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AFTER ENLIGHTENMENT…THE LAUNDRY by John Minto

Written by John Minto, Managing Director, Gede Foundation (jminto@gedefoundation.org)

Although there are some serious questions to be asked about any international ‘targets’, there can be little doubt that the celebrations which greeted the inclusion of mental health into Sustainable Development Goals (SDGs) were justified and well earned. Mental health activists rightly celebrated the fact that, now, there is global recognition of at least two vital issues which are captured in the SDGs –

3.4 – By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being

3.5 – Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol

Goals matter. Targets matter. International agreements matter. Why? Despite the fact that they are often politically motivated and can be based on ‘the loudest voice’ principle, they can capture issues which are of genuine concern and which need resources to address them. In the case of mental, neurological and substance use (MNS), a compelling case has been made that, as a starting point, conditions such as depression and alcohol abuse should be seen as problems ‘across the board’ (that is, they impact negatively on education, health and an ability to earn a living) and can no longer be ignored. On top of this, the global mental health community used ‘shock’ tactics to get their message across effectively – the fact that suicide is the biggest killer of teenage girls around the world garnered a great deal of media attention over the last couple of years in particular.

But, after enlightenment, the laundry as the saying goes. What happens now?

Voices have already been raised in terms of ways in which to address the ‘key issues’ (although even these are open to debate). Should political will and resources be immediately put into the training of a greater number of mental health experts? Should urban based mental hospitals be the focus of service delivery, acting as catalytic players in the drive towards health for all? Should community level mental health take precedence instead? What about stigma and discrimination? Should there be priority populations and conditions initially – such as posttraumatic stress disorder for internally displaced persons?

A recent article by Maya Semrau et al (“Strengthening mental health systems in low-and middle-income countries: the Emerald programme.” BMC Medicine (2015) 13:79) offers a convincing framework related to ways in which health systems can develop and support those needing quality heathcare.

The core of Semrau’s work is an understanding that there is little to be gained from considering isolated elements within any response to a particular health burden. Instead, it is more productive to view a health system as “the sum total of all the organisations, institutions, and resources whose primary purpose is to improve health”. As Semrau also notes, “a well-functioning health system should deliver services of adequate quality to all people, whenever and wherever they need them and should protect the right to health for everyone, including people with mental, neurological and substance use disorders, whether through professional services or non-professional care services such as family or self-care”.

These are important insights for the development of mental health systems in any low and middle income country (LMIC) as they suggest an overall framework in which change can occur. At the time of writing, this framework is being, to some extent, tested in Ethiopia, India, Nepal, Nigeria, South Africa and Uganda through the EMERALD (Emerging mental health systems in LMICs) programme which has already started to report back on some positive developments.

Part of the appeal of the EMERALD project is that it looks at the following key system issues –

1.Health System Inputs

Semrau argues that adequate resources for mental health, fair financing and improved economic outcomes for mental health and sustainable financing for mental health are all essential elements within the inputs needed for an effective mental health system. Pivotally, EMERALD is working on cost estimates and the impact of scaling up interventions for mental illness in particular. Underlying this approach is an important question which is perhaps too infrequently asked – what is the cost of not addressing mental illness in any given society? Are the costs of not treating MNS far larger (especially in the long run) than investing in treatment?

2.Health System Processes

As Semrau notes, “another key objective for EMERALD is the evaluation of the context, process, experience and health system implications of mental health service implementation”. Currently, although it is acknowledged to have strengths and weaknesses, many LMICs are using the WHO mhGAP Intervention Guide which offers guidelines (which can be used by lay health workers) related to diagnosis and treatment of MNS disorders. This is linked to an assessment of the strategies (in LMICs) related to the development and implementation of mental health plans at all levels of healthcare service delivery. The key is to provide evidence regarding ‘what works’ in terms of integrated mental health services using existing health platforms. There is, as we all know, no point in reinventing the wheel and seeing how the mhGAP can be fully implemented within the context of existing structures and platforms is an important element within systems development.

3.Health System Outputs

It is perhaps natural that many mental health commentators and ‘supporters’ want to see output quickly – mainly through more treatment pathways. However, even if possible, this tends to defocus an important issue surrounding the development and monitoring of key indicators for mental health service delivery and overall system performance. This is not to say that what cannot be measured should not be done, but the absence of hard evidence related to outcomes will be a serious barrier to advocating for mental health resources with any Government or donor. This, in itself, raises questions regarding monitoring and evaluation (and the use of modern technology where appropriate) which is often deeply challenging for LMICs whose main focus is often, not unreasonably, on front loaded service delivery.

To complicate an already challenging subject, Semrau also notes the importance of developing partnerships “with service users” which “are essential for the development of evidence-based care in government guidance across the globe. They may protect those who receive involuntary treatment abuses, or those who are marginalised due to their low socio economic status or social stigma attached to MNS disorders, through their greater involvement in the implementation of mental health system processes”. Semrau notes the importance of the work between healthcare professionals, service users/carers and government agencies in relation to the successful implementation of HIV healthcare and poses a question related to lessons learned re mental health.

The key to building a sustainable mental health system in Nigeria will focus on addressing  issues related to health system inputs, processes and outputs. Naturally, the challenges will be found in the detail but with mental health now an SDG, there is clearly an opportunity for all interested parties and stakeholders to work together to build on best practice and to develop something unique to the context of Nigeria.

Few people now seriously doubt the importance and impact of MNS. In itself, this is a major victory for the global mental health community. However, after enlightenment…the laundry.

The Gede Foundation works to bring underserved and stigmatised health burdens ‘out of the shadows’ through high quality research, catalytic partnerships and advocacy which result in long term change at the community level. The Foundation is currently working with partners to establish the prevalence of depression, substance abuse and suicidality among people living with HIV-AIDS while, at the same time, exploring ways in which mental health protocols can be integrated into existing health platforms. The Foundation was recently awarded a BasicNeeds UK franchise (see http://www.basicneeds.org/gede-foundation-joins-as-basicneeds-first-franchisee-in-nigeria) to develop community based mental health programmes which address both mental illness (and epilepsy) and livelihood support for those suffering from mental illness and their carers. The Foundation is also currently working with partners to culturally validate tools for VC programmes throughout Nigeria. In the interests of transparency, Gede is not linked to the EMERALD project in any way

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