The holiday season is generally a cause for joy. Yet for millions of people it can also herald declines in mental health, whether due to economic stress, familial tensions, loneliness, overeating or drinking too much alcohol.
Across the world, countries are recognising that the best way to tackle the growing burden of mental illness is through Universal Health Coverage (UHC). This is achieved when everyone receives the quality health services they need without suffering financial hardship.
An idea whose time has come, UHC has been the overarching concept guiding Dr Tedros Adhanom Ghebreyesus’ stewardship of the World Health Organization since he took over as its Director-General in 2017.
Equity is fundamental to UHC, which ensures that services are allocated according to need and financed based on people’s ability to pay. To ensure effective quality care that is accessible to everyone, the healthy and wealthy must cross-subsidise the sick and poor.
This makes UHC a political choice. To lead the way, governments must be willing to get their hands dirty - they must raise taxes, pool funds and finance services that focus on the needs of the poor and vulnerable. They must also resist market-driven models that ultimately fail the poorest in society.
Given that there is no health without mental health, UHC provides a golden opportunity for the improvement of prevention, treatment and promotion of mental health, leaving no one behind. Global leaders must work to incorporate all three elements within primary health care systems. Both UHC and mental health advocates can also take advantage of the Sustainable Development Goal target to reduce premature mortality from non-communicable diseases by a third by 2030.
For their part, UHC proponents should care about mental health, which affects almost every person directly or indirectly. 300 million people globally have depression, which is the leading cause of disability worldwide. Given these numbers, and the significant burden on health systems, any UHC programme must adequately serve people with mental health conditions.
Unfortunately, mental health gets hardly any public money – less than 1% of national health budgets in low-income countries. Even in the UK, only 11% of health funding goes to mental health trusts, even though the issue relates to 24% of overall health service activities.
To give a sense of what these figures should look like, the Lancet Commission on Global Mental Health recommends that low- and middle-countries should allocate at least 5% of their health budgets to mental health, and high-income countries at least 10%.
Proper funding levels are vital to ensure that health services make special provisions for people with mental health conditions, since existing health systems currently have a poor track record of taking care of them. People with the most serious mental health disorders such as severe depression, bipolar disorder and schizophrenia typically die between ten and twenty years earlier than the general public.
Clearly, people with poor mental health are in deep need of effective services. Yet those with the greatest need for services typically have the least ability to pay for them due often to their difficulties in sustaining permanent employment. This is often exacerbated by discrimination in the labour market. Mental health services need to be free, particularly for the most vulnerable. Financial barriers can have life-threatening consequences or can force people into debt and a cycle of poverty, which often exacerbates mental health challenges.
Moving from budget lines to staff on the frontlines, it’s also important to consider how doctors, nurses and community health workers can act on this issue, because they are ultimately responsible for delivering services and realising the vision of UHC. Stigma around mental health within the health workforce means that medical professionals are less likely to choose this specialty, leaving the world without adequate numbers of psychiatrists; for example, there are only three in Sierra Leone.
Despite all that we still have to achieve, there is much to celebrate. For example, on December 13 2018, Kenya launched a pilot program providing free treatment for mental disorders in four counties. 2019 also marks a big year for UHC. The UN General Assembly will host a High-level Meeting on the topic, bringing Heads of State together to make commitments. The meeting should follow the example of the UN Commission on Non-Communicable Diseases and this year’s High-level Meeting on the same subject, which both featured mental health prominently.
Given the opportunities ahead, let’s make sure the next time this holiday season comes around we are many steps closer to achieving Universal Health Coverage globally, with mental health at the core.