Mental health financing challenges, opportunities and strategies in low- And middle-income countries: Findings from the Emerald project

BJPsych Open, Volume 5, No. 5, Year 2019

Interprétation

BackgroundCurrent coverage of mental healthcare in low- and middle-income countries is very limited, not only in terms of access to services but also in terms of financial protection of individuals in need of care and treatment.AimsTo identify the challenges, opportunities and strategies for more equitable and sustainable mental health financing in six sub-Saharan African and South Asian countries, namely Ethiopia, India, Nepal, Nigeria, South Africa and Uganda.MethodIn the context of a mental health systems research project (Emerald), a multi-methods approach was implemented consisting of three steps: a quantitative and narrative assessment of each country’s disease burden profile, health system and macro-fiscal situation; in-depth interviews with expert stakeholders; and a policy analysis of sustainable financing options.ResultsKey challenges identified for sustainable mental health financing include the low level of funding accorded to mental health services, widespread inequalities in access and poverty, although opportunities exist in the form of new political interest in mental health and ongoing reforms to national insurance schemes. Inclusion of mental health within planned or nascent national health insurance schemes was identified as a key strategy for moving towards more equitable and sustainable mental health financing in all six countries.ConclusionsIncluding mental health in ongoing national health insurance reforms represent the most important strategic opportunity in the six participating countries to secure enhanced service provision and financial protection for individuals and households affected by mental disorders and psychosocial disabilities.Declaration of interestD.C. is a staff member of the World Health Organization. Informed by frameworks developed for other disease priorities in the health sector – such as HIV – the Emerald project developed a streamlined, stepped approach to informing and evaluating country-level financing needs in the area of mental health. Key domains of the Emerald sustainable financing framework include: As shown in Fig. 1, the Emerald project has undertaken an interrelated series of specific research activities along the pathway to determining strategic financing needs for the future, some already reported. In support of domain 1, assessment of the economic burden of mental disorders has been accomplished via a household survey carried out in the six participating countries, which has provided new information on healthcare expenditures, income and production losses and coping mechanisms of households containing a member with MNS disorder.16 In support of domain 2, information on disease burden and health system capacities has been used to generate estimates of overall resource needs and costs associated with the scaled-up delivery of effective and cost-effective interventions in each of the Emerald countries, which has indicated the level of investment needed to move towards universal health coverage.17 Here in this and the associated country-specific papers, the remaining assessment domains of our framework are analysed. Emerald project’s conceptual framework for sustainable mental health financing. In each country, a detailed situational assessment was carried out to better understand the context, barriers and opportunities for more sustainable mental health financing. These national assessments were structured around several domains, subdomains and key indicators, and were subsequently aggregated into a synthesis report that highlighted strengths and weaknesses of the current system or situation, as well as opportunities for and threats to more equitable and sustainable mental health financing. Country-specific estimates of the public health consequences of mental disorders were obtained from local prevalence surveys as well as World Health Organization (WHO) global health estimates databases (http://www.who.int/healthinfo/global_burden_disease/), including rates of prevalence, suicide and disability-adjusted life years. WHO’s health systems framework was used as a suitable structure for carrying out this assessment, which includes six functions or ‘building blocks’ for health system strengthening: governance; health workforce; financing; service delivery; essential health technologies; and information systems.20 Application of this framework to the mental health (and overall health) situation of each country provides relevant contextual information and raises important questions for sustainable financing, such as whether a strategic vision for the future of mental health system and service development is in place and, if so, whether appropriate laws and resources have been committed to enable its realisation. Each country’s overall health system as well as mental health system was described and characterised, informed by nationally available reports and other documentation available through Ministries of Health, Finance and other relevant government departments concerning governance (policies, plans and laws), service availability and access (service organisation, programming and delivery), and financing, as well as health status or outcomes. Particular attention was given to understanding overall health expenditure trends and the contributions made by households towards the cost of healthcare, with reference made to WHO’s global health expenditure database (http://www.who.int/health-accounts). A further level of assessment involved building up an understanding of the broader macro-fiscal context within which scale-up plans and activities are to take place. A country that is experiencing and expecting a prolonged period of economic growth, with manageable levels of indebtedness and a robust tax collection system, is likely to have a very different set of policy options compared with a country with a stagnant economy and/or one with a high level of indebtedness and reliance on external development assistance. In other words, the former country can be expected to have fewer constraints on public spending and therefore more scope to expand services. Accordingly, measures of macroeconomic performance and progress were collated, including current and projected output (total and per capita gross domestic product (GDP)), levels of borrowing and debt (as a percentage of GDP), inflation (year-on-year change in consumer price levels) and (un)employment. Measures of poverty and income inequality provide important complementary information on the distribution of national wealth. Much of the cross-country comparison data were obtained from the World Bank’s development indicators database (https://data.worldbank.org/data-catalog/world-development-indicators). A critical phase of development for identifying potentially feasible strategies for more sustainable mental health financing was the conduct of a series of semi-structured interviews with a range of relevant stakeholders. The Emerald project developed an in-depth mental health financing diagnostic tool, which consisted of four semi-structured interview questionnaires that were adapted for local country use to guide the qualitative interviews with key stakeholders (available at https://www.emerald-project.eu/tools-instruments). These stakeholder interviews were designed to: (a) gain a deeper understanding of the processes for (and potential opposition to) health financing reform, including for mental health, (b) validate emerging findings and implications of the (desk-based) national situational assessments, and (c) activate a participatory, consensus-building approach towards the articulation of sustainable financing mechanisms for mental health services in each country. Findings from the in-depth interviews were grouped under three overarching themes: (a) perceived challenges/constraints (to increased public health financing, including for mental health); (b) options for change (for increased financing for public health including mental health); and (c) key elements/criteria (for improved public health financing, including mental health). Findings and insights from the national assessments and in-depth interviews, together with other accrued project evidence and information relating to resource needs for scale up and the extent of inadequate mental health service access or coverage on household welfare, enabled country teams to identify a set of options for moving towards more sustainable mental health financing (domain 6 of the framework). A generic mental health financing algorithm was developed by the project team to facilitate identification of the main possible mechanisms through which new or existing resources for mental health could be realised (Fig. 2). This algorithm was then populated and adapted as required by the country teams. Emerging options were subsequently subjected to a set of criteria to better isolate those with the greatest utility and feasibility, including: the potential for raising revenue (for health and mental health); the potential for increased equity and financial/social protection; the potential for stable and/or sustainable financing; feasibility (cost, implementation, political acceptability); and links to or integration with other priority health programmes (for example maternal and child health, non-communicable diseases). Emerald project’s mental health financing algorithm.

Résumé de l’IA

Study Justification:

The study aims to address the limited coverage and financial protection for mental healthcare in low- and middle-income countries. It seeks to identify the challenges, opportunities, and strategies for more equitable and sustainable mental health financing in six sub-Saharan African and South Asian countries.

Highlights:

1. Low funding for mental health services and widespread inequalities in access and poverty are key challenges.
2. New political interest in mental health and ongoing reforms to national insurance schemes provide opportunities for improvement.
3. Including mental health in national health insurance schemes is a crucial strategy for more equitable and sustainable financing.

Recommendations:

1. Mental health should be included in ongoing national health insurance reforms.
2. Enhanced service provision and financial protection for individuals and households affected by mental disorders and psychosocial disabilities can be achieved through this inclusion.

Key Role Players:

1. Government officials and policymakers responsible for health and finance sectors.
2. Mental health professionals and experts.
3. Non-governmental organizations working in the field of mental health.
4. Community leaders and advocates for mental health.

Cost Items for Planning Recommendations:

1. Funding for mental health services and infrastructure.
2. Training and capacity building for mental health professionals.
3. Public awareness campaigns and stigma reduction initiatives.
4. Research and data collection on mental health needs and outcomes.
5. Monitoring and evaluation systems to assess the impact of the recommendations.

Force de la preuve

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, as it is based on a multi-methods approach and includes quantitative and narrative assessments, in-depth interviews, and policy analysis. The challenges, opportunities, and strategies for mental health financing in low- and middle-income countries are clearly identified. However, to improve the evidence, it would be beneficial to provide specific data and statistics to support the findings and recommendations.

Abstrait

Informed by frameworks developed for other disease priorities in the health sector – such as HIV – the Emerald project developed a streamlined, stepped approach to informing and evaluating country-level financing needs in the area of mental health. Key domains of the Emerald sustainable financing framework include: As shown in Fig. 1, the Emerald project has undertaken an interrelated series of specific research activities along the pathway to determining strategic financing needs for the future, some already reported. In support of domain 1, assessment of the economic burden of mental disorders has been accomplished via a household survey carried out in the six participating countries, which has provided new information on healthcare expenditures, income and production losses and coping mechanisms of households containing a member with MNS disorder.16 In support of domain 2, information on disease burden and health system capacities has been used to generate estimates of overall resource needs and costs associated with the scaled-up delivery of effective and cost-effective interventions in each of the Emerald countries, which has indicated the level of investment needed to move towards universal health coverage.17 Here in this and the associated country-specific papers, the remaining assessment domains of our framework are analysed. Emerald project’s conceptual framework for sustainable mental health financing. In each country, a detailed situational assessment was carried out to better understand the context, barriers and opportunities for more sustainable mental health financing. These national assessments were structured around several domains, subdomains and key indicators, and were subsequently aggregated into a synthesis report that highlighted strengths and weaknesses of the current system or situation, as well as opportunities for and threats to more equitable and sustainable mental health financing. Country-specific estimates of the public health consequences of mental disorders were obtained from local prevalence surveys as well as World Health Organization (WHO) global health estimates databases (http://www.who.int/healthinfo/global_burden_disease/), including rates of prevalence, suicide and disability-adjusted life years. WHO’s health systems framework was used as a suitable structure for carrying out this assessment, which includes six functions or ‘building blocks’ for health system strengthening: governance; health workforce; financing; service delivery; essential health technologies; and information systems.20 Application of this framework to the mental health (and overall health) situation of each country provides relevant contextual information and raises important questions for sustainable financing, such as whether a strategic vision for the future of mental health system and service development is in place and, if so, whether appropriate laws and resources have been committed to enable its realisation. Each country’s overall health system as well as mental health system was described and characterised, informed by nationally available reports and other documentation available through Ministries of Health, Finance and other relevant government departments concerning governance (policies, plans and laws), service availability and access (service organisation, programming and delivery), and financing, as well as health status or outcomes. Particular attention was given to understanding overall health expenditure trends and the contributions made by households towards the cost of healthcare, with reference made to WHO’s global health expenditure database (http://www.who.int/health-accounts). A further level of assessment involved building up an understanding of the broader macro-fiscal context within which scale-up plans and activities are to take place. A country that is experiencing and expecting a prolonged period of economic growth, with manageable levels of indebtedness and a robust tax collection system, is likely to have a very different set of policy options compared with a country with a stagnant economy and/or one with a high level of indebtedness and reliance on external development assistance. In other words, the former country can be expected to have fewer constraints on public spending and therefore more scope to expand services. Accordingly, measures of macroeconomic performance and progress were collated, including current and projected output (total and per capita gross domestic product (GDP)), levels of borrowing and debt (as a percentage of GDP), inflation (year-on-year change in consumer price levels) and (un)employment. Measures of poverty and income inequality provide important complementary information on the distribution of national wealth. Much of the cross-country comparison data were obtained from the World Bank’s development indicators database (https://data.worldbank.org/data-catalog/world-development-indicators). A critical phase of development for identifying potentially feasible strategies for more sustainable mental health financing was the conduct of a series of semi-structured interviews with a range of relevant stakeholders. The Emerald project developed an in-depth mental health financing diagnostic tool, which consisted of four semi-structured interview questionnaires that were adapted for local country use to guide the qualitative interviews with key stakeholders (available at https://www.emerald-project.eu/tools-instruments). These stakeholder interviews were designed to: (a) gain a deeper understanding of the processes for (and potential opposition to) health financing reform, including for mental health, (b) validate emerging findings and implications of the (desk-based) national situational assessments, and (c) activate a participatory, consensus-building approach towards the articulation of sustainable financing mechanisms for mental health services in each country. Findings from the in-depth interviews were grouped under three overarching themes: (a) perceived challenges/constraints (to increased public health financing, including for mental health); (b) options for change (for increased financing for public health including mental health); and (c) key elements/criteria (for improved public health financing, including mental health). Findings and insights from the national assessments and in-depth interviews, together with other accrued project evidence and information relating to resource needs for scale up and the extent of inadequate mental health service access or coverage on household welfare, enabled country teams to identify a set of options for moving towards more sustainable mental health financing (domain 6 of the framework). A generic mental health financing algorithm was developed by the project team to facilitate identification of the main possible mechanisms through which new or existing resources for mental health could be realised (Fig. 2). This algorithm was then populated and adapted as required by the country teams. Emerging options were subsequently subjected to a set of criteria to better isolate those with the greatest utility and feasibility, including: the potential for raising revenue (for health and mental health); the potential for increased equity and financial/social protection; the potential for stable and/or sustainable financing; feasibility (cost, implementation, political acceptability); and links to or integration with other priority health programmes (for example maternal and child health, non-communicable diseases). Emerald project’s mental health financing algorithm.

Matériaux

N/A

Innovations

Based on the provided information, here are some potential innovations that can be used to improve access to maternal health:

1. Integration of mental health services: Including mental health services within maternal health programs can help address the mental health needs of pregnant women and new mothers, improving overall maternal health outcomes.

2. National health insurance schemes: Including maternal health services within national health insurance schemes can ensure financial protection and improve access to quality maternal healthcare for all women, especially those from low-income backgrounds.

3. Mobile health (mHealth) solutions: Utilizing mobile technology to provide maternal health information, reminders, and access to healthcare providers can improve access to information and services, particularly in remote or underserved areas.

4. Community-based interventions: Implementing community-based programs that provide education, support, and resources for pregnant women and new mothers can improve access to maternal healthcare and promote positive health behaviors.

5. Telemedicine: Using telemedicine platforms to provide remote consultations and monitoring for pregnant women can increase access to healthcare services, particularly for women in rural or isolated areas.

6. Task-shifting and training: Training and empowering community health workers or midwives to provide essential maternal health services can help bridge the healthcare gap and improve access to care, especially in areas with a shortage of skilled healthcare professionals.

7. Public-private partnerships: Collaborating with private healthcare providers and organizations can help expand access to maternal health services, leveraging their resources and expertise to reach more women in need.

8. Innovative financing models: Exploring innovative financing models, such as social impact bonds or results-based financing, can incentivize the provision of quality maternal health services and improve access for marginalized populations.

9. Quality improvement initiatives: Implementing quality improvement initiatives in maternal health facilities can enhance the overall quality of care and ensure that women receive safe and effective services.

10. Data-driven decision making: Utilizing data and technology to collect, analyze, and monitor maternal health indicators can help identify gaps in access and inform targeted interventions to improve access and outcomes.

It is important to note that these recommendations are based on general innovations in healthcare and may need to be adapted to the specific context of maternal health.

AI Innovations Description

The recommendation to improve access to maternal health based on the information provided is to include mental health within national health insurance schemes. This strategy was identified as a key opportunity for more equitable and sustainable mental health financing in low- and middle-income countries. By incorporating mental health into existing or planned health insurance schemes, enhanced service provision and financial protection can be secured for individuals and households affected by mental disorders and psychosocial disabilities. This recommendation is supported by the findings of the Emerald project, which highlighted the challenges of low funding for mental health services, inequalities in access, and poverty. By addressing these challenges through the inclusion of mental health in health insurance schemes, access to maternal health can be improved.

AI Innovations Methodology

To improve access to maternal health, here are some potential recommendations:

1. Mobile health (mHealth) interventions: Develop mobile applications or text messaging services to provide pregnant women with information on prenatal care, nutrition, and safe delivery practices. These interventions can also be used to schedule appointments and reminders for prenatal check-ups.

2. Telemedicine: Implement telemedicine programs to connect pregnant women in remote or underserved areas with healthcare providers. This allows for remote consultations, monitoring of high-risk pregnancies, and timely interventions when necessary.

3. Community health workers: Train and deploy community health workers to provide maternal health education, antenatal care, and postnatal support in rural or marginalized communities. These workers can also identify and refer high-risk pregnancies to appropriate healthcare facilities.

4. Maternal waiting homes: Establish maternal waiting homes near healthcare facilities to accommodate pregnant women who live far away. These homes provide a safe and comfortable place for women to stay during the final weeks of pregnancy, ensuring they are close to the facility when labor begins.

5. Financial incentives: Provide financial incentives, such as conditional cash transfers or maternity vouchers, to encourage pregnant women to seek antenatal care and deliver in healthcare facilities. This helps to reduce financial barriers and increase facility-based deliveries.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Data collection: Gather data on the current status of maternal health access, including indicators such as antenatal care coverage, facility-based deliveries, and maternal mortality rates. This data can be obtained from national health surveys, health facility records, and other relevant sources.

2. Modeling: Use mathematical modeling techniques to simulate the potential impact of the recommended interventions on maternal health access. This involves creating a mathematical model that incorporates relevant variables, such as population demographics, healthcare infrastructure, and the effectiveness of the interventions.

3. Parameter estimation: Estimate the values of the model parameters based on available data and expert knowledge. This may involve conducting literature reviews, consulting with subject matter experts, and analyzing existing data sets.

4. Scenario analysis: Run the model under different scenarios to assess the potential impact of the interventions. This could include varying the coverage and effectiveness of the interventions, as well as considering different population and healthcare system characteristics.

5. Evaluation: Evaluate the results of the model simulations to determine the potential impact of the recommended interventions on improving access to maternal health. This may involve comparing the outcomes under different scenarios and assessing the feasibility and cost-effectiveness of the interventions.

6. Policy recommendations: Based on the findings of the simulation, provide policy recommendations on the implementation of the recommended interventions. Consider factors such as scalability, sustainability, and potential barriers to implementation.

It is important to note that the methodology described above is a general framework and can be adapted and refined based on the specific context and available data.

Auteur

Dima Health

Statistics:

Citations: 25

Identifiers:

DOI: 10.1192/bjo.2019.24

Research Areas:

Community Interventions, Disability, Disparities, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Mental Health, Noncommunicable Diseases, Quality of Care, Social Determinants

Study Countries:

Ethiopia, Multi-Countries, Nigeria, South Africa, Uganda

Study Design:

Cross Sectional Study, Narrative Study

Study Approach:

Mixed-methods, Qualitative, Quantitative

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