5
THERAPEUTIC DRUGS
Definitions
drug policy: a written commitment, endorsed
by the Minister of Health or the Cabinet to ensure accessibility and availability of essential therapeutic drugs. It
contains measures for regulating the selection, purchase,
procurement, distribution and use of essential and appropriate drugs, including those for mental and neurological
disorders. It can also specify the number and types of
drugs to be made available to health workers at each
◆ Therapeutic
level of health service according to the functions of the
workers and the conditions they are required to treat.
Under the national policy, drugs may be supplied free of
charge to all or selected groups.
list of drugs: the officially approved list of essential drugs that the country has adopted. It is usually
adapted from the WHO Model List of Essential Drugs.
◆ Essential
Salient Findings
◆A
therapeutic drug policy or an essential list of drugs is
present in 88.4% of countries covering 90.8% of the
world population. The European Region has the least
number of countries with a policy or drug list (79.2%),
whereas in the South-East Asia Region all countries have
either a policy or a drugs list.
◆ Availability
of psychotropic therapeutic drugs in primary
care varies among countries. Phenobarbital is available in
96.6% of the countries, amitriptyline in 88.6% of the
countries, chlorpromazine in 92.1%. Fluphenazine and
lithium are unavailable at primary care level in more than
30% of the countries. Anti-parkinsonian drugs are
unavailable at primary care level in about 40% of countries.
◆ Almost
20% of countries do not have at least one common anti-depressant (amitriptyline), one anti-psychotic
(chlorpromazine) and one anti-epileptic (phenytoin) in
primary care. This is even worse in the African Region
where 29% of countries do not have all these three
drugs.
◆ Where
these medicines are available in primary care, pricing structure sometimes acts as a barrier to access in
many countries.
◆ The
median cost of treating a patient for depression
(amitriptyline 150mg/day) and psychosis (chlorpromazine
400mg/day) for one year in low income countries is half
and one-fourth, respectively of that in high income countries. This should be seen in the perspective of low
income countries having GNP per capita one-twelfth that
of high income countries.
◆ The
median cost of treating a patient of epilepsy with
300mg of phenytoin per day for one year is low across all
countries, but even then, in low income countries it is
only half of that in high income countries.
Limitations
◆ Information
is unavailable on how many and which psychotropic therapeutic drugs are included in the essential
lists of drugs.
◆ Data
◆ The
◆ Prices
availability of the drugs is not uniform across all primary care centres in a country.
on cost of drugs are available only from few countries and this may not be representative of an entire
WHO Region.
have been converted directly from local currencies
to USD, without consideration of purchasing power.
Implications
◆ The
government has the responsibility of developing a
national drug policy and list of essential drugs. Psychotropic drugs should be included and made available in
primary care at low or no cost. These measures together
with training to primary care professionals can significantly enhance provision of mental health care.
18
◆ Drugs
whose patents have expired are often available at
low prices. They can be provided relatively inexpensively
either through primary or community care.
THERAPEUTIC DRUGS
5.1
al rld
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a
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h
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c
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18
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88.9%
88.9%
80.6%
39.8%
96.6%
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80.6%
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See page 41
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19
6
B U D G E T F O R M E N TA L H E A LT H C A R E
Definitions
budget for mental health: the regular source of
money, available in a country’s budget, allocated for
◆ Specified
actions directed towards the achievement of mental
health objectives.
Salient Findings
◆ 72%
of the countries have a specified budget for mental
health within the total health budget.
◆ 91
countries provided information on actual mental
health expenditure out of the total health budget. Of
these countries, 36.3% spent less than 1% of their health
budget on mental health. More than two billion people
live in these countries.
◆ There
is a marked regional variation in mental health budgets. In the African Region 78.9% of countries spend less
than 1% of their health budget on mental health. 62.5%
of the countries in the South-East Asia Region spend less
than 1% on mental health. On the other hand, in the
European Region more than 54% of countries spend
more than 5% of their health budget on mental health.
◆ Budgets
for mental health also vary by the income group
of countries. Of the low income countries, 61.5% spend
less than 1% on mental health. Even of the high income
countries about 16% spend less than 1% on mental
health.
Limitations
◆ Many
countries, especially in the European Region,
reported having no separate mental health budget. However, they make financial allocations for mental health
within overall health budget at federal or state level.
◆ Some
countries have a federal system where states are
responsible for health expenditure. These countries were
not able to provide aggregate figures.
◆ The
number of countries reporting the amount of specified budget for mental health as a proportion of the total
health budget is relatively small.
Implications
20
◆
A specified mental health budget is usually considered
essential for the development of services especially in
countries where these are at present grossly inadequate.
◆
In view of the large prevalence and burden of mental and
neurological disorders and availability of effective inter-
ventions, the proportion of total health budget spent on
mental health should be in the range of 5% to 15%.
Most countries need to enhance their specified expenditure on mental health care substantially.
B U D G E T F O R M E N TA L H E A LT H C A R E
for
et
g
ud as )
d b ealth (%
e
i
if l h ion th
ec
t
l
Sp enta por hea
o
l
m
r
a
6.1
a p f tot et
o udg
b
80.0%
62.2%
et
dg ach
u
e
d b in rld
ifie care wo
c
e
the
sp th
of heal and
e
n
nc al
se ent egio
R
Pre r m
O
o
6.2 f WH 175
=
72.3%
66.7%
72.0%
a
ric
Af
as
ric
e
Am
an
e
ran
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ite
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Eu
nM
er
ast
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63.0%
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et ortio
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WHO 01.171
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25 000
35 000
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21
7
M E T H O D O F F I N A N C I N G M E N TA L H E A LT H C A R E
Definitions
◆
Out-of-pocket payment: money spent by the consumer
or the consumer’s family as the need arises.
◆
Tax based funding: money for mental health services
raised by taxation: either through general taxation, or
through taxes that are earmarked specifically for mental
health services.
◆
Private insurance: the health care consumer voluntarily
pays a premium to a private insurance company. In
return, the insurance company pays for part or all of the
consumer’s mental health services, should it be needed.
◆
Social insurance: everyone above a certain level of
income is required to pay a fixed percentage of their
income to a government-administered health insurance
◆
External grants: money provided to countries by other
countries or international organizations.
fund. In return, the government pays for part or all of
consumers’ mental health services, should it be needed.
Salient Findings
◆ Taxes
are the primary method of mental health financing
for 60.2% of the countries, followed by social insurance
(18.7%), out of pocket payments (16.4%). Private insurance and external grants account for 1.8% and 2.9%
respectively.
◆ Out-of-pocket
payments are used as the primary method
of financing mental health in 35.9% of countries in the
African Region and 30% of countries in the South-East
Asia Region. No countries in the European Region use this
method as the primary means of expenditure for mental
health.
◆ Social
insurance is a primary method of financing in 50%
of countries in the European region. Countries in the
African, South-East Asia and the Western Pacific Regions
do not use social insurance as the primary method of
mental health financing.
◆ Private
insurance is the primary method of financing in
very few countries.
◆ External
grants support mental health as a primary
method of financing in 7.7% of countries in the Western
Pacific Region, 5.6% of countries in the Eastern Mediterranean Region and 5.1% of countries in African Region.
◆ Tax
is the most common primary method of financing in
all the four income groups.
◆ Out-of-pocket
expenditure is the primary method of
financing in 39.6% of low income countries. It is the primary method of financing in almost none of the higher
income countries.
◆ Social
insurance is the primary method of financing in
38.3% of high income countries and in 29.4% of higher
middle income countries. No low income country uses
social insurance as a primary method of financing mental
health.
Limitations
◆ The
information on methods of financing mental health
should be considered preliminary and indicative, since it is
derived only from governmental sources, pertains only to
the “most important” method of financing and is not
supported at present by actual numbers.
◆ Though
operational definitions of the terms used were
provided, it is possible that some countries may not have
used them accurately while providing information.
◆ It
should also be noted that the information is based only
on government expenditure. It does not account for private or any other non-governmental expenditure on
mental health.
◆ In
some countries traditional healers are responsible for
mental health community care in rural settings. It is difficult to assess modes of payment for their services.
Implications
◆ More
accurate information is needed on methods of
financing mental health care.
◆ Insurance
plays only a small role in financing mental
health care in most countries.
22
◆ Out-of-pocket
expenditure puts excessive unplanned
burden on persons affected by mental disorders and their
families. This should be avoided by shifting to tax-based
or insurance as methods of financing.
M E T H O D O F F I N A N C I N G M E N TA L H E A LT H C A R E
s)
trie
60.2%
n
ou
g
yc
cin ach
db
e
n
e ld
vid
ina
f f re in wor n pro
o
ca the atio
od
eth ealth nd form
m
a in
h
ary ntal gion on
m
d
i
Pr f me Re Base
nt
O
(
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me
H 71
y
7.1
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p
ase
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N
k
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p
of
O
d
18.7%
e
nc
ura
s
l in
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ran
ate
u
ins
v
Pri
orl
W
16.4%
b
ia
oc
S
7
1.8%
2.9%
nts
ra
lg
na
ter
Ex
53.9%
66.6%
66.7%
35.9%
a
c
fri
s
ca
eri
m
A
A
0% 5.1%
5.1%
22.2%
n
n
ea
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50.0%
50.0%
e
rop
Eu
13.3%
16.7%
5.6%
0%
0% 5.6%
3.3%
0%
0%
0%
70.0%
73.1%
30.0%
st
-Ea
ia
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ter
uth
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11.5%
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7.7%
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nt
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fi
of care ntri on
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h
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r
P f m me Bas co
(
7.2 o inco 171 ed by
=
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vid
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64.0%
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le
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Lo
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idd
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er
gh
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12.0%
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1
See page 41
3.8%
3.8%
gh
Hi
2.9%
0% 6.0%
0%
38.3%
0%
0%
0%
23