We identified 37 studies meeting these inclusion criteria. In 18 studies reporting the association between completed suicide and poverty, 31 associations were explored. The majority reported a positive association. Of the 20 studies reporting on the relationship between non-fatal suicidal ideations and behaviours and poverty, 36 associations were explored. Again, almost all studies reported a positive association. However, when considering each poverty dimension separately, we found substantial variations. These findings show a consistent trend at the individual level indicating that poverty, particularly in the form of worse economic status, diminished wealth, and unemployment is associated with suicidal ideations and behaviours. At the country level, there are insufficient data to draw clear conclusions. Available data show a potential benefit in addressing economic poverty within suicide prevention strategies, with particular attention to both chronic poverty and acute economic events.

Positive behavioural support in schools for children and adolescents with intellectual disabilities whose behaviour challenges: An exploration of the economic case.

Decision-makers with limited budgets want to know the economic consequences of their decisions. Is there an economic case for positive behavioural support (PBS)? A small before-after study assessing the impact of PBS on challenging behaviours and positive social and communication skills in children and adolescents with intellectual disabilities and behaviours that challenge was followed by an evaluation of costs. Results were compared with the costs of alternative packages of care currently available in England obtained from a Delphi exercise conducted alongside the study. Children and adolescents supported with PBS showed improvement in challenging behaviours and social and communication skills, at a total weekly cost of GBP 1909 (and GBP 1951 including carer-related costs). PBS in schools for children and adolescents with intellectual disabilities and behaviours that challenge may help to support them in the community with potential improvements in outcomes and also cost advantages.

Dementia care costs and outcomes: a systematic review.

OBJECTIVE: We reviewed evidence on the cost-effectiveness of prevention, care and treatment strategies in relation to dementia. METHODS: We performed a systematic review of available literature on economic evaluations of dementia care, searching key databases and websites in medicine, social care and economics. Literature reviews were privileged, and other study designs were included only to fill gaps in the evidence base. Narrative analysis was used to synthesise the results. RESULTS: We identified 56 literature reviews and 29 single studies offering economic evidence on dementia care. There is more cost-effectiveness evidence on pharmacological therapies than other interventions. Acetylcholinesterase inhibitors for mild-to-moderate disease and memantine for moderate-to-severe disease were found to be cost-effective. Regarding non-pharmacological treatments, cognitive stimulation therapy, tailored activity programme and occupational therapy were found to be more cost-effective than usual care. There was some evidence to suggest that respite care in day settings and psychosocial interventions for carers could be cost-effective. Coordinated care management and personal budgets held by carers have also demonstrated cost-effectiveness in some studies. CONCLUSION: Five barriers to achieving better value for money in dementia care were identified: the scarcity and low methodological quality of available studies, the difficulty of generalising from available evidence, the narrowness of cost measures, a reluctance to implement evidence and the poor coordination of health and social care provision and financing.

Mental and neurological health research priorities setting in developing countries.

INTRODUCTION: A multi-region consultation process designed to generate locally produced regional and global research priorities on mental and neurological health in low- and middle-income countries. METHODS: Between 2003 and 2005, priority setting exercises on MNH research, using the systematic combined approach matrix (CAM) were held in the six regions of the developing world. One regional meeting per region was convened, and a global meeting was organized before and after the regional exercises. RESULTS: During regional meetings, regional agendas were created listing both research priorities and local problems in MNH. During global meetings, a global research agenda was established and four crucial areas of research priorities were identified: awareness and advocacy, enhancement of research capacity, training for service delivery, and development of evidence based policy. CONCLUSIONS: The combined matrix approach enabled the development of regional and global MNH research agendas, derived from bottom up consultations within and between low- and middle-income countries. Collaboration between regions with similar priorities was instituted. Such research agendas are designed to assist policy-makers and donors in the allocation of scarce resources, but they require regular review to reflect changing needs.