This two-part series to mark World Mental Health Day examines some of the ways we can improve the delivery of mental health services in low- and middle-income countries (LMICs). 

Read part 2 here.

Around the world, close to a billion people suffer from a mental health condition. In 2018, nearly 800 million were living with a mental or psychological disorder, 264 million suffered from depression, and another 178 million had a substance abuse disorder.

In its broadest sense, the term “mental health” means much more than the mere absence of a psychological disorder. The World Health Organization (WHO) offers a more expansive definition that speaks to a sense of overall well-being, defining mental health as the “subjective well-being, perceived self-efficacy, autonomy, competence, intergenerational dependence and recognition of the ability to realize one’s intellectual and emotional potential.” 

“Mental health is crucial to strong health systems, thriving economies, and well-functioning societies,” says Martin Bernhardt, Director of Access Accelerated. “It is fundamental to overall health and well-being, and a critical contributor to achieving the UN Sustainable Development Goals.” 

The cost of ignoring mental health 

Unfortunately, both policymakers and society as a whole have been slow to accept poor mental health as a legitimate public health threat. A lack of awareness plays a part, as does the invisible and often elusive nature of mental illness. There’s also a pervasive belief that mental health and well-being are “luxuries” that many countries cannot afford to invest limited funds into addressing. 

Long hidden, largely invisible and often dismissed: that is the reality of mental health today as governments continue to under-prioritize and under-invest in tackling the challenge. On average, governments dedicate just 2% of health budgets to mental health—the WHO recommends 4%—while development funding “has never been more than 1% of global development assistance for health.” 

However, recent events, particularly the global COVID-19 pandemic, have opened many eyes to the devastating impact of poor mental health on societies and economies. In financial terms, it accounts for one third of the global cost of NCDs at an approximate cost of USD$2.5 trillion per year—and is expected to rise to USD$6 trillion by 2030.  

A whole-of-government approach 

Poor mental health doesn’t develop out of nowhere. Many factors contribute, including unemployment, substance abuse, housing insecurity and homelessness, intimate partner violence, and physical illness. Because these contributing factors are complex and often intertwined, the challenge of improving mental health in a society demands a whole-of-government approach, according to Rialda Kovacevic, Health Specialist at World Bank, an Access Accelerated strategic partner. 

“The mental health agenda deserves and needs a whole of government and whole of society approach, it cannot be solely left on the shoulders of the ministry of health. The most impactful and sustainable solutions occur when there is collaboration with communities, local officials, providers, civil societies, as well as ministries of education, social protection and jobs, finance, and housing, to name a few.” 

The mental health challenge in low-and middle-income countries 

“What is often overlooked in conversations and coverage of mental health is its impact on LMICs, where mental health services and resources are hugely lacking,” says Martin. 

The large majority (80%) of mental health conditions occur in LMICs, creating yet another obstacle to these countries’ economic development. People of lower income backgrounds are more likely to develop a mental health condition, as are populations within a younger age range. Natural disasters, from earthquakes to famines, and armed conflict further exacerbate the growing mental health crisis in lower income settings. 

To begin addressing these challenges, the World Bank and Access Accelerated have embarked on an initiative aimed at helping eight low- and middle-income countries in Latin America, the Caribbean, and Africa to improve access to mental health services by working with communities to address stigma and gender-based violence. The initiative is also helping to establish baseline data where none currently exist to understand and inform how services are provided. 

The initiative is still in its early days, but it has already yielded some important insights, including the critical need to engage at the community level for both policy development and service delivery.  

“If policies are created in isolation of the local context, and without the collaboration with the communities and considering their needs and wants, a desired outcome will simply not be achieved,” says Rialda. “Collaboration and clear communication between policymakers and communities are the key to sustainable, scalable solutions.”

 

Shortage of mental health providers, paucity of data, lack of guidelines and protocols, long-standing stigma associated with mental health, as well as insufficient funding are among the many barriers that impede access to mental health services in LMICs. However, concrete progress is being made. Through the partner projects, nurses at the primary care level are being trained to recognize and support mental health patients, online counseling programs are reaching rural communities, and strategies linking mental health and anti-violence are being piloted.

“These projects show that it is possible to overcome these barriers, “says Martin. “Through political will, investment, innovation, planning, and community engagement, we are starting to change the conversation and how we tackle mental health in LMICs.”