Benedetto Saraceno Gulbenkian Professor of Global Health University of Lisbon

1. Barriers to Implementation of Effective Strategies for Scaling-Up Mental Health Care: Examples from Brazil, Chile, Jordan and Sri Lanka Benedetto Saraceno Gulbenkian Professor of Global Health University of Lisbon Director WHO Collaborating Centre University of Geneva B.Saraceno, 2014

2. SUMMARY • Different types of gaps in mental health care: insufficiency, inequity, inefficiency. • The Optimal Mix of Services is prevented by 5 Barriers: • Mental health resources centralized in and near big cities and in large institutions. • Difficulties in integrating mental health care in primary health care services. • Lack of investment in secondary care. • Political will (& thus funding) for mental health is low. • Mental health leadership lacks public health skills and often serves narrow interests. 3. One conclusion and two critical questions B.Saraceno, 2014

3. Different Types of Gaps B.Saraceno, 2014

4. The Key Issue: The Resources Gap • Resources to treat and prevent mental disorders remain insufficient. • Resources for mental health are inequitably distributed. • Resources for mental health are inefficiently utilized. B.Saraceno, 2014

5. INSUFFICIENCY: Mental Health Budget and Total Health Budget (WHO, 2004) B.Saraceno, 2014

6. INSUFFICIENCY: Burden/Budget Gap: Too Large ! 15% 13% 10% Budget Burden 5% 3% 0% B.Saraceno, 2014

7. INEQUITY: Number of Psychiatrists Per 200,000 Population (WHO, 2001) B.Saraceno, 2014

8. INEFFICIENCY: Where are the Beds? (WHO 2011) B.Saraceno, 2014

9. Service Organization: Optimal Mix of Services (adapted from WHO) Mental Hospitals & Specialist Services Community Mental Health Services Psychiatric Services in General Hospitals Mental Health Services through PHC INFORMAL COMMUNITY CARE SELF CARE QUANTITY OF SERVICES NEEDED HIGH LOW FREQUENCY OF NEED COSTS LOW HIGH B.Saraceno, 2014

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11. The Resources Gap Results in the Treatment Gap • Serious cases receiving no treatment during the last 12 months. • Developing countries: 76.3 to 85.4 % • Developed countries: 35.5 to 50.3 % WHO World Mental Health Consortium JAMA, June 2nd 2004 B.Saraceno, 2014

12. The Treatment Gap (WHO, 2004) B.Saraceno, 2014

13. The Resources are Far from the NeedsFar = insufficient and/or wrongly allocated • People need more services (more absolute coverage). • With more rational allocation of resources (reversing the pyramid). • With more focus (less avoidable treatments). • People need services close to home: Primary Care and Secondary Care represent (should represent) the main components of an effective Mental Health System. B.Saraceno, 2014

14. Location of Care is not Matching with Needs: Six Common Mistakes • Too many psychiatric hospitals. • Too many beds in existing psychiatric hospitals. • Not enough alternative solutions for long term users. • Not enough beds in General Hospitals. • Not enough Community Mental Health. • Not enough mental health literacy in PHC. B.Saraceno, 2014

15. LANCET SERIES: Global Mental Health Benedetto Saraceno, Mark van Ommeren, Rajaie Batniji, Alex Cohen, Oye Gureje, John Mahoney, Devi Sridhar, Chris Underhill. Barriers to improvement of mental health services in low-income and middle-income countries. Lancet 2007 Sep 29; 370(9593):1164-74. B.Saraceno, 2014

16. Barrier 1: Mental Health Resources Centralized in and near Big Cities and in Large Institutions • Need for extra funding to shift to community-based services. • Resistance by mental health professionals and workers, whose interests are served by large hospitals. B.Saraceno, 2014

17. INEFFICIENCY: Psychiatric Beds in each WHO Region and the World(WHO, 2005) B.Saraceno, 2014

18. Total Mental Health Beds in Europe Per 100,000 Population B.Saraceno, 2014

19. The Brazil Case 1990 • The Sistema Unico de Saude (SUS) is created. • 1st National Mental Health Conference. • The “reform” movement starts. 2001 • The Federal Law is approved with budget. • 2nd National Mental Health Conference (30,000 participants). • Changing size and profile of psychiatric hospitals. • Bed reduction starts in parallel to establishment of CAPS (Community Mental Health Centers). • “da volta para casa” programme (a programme promoting deinstitutionalization and offering residential alternatives). B.Saraceno, 2014

20. Mental Health Services Coverage: FOUR SCENARIOS VERY LOW MIX ONLY HOSPITAL GOOD B.Saraceno, 2014

21. Beds Reduction (Delgado 2013) B.Saraceno, 2014

22. Hospital Size Reduction (Delgado 2013) B.Saraceno, 2014

23. Barrier 2: Difficulties in Integrating Mental Health Care in Primary Health System • Primary care workers already overburdened. • Lack of supervision and specialist support after training. • Lack of continuous supply of psychotropics in primary care in many low income countries. B.Saraceno, 2014

24. Brazil Primary Care: Family Health Teams 1998-2009 1998 2009 B.Saraceno, 2014

25. The Sri Lanka Case (WHO, 2013) The Ministry of Health and the Sri Lanka College of Psychiatrists initiated a one-year diploma course in psychiatry. • Participants received specialized training in psychiatry, including theory and field placement under the supervision of a consultant psychiatrist. • Nearly 60 diploma holders are now working in the country, and all 25 districts in the Country have at least one doctor with the diploma in psychiatry. They are based mainly in secondary-level hospitals, and conduct hospital as well as outreach clinics in the district. B.Saraceno, 2014

26. The Sri Lanka Case Apart from psychiatry diploma graduates, 131 Medical Officers of Mental Health and 34 Medical Officers of Psychiatry are now serving in different parts of the country. • They receive 3-months of mental health training. • Their duty list is similar to that of psychiatry diploma holders. • They work under the supervision of district Psychiatrists. • They de facto fulfil the role of leading the mental health response. B.Saraceno, 2014

27. The Sri Lanka Case • Community support officers • Community volunteers paid to provide social support and first psychological aid (trained after Tsunami 2005) • These officers have referred more than half of all inpatients and this proportion rose to 75% in areas without psychiatric services (H. Minas, unpublished) B.Saraceno, 2014

28. The Chile Case • By 2004, Chile’s public mental health network included an impressive array of services including: • 472 primary care centers with mental health professionals • 38 community mental health centers • 58 outpatient clinics • 40 day hospitals • 18 psychiatric units in general hospitals • 25 day centers in the community • 96 group homes for severely mentally ill • Innovative large-scale initiatives such as the national program on depression have led to substantial progress in the identification and treatment at PHC level of people with common mental disorders who would otherwise not seek care. B.Saraceno, 2014

29. The Jordan Case (WHO, 2013) Mental Health program 2008 – 2010 • Supported by the World Health Organization, Jordan Office, in partnership with the Ministry of Health and the Jordanian Nursing Council. • Draft of First National Policy and Action Plan developed by the established National Steering Committee for Mental Health. • 3 community mental health services and an acute inpatient model unit established at the Ministry of Health facilities. • Service and human resource development focuses on mental health training and supervision of a relevant number of general practitioners, paediatricians and nurses in primary health care B.Saraceno, 2014

30. Jordan: Mental Health Workers Outside Psychiatric Hospitals Before and Since 2008 (WHO,2013) 180 Secondary care workers 225 PHC workers 130 Service users and families B.Saraceno, 2014

31. Barrier 3: Lack of Investment in Secondary Care, the Missing Number • 3 • ? • 1 B.Saraceno, 2014

32. Mental Disorders often Determine Long Term Disabilities Mental disabilities are long term conditions and, therefore, require: community long-term care, provided by primary- and secondary-levels teams together. B.Saraceno, 2014

33. Long Term Care = 5 C’s • Comprehensiveness broad spectrum of offers (psychiatric care, family support, housing, employment, inclusion strategies) • Community Long Term Care long term-----forever • Continuity of care one service • Collegiality multiprofessional team+users&families • Capacity new skills are needed B.Saraceno, 2014

34. Brazil: Strong Investment in Community Mental Health Centers • The Psychosocial Community Centers (CAPS) provide day hospital care, which is considered intensive care. They were developed for treating severe mental disorders and are classified according to three degrees: complexity, population covered, and funds allocated. • In June 2006, there were 848 CAPS registered in Brazil: 673 for adults, 109 for problems related to alcohol and drug use, 66 of which are for children and adolescents only. • Brazil has today 1,513 CAPS, but distribution is still uneven. In the state of Amazon, for example, with 3 million residents, there are only four centers. • Across the country there are 564 therapeutic homes, sheltering 3,062 residents. B.Saraceno, 2014

35. Brazil: CAPSCommunity mental health services network has increased (Delgado,2013) B.Saraceno, 2014

36. Brazil: Visual representation of the massive increase of community centers (Delgado 2013) 2002 2010 B.Saraceno, 2014

37. Barrier 4: Political Will (& thus Funding) for Mental Health is Low Reasons: • Inconsistent and unclear advocacy by Mental Health advocates (for example: do members of the Global Movement share the same values and vision???) • People with disorders not organized in a powerful lobby in many countries (and often funded by Big Pharma!!!) • Incorrect belief that care is cost-ineffective (but we still use too often only output rather than outcome indicators and this decreases our credibility vis-à-vis politicians and funders!!!!) B.Saraceno, 2014

38. Brazil: Reverting Expenditure • The outlay on mental health rose 51.3% in the period 2001-2009. • The breakdown of the expenditures revealed a significant increase in the extra-hospital value (404.2%) and a decrease in the hospital one (-39.5%). • The per capita expenditures had a lower, but still significant, growth (36.2%). • The historical series of the disaggregated per capita expenditures showed that in 2006, for the first time, the extra-hospital expenditure was higher than the hospital one. The extra-hospital per capita value increased by 354.0%; the per capita hospital value decreased by 45.5%. B.Saraceno, 2014

39. Hospital vs. Community: Reverting Expenditure (Delgado 2013)red = % of costs devoted to community careblue: % of costs devoted to hospital care B.Saraceno, 2014

40. Mental Health Reform in Chile • Between 1999 and 2006, the fraction of the health budget allocated to mental health increased almost 2-fold, from 1.2% to 2.1%. • In the same period, the percentage of the mental health budget allocated to psychiatric hospitals decreased from 57% to 33%. B.Saraceno, 2014

41. Barrier 5: Mental Health Leadership Lacks Public Health Skills & Serve Narrow Interests • Those who rise to leadership positions often only trained in clinical management. • Public health training does not include mental health. • Conservative views prevail in professional organizations. • Pharma industry still too influential. B.Saraceno, 2014

42. Six Critical Areas in Service Planning • Complying with the UN Convention on the Rights of Persons with Disability (CRPD). • Decreasing the role of psychiatric hospitals. • Increasing the role of general hospitals. • Increasing Community Mental Health care provision. • Developing effective long term care and rehabilitation strategies. • Increasing support to Primary Health Care. B.Saraceno, 2014

43. One Conclusion & Two Key Questions CONCLUSION: • Good policy and good plans do not warrant good services. • Service organization should be the priority. QUESTION 1: What do we really want to scale – up? • Just treatment packages or Comprehensive Services reform +treatment packages? QUESTION 2: Whatare weactually able to scale-up? • Rational use of psychotropicdrugs or Comprehensive Mental Health Interventions? B.Saraceno, 2014

44. References Dawani H. , Mental Health System in Jordan, 2010 (unpublished lecture in Boston) Delgado PG.,Mental Health Reform in Brazil: changing hospital centred paradigm to ensure access to, in Souqonline, November 2013 at: http://www.souqonline.it/home2_2_eng.asp?idpadre=955&idtesto=949#.UoyRqSe3eKQ Saraceno B, van Ommeren M, Batniji R , Cohen A , Gureje O , Mahoney J, Sridhar D, Underhill C . Barriers to improvement of mental health services in low-income and middle-income countries. Lancet 2007 Sep 29; 370(9593):1164-74. World Health Organization, The World Health Report 2001 - Mental health: new understanding, new hope, WHO, Geneva 2001. World Health Organization, Investing in Mental Health, WHO, Geneva 2004. WHO World Mental Health Survey Consortium, «Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys», in JAMA, 2004, 291, pp.2581-2590. World Health Organization, Mental Health Atlas 2005, WHO, Geneva 2005 World Health Organization, Mental Health Atlas 2011, WHO, Geneva 2011 World Health Organization, Building back better: sustainable mental health care after emergencies, WHO, Geneva 2013 B.Saraceno, 2014