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Opinión y analisis / Opinion and analysis
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Key words: words
266 Rev Panam Salud Publica 36(4), 2014
Pan American Jo
urnal
of Public Health
Opinión y análisis / Opinion and analysis
Pan American Jo
urnal
of Public Health
Call for a change in
research funding
priorities: the example of
mental health in
Costa Rica
Javier Contreras,1
Henriette Raventós,1
Gloriana Rodríguez,2
and Mauricio Leandro2
Suggested citation: Contreras J, Raventós H, Rodríguez
G, Leandro M. Call for a change in research funding priorities:
the example of mental health in Costa Rica. Rev Panam Salud
Publica. 2014;36(4):266–9.
synopsis
The World Health Organization (WHO) Mental Health Ac-
tion Plan 2013–2020 urges its Member States to strengthen
leadership in mental health, ensure mental and social health
interventions in community-based settings, promote mental
health and strengthen information systems, and increase
evidence and research for mental health. Although Costa
Rica has strongly invested in public health and successfully
reduced the burden of nutritional and infectious diseases,
its transitional epidemiological pattern, population growth,
and immigration from unstable neighboring countries has
shifted the burden to chronic disorders. Although policies
for chronic disorders have been in place for several decades,
mental disorders have not been included. Recently, as the
Ministry of Health of Costa Rica developed a Mental Health
Policy for 2013–2020, it became evident that the country
needs epidemiological data to prioritize evidence-based
intervention areas. This article stresses the importance of
conducting local epidemiological studies on mental health,
and calls for changes in research funding priorities by public
and private national and international funding agencies in
order to follow the WHO Mental Health Action Plan.
Keywords: mental health; mental disorders; research,
funding; research promotion; research policy evalua-
tion; policy making; Costa Rica.
The World Health Organization (WHO) has a compre-
hensive mental health action plan for 2013–2020 that
summarizes the efforts of stakeholders and experts
from 135 Member States. Its four objectives are:
1. Strengthen effective leadership and governance.
This includes empowering people with mental dis-
abilities and moving away from the purely medical
model.
2. Provide comprehensive, integrated, and responsive
mental health and social care services in community-
based settings. This includes an emphasis on human
rights, and services that include income generation,
education opportunities, housing, and other social
determinants of mental health required for a com-
prehensive response to mental health.
3. Implement strategies for promotion and prevention
in mental health. This encompasses suicide preven-
tion and measurable indicators, such as 20% in-
crease in service coverage for severe disorders and
a 10% reduction of the suicide rate by the year 2020.
4. Strengthen information systems, evidence, and
research. This includes generating new knowledge
through research that addresses local scientific
questions, thereby enabling policies and actions
founded on evidence and best practices (1).
Furthermore, the mental health system must
include the following indicators: prevalence of mental
disorders; identification of major risk and protective
factors for mental health and well-being; coverage of
policies and legislation; interventions and services;
health; and social and economic outcome data (2).
COSTA RICA CONTEXT
Costa Rica is a middle-income and politically
stable country in Central America with a population of
4.4 million. Its strong investment in a public universal
health care system, sanitation, and public education
during the past century has contributed to health in-
dicators comparable to those of developed countries,
a very low illiteracy rate, and an economy rated by
the World Bank as upper middle-income. Costa Rica
has markedly reduced the impact of nutritional and
infectious diseases in the last 50 years, has an infant
mortality rate under 15 per 1 000, and a life expectancy
of 75 years.
Over 90% of the health care facilities in Costa
Rica are operated by the Caja Costarricense del Se-
guro Social (Costa Rican Social Security Fund; CCSS),
which provides public and universal coverage and
is supported by compulsory contributions from all
Costa Rican workers and employers (3). Nonetheless,
1 Centro de Investigación en Biología Celular y Molecular, Univer-
sidad de Costa Rica, San José, Costa Rica. Send correspondence to
Javier Contreras, email: dr.javiercontreras@gmail.com
2 Escuela de Psicología, Universidad de Costa Rica, San José, Costa Rica.
Contreras et al. • Mental health research funding in Costa Rica Opinion and analysis
Rev Panam Salud Publica 36(4), 2014 267
CCSS is burdened by a transitional epidemiological
pattern and population growth, along with increased
needs generated by immigration from economically
and politically unstable neighboring countries. Conse-
quently, the proportional burden of chronic disorders,
such as congenital malformations, genetic illnesses,
cancer, cardiovascular diseases, and mental disor-
ders, has substantially increased. Although specific
evidence-based policies have been in place for other
chronic disorders for several decades, mental disor-
ders have not been included.
This work highlights the importance of conduct-
ing local epidemiological studies on mental health
and their role in forming public health interventions.
It provides a discussion of current research initiatives
and proposes a change to divert more research fund-
ing toward mental health.
MENTAL HEALTH IN COSTA RICA
No epidemiological studies on mental disor-
ders have been conducted in Costa Rica in the last 35
years (4). The studies conducted by Adis-Castro and
his group between 1968 (5) and 1984 (6), although
flawed by different diagnostic categories and non-
representative population samples, showed a preva-
lence of alcoholism of 10%–14%; psychotic symptoms,
1%–3%; depressive personality, 5%–7%; and anxiety,
16%–26%. Other indicators also suggest that mental
disorders are a burden in Costa Rica. Violent deaths
(suicide, homicide, and traffic accidents) are the third
cause of mortality, and the first among young adults.
Costa Rica is situated in one of the most violent parts
of the world. The violence is mostly drug-related
and has permeated the whole area. Drug and alcohol
consumption and abuse are on the rise; 22% of Costa
Ricans are at risk and 4% have alcohol-dependence
(7). Growing indexes on extreme poverty, domestic
violence, school desertion, poor waste management,
inexistent urban planning, and an inefficient public
transportation system, among others, indicate nega-
tive effects on health and wellbeing (8).
Additionally, data from the CCSS suggest that
mental health disorders have not been a priority,
notwithstanding the known disability and suffering
caused by these conditions. According to the Evalu-
ation of the Costa Rican Mental Health System, the
country invested only 3% of the total health budget
in mental health and 70% of this investment went to
inpatient facilities (9). The rate of specialists in psy-
chiatry per 100 000 inhabitants is only 3.7, similar to
the rate Mexico (1 to 5 depending on rural or urban
area), but less than the United States of America and
Canada. Additionally, the distribution per popula-
tion density is not homogeneous. Some areas outside
main cities have one or fewer psychiatrists per 100 000
inhabitants (9).
Contreras and Raventós (10) summarized the
opinions of policymakers, researchers, clinicians, and
patient organizations in Costa Rica during a workshop
on mental health services in 2011. The conclusions of
this workshop were: mental disorders are generally
treated by psychiatrists who work in the two special-
ized psychiatric hospitals; time per patient is short and
specialist referrals are difficult to obtain; access to new
drug protocols and non-pharmacological therapies,
such a psychotherapy, is limited; trained community-
level non-specialized health personnel is lacking,
which delays accurate diagnosis and treatment; and
few interventions are conducted on mental health
promotion, prevention, or rehabilitation.
During the last decades, assessments of mental
health in Costa Rica have been conducted with statisti-
cal data from different institutions, e.g., the Ministry of
Health, CCSS, the Ministry of Public Education, men-
tal health hospitals, the National Institute of Statistics
and Census, and others. Both WHO and the CCSS
acknowledge that epidemiological data is necessary to
improve health services for mental disorders (10, 11).
In order to remedy the absence of an explicit
mental health policy in Costa Rica, the Ministry of
Health convened a diverse group of experts from the
public and private sectors to meet regularly during
the course of 2012 to develop the 2013–2021 National
Policy on Mental Health (12). During these sessions,
indirect indicators of prevalence, disability, quality,
and quantity of mental health services and treatment,
and environmental and biological determinants were
discussed. Due to the lack of local studies, the Policy
was also based on results from other countries; in
fact, most low- and middle-income countries (LMIC)
define their health policies, interventions, and pro-
grams using data generated in high-income countries
(13, 14). However, since other countries’ results can-
not be directly extrapolated to the local setting, an
additional priority of the Policy was to conduct an
epidemiological study that would determine more
precisely the prevalence, disability, comorbidity, and
sociodemographic correlates for mental disorders in
Costa Rica. The WHO-Composite International Di-
agnostic Interview (CIDI), which has proven useful
for epidemiological studies by non-clinical personnel,
provides diagnosis according to the Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV) and
the International Classification of Diseases, 10th edi-
tion (ICD-10) with a confidence of 85%–95% for most
disorders, even in different cultural settings (15, 16).
Studies done in Guatemala and Mexico have shown
that the instrument can detect differences even in
similar contexts, supporting the need to conduct local
assessments in each country and setting (17).
CHANGING PRIORTIES FOR MENTAL
HEALTH RESEARCH FUNDING
Mental disorders are complex conditions influ-
enced by the interaction of biological, environmental,
lifestyle, and socioeconomic factors. It is now widely
accepted that the burden of mental illness and its dis-
abilities represents a challenging concern for public
health systems in LMIC, a situation that needs an-
swers from the research community. Epidemiological
Opinion and analysis Contreras et al. • Mental health research funding in Costa Rica
268 Rev Panam Salud Publica 36(4), 2014
services and promotion and prevention strategies. It
is crucial to develop a prioritized research agenda
for mental health, improve research capacity, and
strengthen collaboration between national, Regional,
and international research centers.
Epidemiological studies in mental health will
provide a better view of the current mental health
situation in Costa Rica. Such research will reduce bias
obtained through statistical data. More accurate data
is necessary for reporting to WHO and will lead to
better planning and distribution of existing resources.
Improved data quality and reporting would not only
make sense to possibly alleviate some of the economic
burden of mental disorders, but most importantly, to
improve the wellbeing of the population overall, to
protect human rights, and to diminish the suffering
endured by those directly affected, as well as that of
their families and communities.
Conflict of interest: None.
sinopsis
Solicitud de un cambio en las prioridades de
financiamiento de la investigación: el ejemplo
de la salud mental en Costa Rica
El Plan de Acción sobre Salud Mental 2013–2020 de la
Organización Mundial de la Salud (OMS) insta a sus Es-
tados Miembros a que fortalezcan el liderazgo en el ám-
bito de la salud mental, garanticen las intervenciones de
salud mental y asistencia social en los entornos comu-
nitarios, promuevan la salud mental y fortalezcan los
sistemas de información, e incrementen los datos cientí-
ficos y las investigaciones sobre salud mental. Aunque
Costa Rica ha invertido mucho en salud pública y ha re-
ducido con éxito la carga de enfermedades nutriciona-
les e infecciosas, su modelo epidemiológico transitorio,
el crecimiento de la población y la inmigración desde
países vecinos inestables han desplazado la carga de
morbilidad hacia los trastornos crónicos. Aunque exis-
ten políticas en vigor dirigidas a los trastornos crónicos
desde hace varios decenios, no se ha incluido en ellas
a los trastornos mentales. Recientemente, cuando el
Ministerio de Salud de Costa Rica elaboró una Política
Nacional de Salud Mental para el periodo del 2013 al
2020, se hizo evidente que el país necesita datos epi-
demiológicos para priorizar las áreas de intervención
con base en pruebas científicas. Este artículo subraya la
importancia de llevar a cabo estudios epidemiológicos
de ámbito local sobre salud mental, y solicita cambios
en las prioridades de financiamiento de la investigación
por parte de los organismos de financiamiento públicos
y privados, nacionales e internacionales, con objeto de
cumplir con lo que establece el Plan de Acción sobre
Salud Mental de la OMS.
Palabras clave: salud mental; trastornos mentales; in-
vestigación, economía; promoción de la investigación;
evaluación de políticas de investigación; formulación
de políticas; Costa Rica.
studies on mental health are needed to understand
risk factors and the burden of disease so that evidence-
based policies can be enacted (14). In 2004, the WHO-
sponsored Mental Health Study was published with
results on 14 of the 30 participating countries, and
showed that mental disorders are highly prevalent
and constitute disabling conditions that frequently are
not diagnosed or treated (18). According to WHO (19),
less than 70% of its Member States have mental health
programs; in LMICs only 1% of the health budget is
dedicated to mental health; and over 30% of the years
lived with disability are caused by mental disorders.
The Mental Health Atlas 2011 (20) shows that
the gap between available resources and the burden
of neuropsychiatric disorders is larger in low-income
countries than in high-income ones. It estimated that
neuropsychiatric disorders contribute to 26.3% of the
burden of disease in Costa Rica. No data was avail-
able for two crucial indicators: number of people with
mental disorders treated by primary health care, and
interventions (psychopharmacological and psycho-
social) delivered by primary health care to people
with mental disorders. The system lacks information
on number of people, age, gender, diagnosis, and
activities conducted to promote mental health in the
primary care setting (21). One of the priorities defined
by WHO during the General Assembly in May 2013
was the implementation of a set of global actions that
include research on the nature, determinants, and
treatments for these disorders (1).
WHO has developed assessment instruments to
collect essential information on the mental health sys-
tem of Member States. In Costa Rica, this information is
provided by the Ministry of Health based on statistical
information from health providers. Epidemiological
studies will ensure accuracy of the data presented in
these reports. However, funding for epidemiological
studies is limited and difficult to obtain. The overall
investment in science and technology in these coun-
tries is low, usually under 0.5% of the Gross National
Income (22), and these studies are expensive endeavors
for national agencies. Most international agencies do
not include mental health research in their priorities,
exclude middle-income countries such as Costa Rica,
or have a very limited budget for these studies.
The WHO Mental Health Action Plan established
a specific goal to measure the global impact of its fourth
objective (strengthen information systems, evidence,
and research for mental health). The goal is to have
80% of the countries collect and report mental health
indicators every 2 years through their national health
and social information systems (1). If mental health is
to be considered a global health priority, as put forth
by the World Health General Assembly last year, local
and international organizations should allocate the nec-
essary resources to study the state of mental health in
each country. Resources are needed for epidemiological
studies on which to implement an evidence-based and
active surveillance system for mental health. This will
allow Member States to integrate mental health into the
routine health information system, periodically report-
ing and using core mental health data to improve health
Contreras et al. • Mental health research funding in Costa Rica Opinion and analysis
Rev Panam Salud Publica 36(4), 2014 269
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