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
SUMMARY
1.
Different types of gaps in mental health care:
insufficiency, inequity, inefficiency.
2.
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
Different Types of Gaps
PREVENTION
ACCESS
QUALITY
B.Saraceno, 2014
The Key Issue: The Resources Gap
1. Resources to treat and prevent mental
disorders remain insufficient.
1. Resources for mental health are
inequitably distributed.
1. Resources for mental health are
inefficiently utilized.
B.Saraceno, 2014
INSUFFICIENCY: Mental Health Budget and
Total Health Budget (WHO, 2004)
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INSUFFICIENCY: Burden/Budget Gap:
Too Large !
15%
13%
10%
Budget
Burden
5%
3%
0%
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INEQUITY: Number of Psychiatrists Per
200,000 Population (WHO, 2001)
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INEFFICIENCY: Where are the Beds?
(WHO 2011)
Residential
Facilities 16%
General Hospitals
21%
Mental Hospitals
62%
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Service Organization: Optimal Mix
of Services (adapted from WHO)
HIGH
LOW
Mental Hospitals
& Specialist
Services
FREQUENCY
Community
Mental
Health
Services
OF NEED
COSTS
Psychiatric
Services in
General
Hospitals
INFORMAL
COMMUNITY
CARE
Mental
Health
Services through
PHC
SELF CARE
QUANTITY OF SERVICES NEEDED
LOW
HIGH
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MIX OF SERVICES IN JORDAN
Dawani 2010
Low
High
Mental Hospitals & specialist services
Community mental health services
COSTS
Informal community care
OF NEED
FREQUENCY
Mental Health through PHC
Self Care
High
Low
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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
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The Treatment Gap (WHO, 2004)
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The Resources are Far from the Needs
Far = 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
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
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
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.
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INEFFICIENCY: Psychiatric Beds in each WHO Region and the World
(WHO, 2005)
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Total Mental Health Beds in Europe Per 100,000 Population
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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).
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Mental Health Services Coverage:
FOUR SCENARIOS
VERY LOW
MIX
ONLY
HOSPITAL
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GOOD
Beds Reduction (Delgado 2013)
Ano
Leitos
2001
52.962
60.000
2002
51.393
52.962
51.393
48.303
2004
40.000
45.814
Número de leitos
2003
2005
2006
2007
42.076
30.000
39.567
Número de leitos
50.000
60,000
48.303
52,962
45.814
50,000
51,393
42.076
48,303
39.567 37.988
36.797
45,814
40,000
42,076
39,567
37,988
34.601
32.735
36,797
34,601
30,000
32,735
20.000
37.988
20,000
2008
36.797
10.000
2009
34.601
2010
0
32.735
2001
2011
32.284
10,000
2002
0
2003
2001
2004
2002
2005
2003
2004
Anos
2006
2005
2007
2006
2008
2007
2008
20092009
2010
2010
Anos
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Hospital Size Reduction (Delgado 2013)
Série Histórica - % de Leitos psiquiátricos por porte hospitalar
Historical series - % of psychiatric beds according to
hospital size
50
40
% do total de leitos existentes
% do total de leitos existentes
60
60
30
Até 160 leitos
Até 160 leitos
De 161
a 240 leitos
De 241a 400 leitos
De 161
240 leitos
leitos
Acima
de a400
50
40
20
30
De 241a 400 leitos
20
10
10
Acima de 400 leitos
0 0
2002
2003
2004
2005
2006
2002 2003 2004 2005 2006
2007
2007
2008
2008
2009
2009
2010
2010
Anos
Anos
B.Saraceno, 2014
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.
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Brazil Primary Care: Family Health Teams
1998-2009
1998
2009
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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
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.
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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
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
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
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
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Barrier 3: Lack of Investment in Secondary
Care, the Missing Number
•3
•?
•1
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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.
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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
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
Brazil: CAPS
Community mental health services network has increased
(Delgado,2013)
1800
1620
1600
1467
1326
1400
1155
1200
1010
CAPS
1000
738
800
605
600
424
400
200
500
295
148
179
208
1998
1999
2000
0
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Anos
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Brazil:
Visual representation of the massive increase of
community centers (Delgado 2013)
2002
2010
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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
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
Hospital vs. Community: Reverting Expenditure
(Delgado 2013)
red = % of costs devoted to community care
blue: % of costs devoted to hospital care
80
% do Total de Gastos do Programa
75,24
70
66,71
60
63,35
61,83
50
52,77
47,23
40
67,71
55,92
44,08
38,17
30
65,54
36,65
33,29
34,46
24,76
32,29
20
10
0
2002
2003
2004
2005
2006
2007
2008
2009
Anos
B.Saraceno, 2014
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
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
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
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:
What are we actually able to scale-up?
• Rational use of psychotropic drugs or Comprehensive Mental
Health Interventions?
B.Saraceno, 2014
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