Priority conditions

A disease area can be considered a priority if it represents a large burden (in terms of mortality, morbidity or disability), has high economic costs, or is associated with violations of human rights. The area of mental, neurological and substance use consists of a large number of conditions. The priority conditions identified by the above criteria for mhGAP are depression, schizophrenia and other psychotic disorders, suicide, epilepsy, dementia, disorders due to use of alcohol, disorders due to use of illicit drugs, and mental disorders in children. These disorders are common in all countries where their prevalence has been examined, and they substantially interfere with the abilities of children to learn and with the abilities of adults to function in their families, at work, and in broader society. Because they are highly prevalent and persistent, and cause impairment, they make a major contribution to the total burden of disease. Disability is responsible for most of the burden attributable to these disorders; however, premature mortality – especially from suicide – is also substantial. The economic burden imposed by these disorders, includes loss of gainful employment, with the attendant loss of family income; the requirement for caregiving, with further potential loss of wages; the cost of medicines; and the need for other medical and social services. These costs are particularly devastating for poor populations. Annex 1 summarizes the burden created by these disorders and the links with other diseases and sectors. Moreover, MNS disorders are stigmatized in many countries and cultures. Stigmatization has resulted in disparities in the availability of care, discrimination and in abuses of the human rights of people with these disorders.

Intervention package

Considerable information about the cost effectiveness of various interventions for reduction of the burden of MNS disorders is now available. Although it is useful to determine which interventions are cost effective for a particular set of disorders, this is not the end of the process. Other criteria need to be considered in decisions about which interventions to deliver, such as the severity of different disorders (in terms of suffering and disability), the potential for reduction of poverty in people with different disorders, and the protection of the human rights of those with severe MNS disorders.

The package consists of interventions for prevention and management for each of the priority conditions, on the basis of evidence about the effectiveness and feasibility of scaling up these interventions. In this context, an intervention is defined as an agent or action (biological, psychological, or social) that is intended to reduce morbidity or mortality. The interventions could be directed at individuals or populations, and were identified on the basis of their efficacy and effectiveness, cost effectiveness, equity, ethical considerations including human rights, feasibility or deliverability, and acceptability.

Interventions cannot be provided as freestanding activities, but should instead be delivered in a variety of packages and through different levels of a health system. Delivery of interventions as packages has many advantages, and is the most cost-effective option in terms of training, implementation, and supervision. Many interventions go naturally together because they can be delivered by the same person at the same time – e.g. antipsychotics, and family and community interventions for treatment of schizophrenia.

Table 1 presents a template for interventions for each of the priority conditions which can be adapted to the situation in different countries.

Table 1

Evidence-based interventions to address the priority conditions.

This template will need to be adapted for countries or regions on the basis of the prevalence and burden of each of the priority conditions; evidence about efficacy, feasibility, cost, and acceptability of the interventions in specific contexts; health system requirements for implementation (including financial and human resource implications); and cultural choices, beliefs, and health-seeking behaviours in specific communities. The priorities and the methods used will inevitably vary between settings. Thus the intervention packages and the delivery of the packages might differ between countries, and even between different areas in the same country. For example, in many low-income countries, more than three quarters of the population live in rural areas. Few services, including human resources, reach such areas. The shortage of human resources thus demands pragmatic solutions. Community workers – after specific training and with necessary back-up, e.g. phone consultations with general practitioners – can deliver some of the priority interventions.

Identification of countries for intensified support

Most of the global burden of mental, neurological, and substance use disorders occurs in countries with low and lower middle incomes. These countries not only have the highest need to tackle this burden but also the fewest resources available to do so. The conceptual principle of mhGAP is that since a small number of low-income and lower middle-income countries contribute most to the global burden, and have comparatively few human and financial resources, a strategy that focuses on mental health care in these countries has the potential for maximum impact. mhGAP thus aims to provide criteria to identify the countries with low and lower middle incomes which have the largest burdens of MNS disorders and the highest resource gap, and to provide them with intensified support. It should be noted, however, that the framework mhGAP provides for country action is adaptable and can be used in any country where the possibility for technical support exists. Therefore, this process does not mean denial of support to other countries.

Selection of countries for intensified support could use many criteria. One criterion could be the burden of MNS disorders. The approach used in the Global Burden of Disease project was to use DALYs as a summary measure of population health across disease and risk categories. For example, total DALYs can be used as a measure of disease burden to identify the countries with low and lower middle incomes which have the highest burdens of priority conditions. DALYs per 100 000 population can also be used to measure disease burden. This criterion is useful to ensure that countries with small populations but high rates of MNS burdens are included. Another criterion could be gross national income (GNI) per capita, which is indicative of the relative poverty of countries.

Annex 2 provides a list of countries with low and lower middle incomes that have been identified for intensified support by use of these criteria. The countries were selected from three lists of countries for each of the six WHO regions. The first list rank-ordered countries by the total number of lost DALYs. The top four contributing countries from each of the six WHO regions were selected from this list. The second list rank-ordered countries by MNS burden rate. Any country from the top four contributing countries from each of the six WHO regions, which was not already selected from the previous list, was included. The third list rank-ordered countries by their GNI per capita. Any country from the top four poorest countries from each of the six WHO regions, which was not already selected from the previous lists, was included. Most of the identified countries, also have few resources available for health and a large resource gap, as evident from the scarcity of health providers and mental health professionals in these countries.

Another criterion could be the country’s readiness for scaling up. Although “hard” indicators to measure a country’s readiness do not exist, “soft” indicators could include any request for support from the country for scaling up activities in the area of MNS disorders; any previous or ongoing collaboration between WHO and the country; or any donor interest.

Scaling up

Scaling up is defined as a deliberate effort to increase the impact of health-service interventions that have been successfully tested in pilot projects so that they will benefit more people, and to foster sustainable development of policies and programmes. However, pilot or experimental projects are of little value until they are scaled up to generate a larger policy and programme impact. Until now, practical guidance about how to proceed with scaling up has been inadequate. mhGAP aims to identify general approaches and specific recommendations for the process of scaling up.

Scaling up involves the following tasks:

• identification of a set of interventions and strategies for health-service delivery, and planning of a sequence for adoption of these actions and of the pace at which interventions can be implemented and services expanded;
• consideration of obstacles that hinder the widespread implementation of the selected interventions, and the options that are available to deal with these obstacles; and
• assessment of the total costs of scaling up and sustaining interventions in a range of generalizable scenarios.

These tasks require a clear understanding of the type and depth of constraints that affect a country’s health system. Such constraints could operate at different levels, such as community and household, health-service delivery, health-sector policy and strategic management, cross-sectoral public policies, and environment and context. One paper in the recently published Lancet series on global mental health reviewed barriers to development of mental health services through a qualitative survey of international mental health experts and leaders (box 3).

Box 3

Barriers to development of mental health services. The greatest barrier to development of mental health services has been the absence of mental health from the public health priority agenda. This has serious implications for financing mental health care, (more...)

However, the barriers discussed in box 3 refer only to constraints on scaling up the supply of mental health services, whereas uptake is equally important for efficient delivery of services. Evidence suggests that demand-side barriers can deter patients from accessing available treatment, especially if they are poor or vulnerable. Barriers to uptake of mental health services include costs of access; lack of information; and gender, social, and cultural factors.