A global scope for global health—including mental health

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The Lancet, Volume 378, Issue 9803, Pages 1613 - 1615, 5 November 2011
Giuseppe Raviola,  Anne E Becker , Paul Farmer

Unprecedented opportunities to promote excellence and equity in health-care delivery for the world's most underserved populations are upon us. Successful programmes to reduce the transmission of and mortality from infectious diseases have invigorated discourse about the human right to health, and have resulted in viable platforms for comprehensive health programmes that provide care to millions of people facing both poverty and chronic disease.1 Indeed, the past decade has seen the introduction of the first such platforms designed to treat incurable disorders, from AIDS to diabetes. Rapid scientific advances and health-system improvements that help us to understand and redress the biosocial roots of poor health and to develop diagnostics, therapeutics, and the technology and infrastructure to disseminate and implement them, promise to extend benefits to care delivery in the realm of non-communicable diseases.
However, delivery of mental health services in low-resource settings lags unacceptably and unjustly far behind that of other services. Neuropsychiatric disorders comprise a substantial share of disease-related burden and disability—approaching 14%, with depression the leading global cause of disability—but receive a disproportionately low resource allocation: the average across countries is under 4% of overall health-care budgets.2, 3 Resources for mental health research are also scarce and knowledge gaps persist.4 Alongside a shortfall in trained mental health professionals, these deficits are the backdrop to a disconcerting treatment gap for neuropsychiatric disorders in low-income countries, with over 75% of patients untreated.5, 6 Even these dismal metrics do not fully convey the unconscionable neglect, social discrimination, and frequent abuse endured by the mentally ill,7 a situation aptly described as a “failure of humanity”.8
Although uncontested, neither inventories of need,9 nor the pragmatic refrain of “no health without mental health” by Prince and colleagues,2 which opened The Lancet's 2007 Series on global mental health, have gained sufficient purchase. How the message could be amplified further to transform a narrative of global neglect is difficult to imagine.
Additional structural (largely economic) and cultural obstacles beset efforts to provide more effective and accessible care for mental disorders in low-resource settings.9 However, barriers that prevent patients from seeking help and impede care for mental disorders—eg, functional impairment, social stigma, and low health literacy in patients and caregivers—have been encountered and overcome for other disorders, as the success of the movement to confront HIV/AIDS shows. Notably, this triumph for global health equity was achieved when prevention was integrated with high-quality care through the creation of new financing mechanisms.10, 11 Although much remains to be done, the successful implementation of programmes in poorer parts of the world should act as a model for care delivery in other health-care domains, including mental health, as the coalition Movement for Global Mental Health has declared.12
Strategies to close the mental health resource gap in low-income regions are in sight, a research agenda is being set, and new protocols are ready for implementation.13, 14 In 2010, WHO released its much-anticipated mental health Gap Action Programme Intervention Guide to support the implementation of treatment for mental, neurological, and substance-use disorders in primary-care health settings.15 Thoughtfully conceived basic treatment packages for common mental health disorders could improve delivery of key services at low expenditure in countries of low and middle income.16—18 Straightforward treatment algorithms and innovative task-shifting mechanisms—well established for other conditions—render affordable and effective mental health care within reach, and with it potentially vast collateral health and social benefits.19
However, an argument based solely on cost-effectiveness is unwise if it promotes only one narrow sector of the health agenda at the expense of others. Investments are needed that build on, rather than compete with, the newly created platforms to prevent and treat other chronic illnesses. The broad health benefits of programmes focused on HIV/AIDS prevention and care show that good mental health care would not dilute primary health care, but could strengthen it.10, 11 A unified call for integrated and comprehensive models of health-care delivery, inclusive of non-communicable diseases and mental disorders, would be compelling.
The UN General Assembly High-level Meeting on Non-communicable diseases in September was only the second Special Session convened about a health-related issue.20 Preceding optimism was warranted, but if the collective ambition of global-health advocates, scientists, and practitioners is to promote social and economic rights and equitable access to evidence-based health services for all, we must also construe and promote global health as encompassing a global scope of health domains.
We join the call for the inclusion of mental health in a comprehensive health agenda for the world's poorest populations.21 The pragmatic and moral imperatives are self-evident: without mental health care, there is no justice. The methods are in hand, the advocates have been mobilised, and the message should be unified action.


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a Program in Global Mental Health and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA 02115, USA


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