The World Health Organization (WHO), established 60 years ago, emphasized in its constitution that mental health is fundamental to “happiness, harmonious relations, and security for all people.” This commitment was reiterated in the Alma Ata Declaration 30 years ago, which advocated for integrating mental health into primary health care
Despite being recognized as essential to overall health, mental health remains neglected. Evidence highlights its immense global burden, yet political will and resources are insufficient [5,6], reflecting not only a technical gap but a moral failure.
Low- and middle-income countries face critical shortages in mental health services, even as social and economic changes exacerbate the burden [8,9]. This paper examines the causes of this gap and explores potential solutions.
Mental Health Burden
Updated projections of global mortality and disease burden (2002–2030) for 192 WHO Member States confirm earlier predictions by Murray and Lopez that the impact of mental disorders is steadily rising [3,4]. Recent reviews highlight that mental health’s indirect burden extends beyond psychiatric disorders, influencing both communicable and noncommunicable diseases and potentially hindering progress toward the Millennium Development Goals.
Mental Health Services in Developing Countries
Despite global advocacy and calls for action following the 2001 World Health Report , progress in mental health services remains limited, especially in low-income countries, where significant gaps persist:
Access to care is further hindered by stigma, lack of awareness, and reliance on isolated hospital-based interventions instead of integrated services.
Policy Challenges and Solutions
Needs Assessment
Many countries focus on burden-of-disease measurements via large epidemiological surveys, but this approach is often impractical in regions with a 90% treatment gap. Instead, qualitative studies and mental health system mapping, such as the WHO-AIMS tool, are more effective for identifying priority areas and informing service planning.
Service Development
Barriers to improving mental health services in low- and middle-income countries include insufficient funding, centralization of resources, and a lack of trained workers [8]. The WHO's Mental Health Gap Action Programme (mhGAP) aims to scale up services in these regions by fostering partnerships and reinforcing commitment.
Prevention and Promotion
Mental health is often overlooked in public health compared to other noncommunicable diseases. While primary prevention is ideal, the complexity of mental health risk factors and the need for more data make it challenging. A balanced approach, focusing on early detection and management, can reduce the burden of mental disorders.
Integration into Primary Care
Integrating mental health into primary health care is shown to be cost-effective and feasible, even with general practitioners and multipurpose health workers in developing countries. However, more research is needed to identify the most effective methods for integration, and community-based alternatives may be necessary where strong primary care systems are lacking.
Substance Abuse Prevention and Management
Substance abuse has garnered more global attention than other mental health issues, partly due to its link with HIV transmission and its recognition as a health risk by the WHO. However, this focus has sometimes led to neglect of broader mental health concerns.
Key issues include shifting the perception of substance abuse from a legal to a public health problem, treating substance abusers as patients rather than criminals, and promoting evidence-based prevention and harm reduction strategies. WHO has included methadone and buprenorphine in its essential medicines list, but these treatments remain unavailable in many countries, exacerbating HIV and hepatitis risks.
The WHO also adopted a resolution to reduce harmful alcohol use in 2008, highlighting the need for a global strategy tailored to different regional contexts. Brief interventions, such as the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), offer cost-effective management, especially at the primary health care level.
Protecting Patients' Rights
Progress in improving societal inclusion and reducing stigma for those with mental illness has been slow, despite proposed strategies. WHO emphasizes the importance of mental health legislation to protect patients' rights, though implementation remains a challenge. In countries with weaker infrastructures or in post-crisis settings, a bottom-up approach, such as the WHO's Chain-Free Initiative in Somalia and Afghanistan, may be more effective for improving patient dignity and care.
Protecting Patient Rights and Dignity
Progress has been slow in many countries regarding the inclusion of people with mental illness in society and reducing discrimination. While various strategies have been proposed, more evidence is needed to identify cost-effective solutions. WHO emphasizes that mental health legislation is crucial for safeguarding the rights of individuals with mental disorders, both in institutions and communities. However, legislation alone is insufficient. Effective implementation may require a top-down approach in countries with strong infrastructure and a bottom-up approach in regions with weak systems, like those affected by conflict. WHO’s Chain-Free initiative, launched in Somalia and Afghanistan, exemplifies this by improving care in hospitals and advocating for human rights at the community level.
Emergency Mental Health
The development of the Interagency Standing Committee (IASC) Guidelines marked a key moment in emergency mental health and psychosocial support. There is now widespread agreement that coordinated efforts should focus on providing a safe environment for survivors and offering psychological first aid, rather than relying on single-session debriefing. Special attention is needed for those with pre-existing mental disorders. The new approach emphasizes distinguishing between distress and disorder and recommends a mix of non-professional and interdisciplinary professionals. Further work is needed to explore non-pharmaceutical interventions for severe distress and optimize service coverage in large-scale disasters.
Advocacy, Fundraising, and Strengthening Mental Health Services
Mental health has long been marginalized and requires affirmative action to gain proper attention and support. Advocacy efforts are underway in many countries, but these are often ad hoc and limited to specific days or events. There is a lack of evidence on the impact of these efforts, highlighting the need for planned, results-based advocacy and anti-stigma activities at the national level with clear outcome measures.
Mental health units within many ministries of health are underpowered or absent, and must be established, strengthened, and properly funded. In some countries, separate units for mental health and substance abuse lead to duplication of work and inefficiency. Unifying these units could improve resource use and reduce costs.
Fundraising is crucial, and all mental health policies should include a fundraising component. Although WHO/AIMS has incorporated a mental health budget item, there is no standardized approach for calculating mental health spending. Most countries allocate less than 3% of their health budgets to mental health. A 2007 initiative by WHO/EMRO to implement mental health sub-accounts within national health accounts provides a framework for better tracking of mental health expenditures. A uniform approach should be adopted where national health accounts exist.
In summary, mental health services must be integrated into national health systems. While integration across health areas is vital, vertical affirmative action is also necessary to ensure mental health receives the attention it deserves.
Possible Solutions
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