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This report was written by Seth Mnookin (MIT). It is the product of almost two years
of activities of a Working Group chaired and directed by Arthur Kleinman (Harvard
University Asia Center). The Working Group consists of Timothy Evans (World Bank
Group), Patricio Marquez (World Bank Group), Shekhar Saxena (World Health
Organization), Daniel Chisholm (World Health Organization), Anne Becker (Harvard
Medical School), Pamela Collins (U.S. National Institute of Mental Health), Mary
de Silva (Wellcome Trust), Pablo Farias (Harvard Medical School), Roberto Iunes
(World Bank Group), Akiko Ito (United Nations Department of Economic and Social
Aairs), Dean Jamison (University of Washington), Yoshiharu Kim (National Institute
of Mental Health, Japan), Judith Klein (Open Society Foundations), Vikram Patel
(London School of Hygiene and Tropical Medicine), and Benedetto Saraceno (NOVA
University of Lisbon).
In addition to members of the Working Group, it includes research by Pim Cuipers
(Vrije Universiteit Amsterdam), Amanda Glassman (Center for Global Development),
Bruce Rasmussen (Victoria University), Peter Sheehan (Victoria University), Filip Smit
(Vrije Universiteit Amsterdam), Kim Sweeny (Victoria University), Leslie B. Tarver
(Massachusetts General Hospital), and Daniel Vigo (Harvard University).
The Working Group acknowledges the contributions of Mary Dethavong, Annikki
Herranen-Tabibi, and members of the stas of the World Bank Group and the World
Health Organization. It also would like to thank The National Academies of Sciences,
Engineering, and Medicine’s Health and Medicine Division for its support of a
meeting of the Working Group on April 20, 2015.
This paper was rst presented during the keynote panel of a World Bank Group/
World Health Organization high-level meeting on making mental health a global
development priority. The two-day event was held on April 13 and 14, 2016, as
part of the World Bank Group/International Monetary Fund spring meetings in
Washington, D.C.
This meeting would not have been possible without the sponsorship of: World
Health Organization, Harvard University Asia Center, National Institute of Mental
Health (U.S.), Grand Challenges Canada, Wellcome Trust, Nippon Foundation,
Rockefeller Foundation, Fundação Calouste Gulbenkian, Open Society Foundations,
Mental Health Innovations Network, Kennedy Forum, Jack.org, iFred, Secretariat for
the UN Convention on the Rights of Persons with Disabilities, Plan International USA,
International Medical Corps, Strongheart Group, African Union Commission, Global
Health Council, World Economic Forum, Department of State (U.S.)/APEC Mental
Health Initiative, National Institute of Mental Health (Japan), Fundación Santa Fe de
Bogota, Carter Center, European Commission Directorate General for Health and
Food Safety, Fundación Once, Fracarita International, Nature, and George Washington
University Milken Institute School of Public Health.
The organizers of the event also express their appreciation for the support provided
by the Oce of the United States Executive Director for the World Bank Group.
Disclaimers
The ndings, interpretations, and conclusions expressed in this work do not necessarily
reect the views of The World Bank, its Board of Executive Directors, or the governments
they represent.
Sta members of the World Health Organization who contributed to this report are
responsible for the views expressed in this publication, which do not necessarily represent
the decisions, policy, or views of the World Health Organization.
2© 2016 Seth Mnookin, World Bank Group, and World Health Organization.
OUT OF THE SHADOWS
Executive Summary
• Mental disorders impose an enormous burden on society, accounting
for almost one in three years lived with disability globally.
• In addition to their health impact, mental disorders cause a signicant
economic burden due to lost economic output and the link between
mental disorders and costly, potentially fatal conditions including
cancer, cardiovascular disease, diabetes, HIV, and obesity.
• 80% of the people likely to experience an episode of a mental disorder
in their lifetime come from low- and middle-income countries.
• Two of the most common forms of mental disorders, anxiety and
depression, are prevalent, disabling, and respond to a range of
treatments that are safe and eective. Yet, owing to stigma and
inadequate funding, these disorders are not being treated in most
primary care and community settings.
• Confronting mental disorders will require new sources of funding
to bridge current resource gaps. Investment from a combination
of national governments and international development partners
could bridge these gaps and result in cost-eective mental health
interventions.
• This funding will provide a strong return on investment, with scale-up
leading to good returns in restored productivity as well as
improved health.
Making Mental Health a Global Development Priority
3
OUT OF THE SHADOWS
4
Introduction
It is no secret that mental disorders cause untold
human misery: Studies estimate that at least 10%
of the world’s population is aected1 and that
20% of children and adolescents suer from
some type of mental disorder.2 In fact, mental
disorders account for 30% of non-fatal disease
burden worldwide (Figure 1)
and 10% of overall
disease burden, including death and disability.3
Suicide, which is frequently caused by mental
disorders, also exacts an enormous toll on
society:
In India, it has overtaken complications
from pregnancy
and childbirth as the leading
cause of death among
women aged 15 to 49.
4
It is also well known that anxiety
and depression,
two of the most common mental disorders,
respond well to a variety of treatments. If we
accept that we have an obligation to alleviate
death and suering when it is within our power
to do so, a strong argument can be made that
adequate mental health treatment should be
considered a fundamental human right and a
moral imperative.
Unfortunately, the realities of the world mean
that there is not adequate funding for every
intervention that would improve our health and
happiness. As a result, when looked at within a
framework of resource allocation, the case for
robust investment in mental health treatment
may initially seem tenuous. This is only true,
however, if one ignores the many ripple eects
created by mental disorders. This discussion
will show that, in addition to the moral case
for treating mental disorders, there is also a
strong economic argument to be made.
Indeed, careful analysis shows that treating
anxiety and depression is an aordable and
cost eective way to promote well-being and
prosperity in a given population – and that failure
to treat them can be a signicant contributor
to impoverishment at the household level and
to diminished economic growth and social well-
being at the national level.
17%
Communicable, maternal, perinatal
and nutritional conditions
6%
Injuries
31%
Mental, neurological
and substance use
disorders
14%
Musculoskeletal
diseases
31%
Other non-
communicable diseases
(e.g. CVD, cancer,
diabetes, respiratory
diseases)
10% Depression
4% Anxiety disorders
4% Alcohol use disorders
14% Other disorders
Figure 1
Global distribution
of non-fatal disease
burden of disease5
(years lived with disability)
Making Mental Health a Global Development Priority
5
There are two main reasons for this. The rst is the
lost economic output caused by untreated mental
disorders as a result of diminished productivity
at work, reduced rates of labor participation,
foregone tax receipts, and increased welfare
payments. Based on an investment-case analysis
prepared for this meeting, it is projected that the
global cost of this lost production amounts to
more than 10 billion days of lost work annually –
the equivalent of US$1 trillion per year.6
The second is the two-way relationship that
exists between mental disorders and unhealthy
behaviors such as poor diet and physical inactivity.
These, in turn, are contributing factors to cancer,
cardiovascular disease, obesity and diabetes,
and a range of other costly and potentially
conditions.7 Mental disorders also increase the
likelihood of drug and alcohol abuse, which can
lead to risky sexual behaviors that increase the
risk of HIV infections and other injuries. Finally,
and most tragically, they are a signicant factor
in suicides. Because of these relationships,
improvement in a population’s mental health
will lead to improvement in its physical health
– and will help enhance overall social and
economic welfare. It will also help achieve one
of the targets in the Sustainable Development
Goals endorsed at the United Nations General
Assembly in September 2015: Promoting mental
health and well-being and reducing mortality
from non-communicable diseases by one third
by 2030.8
The combination of overall lack of resources
devoted to mental health and budgetary
constraints in the world’s poorest regions means
that the countries that can least aord lost
economic output and increased health care
costs are the ones aected the most. A recent
WHO survey indicates that most low- and
middle-income countries spend less than US$2
– and often less than US$1 – per person on the
STORIES FROM THE FIELD:
A 52-YEAR-OLD HOUSEWIFE
FROM INDIA
Last year, I was having terrible head and body
aches due to a cold and was also experiencing
heaviness in my head, which meant I couldn't
sleep. I did not feel like eating food and I had
no interest in completing my daily household
chores. I was worried about my daughter, and I
had to help her end her marriage because her
husband was not treating her properly. This issue
caused frequent ghts and arguments with my
husband and son. I began getting disturbing
thoughts and had no interest in doing anything.
I thought that my existence is of no worth and
wanted to end my life.
I went to the primary health center where a
gentleman oered me counseling and helped
me immensely. He helped me understand
my health problem in an easy manner.
After following the suggestions oered by him,
my disturbing thoughts have reduced. I don’t
have thoughts of ending my life. I have started
doing household work again and I also go to
temple for worshipping and take part in the
activities organized by the temple authority.
As per the counselor’s suggestion, I am also
interacting with my neighbors. I feel good
these days.
OUT OF THE SHADOWS
6
treatment and prevention of mental disorders,9
a gure not remotely proportionate to the public
health and economic burden these illnesses
cause.10 On average, low-income countries assign
only 0.5% of their health budget to mental health.
High-income countries, on the other hand, devote
5.1% – an amount sucient to implement a series
of highly cost-eective interventions, but still
disproportionately small given the prevalence
and impact of mental disorders.11 Indeed, the
proportion of development assistance provided
for poor countries for mental health is under 1%.
It is not hard to understand why this gap exists:
The poorer the country, the greater the urgency
of the competing priorities for scarce resources.
Existing policies and funding priorities, combined
with the stigma associated with mental disorders,
have the eect of calcifying the problem: It is
always easier to continue upon the path one is
already on, especially if changing course would
require addressing neglected problems or facing
uncomfortable truths. But the strong correlation
of mental disorders with poverty and poor
physical health illustrates that interventions can
and should be viewed as an integral part of anti-
poverty policies and programs. That is, mental
health assistance is central to development.
There is also evidence showing that refugees
from war and terror, as well as people aected
by natural disasters and epidemics, suer from
signicantly higher rates of depression and
anxiety than the general population.12 Because
of this, mental health treatment should be
considered a major component of resettlement
and recovery eorts in war-torn regions and
an integral component of national disaster risk
management initiatives.
The good news is that for a problem with such
wide-reaching eects, there are feasible solutions
currently available across sectors. For depression
and anxiety disorders, self-care, psychological
and social interventions, and antidepressant
medication are all among the low-cost, cost-
eective forms of treatment that will lead to
signicant economic, social, and health gains.
The question, then, becomes: Are these sucient
to justify the political will and nancial capital
achieving them will require? Our investment-
case analysis, which measured the costs and
benets associated with a scaled-up response
to depression and anxiety over the period 2016-
2030, makes abundantly clear that they are.13 This
paper will explicate eective options and settings
for treating common mental disorders, analyze
potential impediments to incorporating these
treatments into new mental health initiatives,
and identify potential sources of funding for
implementing new mental health strategies.
I. The case for investing in
mental health
Health relevance and impact
Recent analyses have indicated that the
burdens of mental disorders are signicantly
underestimated.14 Even so, as mentioned above,
conservative estimates are that at least 10% of
the world’s population is aected by one or more
mental disorders.15 Through a combination of
its health eects, injuries, and suicide, mental
disorders are also a major killer. Even using the
most conservative gures available, mental
disorders are the leading cause of years lived with
disability globally.16 Evidence also indicates that
they are on the rise: A 2015Lancetstudy found
that theprevalence of anxiety disordersincreased
by42percentand depressive disorders by 54
percentbetween 1990 and 2013.17 Because
mental disorders greatly increase the risk of a
person developing another chronic disease, and
vice versa,18 it is clear that mental disorders aect
both a signicant portion of the population and
disproportionate numbers of the vulnerable and
the underserved.
Making Mental Health a Global Development Priority
7
Country Year Direct Costs
(Billions)
Indirect Costs
(Billions)
Total Costs
(Billions) % of GDP
CANADA 2011 CAD 42.3 CAD 6.3 CAD 48.6 4.40
ENGLAND 2009/10 GBP 21.3 GBP 30.3 GBP 51.6 4.10
FRANCE 2007 EUR 22.8 EUR 21.3 EUR 44.1 2.30
GLOBAL 2010 USD 823 USD 1,670 USD 2,493 4.00
Table 1
Direct and indirect costs of mental disorders: Results from selected studies23
Economic impact
In 2010, the global cost of mental disorders was
estimated to be approximately US$2.5 trillion;
by 2030, that gure is projected to go up by
240%, to US$6.0 trillion. In 2010, 54% of that
burden was borne by low- and middle-income
countries (LMICs); by 2030, that is projected to
reach 58%.19 The overwhelming majority —
roughly two-thirds — of those costs are indirect
ones associated with the loss of productivity
and income due to disability or death. There is
also signicant evidence showing that social
conditions associated with poverty create stress
and trigger mental disorders, and that the labor
insecurity and the health care costs associated
with mental disorders in turn move many into
poverty.20 This circular relationship between
mental disorders and poverty creates a cycle that
leads to ever-rising rates for both. Several recent
studies in high-income countries have found that
the total costs associated with mental disorders
total between 2.3% and 4.4% of GDP (Table 1).
Costs and benets of investing in mental health
There is intrinsic value in increased mental health
treatment in the form of patients’ improved well-
being. There is also instrumental value that results
when those receiving treatment are better able
to form and maintain relationships; to study, work
or pursue leisure interests; and to make decisions
in everyday life. Assessment of these benets –
and relating them back to investment costs to
establish the rate of return – can be achieved by
estimating current and future levels of mental
disorders, the costs associated with eective
treatment coverage, and the social and economic
impacts of improved mental health outcomes.
Just as mental disorders generate large economic
and social costs, treating or preventing them can
generate substantial health and economic gains.
Earlier work has assessed the cost-eectiveness
of many of the evidence-based interventions
discussed below.
A 2005 paper, for instance, looked at low- and
middle-income regions around the world and
found that each year of healthy life gained cost
less than average annual per capita income,21
while a 2007 paper focused on Nigeria found
that
a package of selected mental health interventions
generated an additional year of healthy life at a
cost below that country’s average per capita
income.22 These studies mirror research
conducted in high-income countries: In the UK,
OUT OF THE SHADOWS
8
While these costs are sizable, the returns on this
investment are also substantial. A 5% improvement
in labor participation and productivity produces
an estimated global return with an NPV of more
than US$399 billion, US$230 billion of which is
the result of scaled-up depression treatment and
US$169 billion of which comes from treatment of
anxiety disorders. The economic value of improved
health is also signicant (an NPV of US$250 billion
for scaled up depression treatment alone). The end
result is a favorable benet-to-cost ratio, ranging
between 2.3-3.0 to 1 when economic benets
only are considered and 3.3-5.7 to 1 when social
returns are also included (Figure 2).28
Low-income
countries
(N=6)
Lower
middle-income
countries
(N=10)
Upper
middle-income
countries
(N=10)
High-income
countries
(N=10)
4.2
3.3 3.8
5.7 5.4 5.3
3.9 4.0
for instance, the returns on investment in 10 out
of 15 interventions that prevent mental disorders
are greater than ve-to-one.24 In short, available
evidence strongly points to the cost-eectiveness of
scaling up mental health interventions in LMICs.
25
Box 1:
Scaling-up the care of depression
and anxiety: returns on investment
Using the estimated prevalence of depression
and anxiety in dierent regions of the world,26
a new analysis of treatment costs and outcomes
over the period of 2016-2030 has been carried out
for 36 low-, middle-, and high-income countries
that between them account for 80% of the global
burden of common mental disorders. A modest
improvement of 5% in both the ability to work
and productivity at work was factored in as a result
of treatment and was subsequently mapped to
the prevailing rates of labor participation and GDP
per worker in each of the 36 countries analyzed.27
The key outputs of the analysis were year-by-year
estimates of the total costs of treatment (the
investment), increased healthy life years gained as a
result of treatment (health return), enhanced levels
of productivity (economic return) and the intrinsic
value associated with better health. The stream
of costs incurred and benets obtained over the
period 2016-2030 were discounted at a rate of 3%,
to give a Net Present Value (NPV).
Results show that the investment needed to scale
up eective treatment coverage for common
mental disorders is substantial: The NPV of all
investments in the 36 large countries examined
over the period 2016-2030 amounts to US$141
billion, with US$91 billion going towards treatment
of depression and US$50 billion going toward
treatment of anxiety disorders.
Figure 2
Ratio of (economic and social) benet
to cost for scaled-up treatment
Depression
Anxiety
As well as the direct impact of interventions on
health, eective treatment also leads to increased
participation in the workforce, reduced rates of
absenteeism, and substantially improved
functioning while at work. Findings from a new
analysis indicate a favorable economic return
will follow from eorts
to scale-up services for
depression and anxiety (Box 1).
Making Mental Health a Global Development Priority
9
II. Dealing with common mental
disorders
Perhaps the single most important intervention
by a health care practitioner is encouraging
patient expectation of improvement with self-
care and support from family and social networks.
Self-care (paying careful attention to diet, exercise,
sleep, etc.) enables people living with mental
disorders to take the rst step at eective
management of their conditions. Because of this,
a shift towards acknowledging depression and
anxiety as legitimate health concerns, and not the
result of individual shortcomings, will pay almost
immediate dividends. In the majority of cases,
however, self-care will not be sucient for a full
or sustained recovery.
Treatment of moderate to severe conditions
The primary treatments for moderate to severe
depression and anxiety disorders are antidepressant
drugs and structured, time-limited psychological
treatments.
Psychological treatments
Numerous randomized trials support the
ecacy of depression-specic psychotherapies,
especially in the form of brief treatments based
on cognitive, behavioral, and inter-personal
mechanisms. Examples of these are cognitive
behavioral therapy, problem solving therapy,
behavioral activation, and interpersonal therapy
for mood and anxiety disorders.29 There appears
to be relatively small dierences between these
types of treatment; as a group, they were shown
to be consistently superior to unstructured
psychosocial support.30 These treatments share
many strategies in common; what’s more,
‘trans-diagnostic’ treatments (viz. those that are
designed to address mood, anxiety, and some
other disorders) have been shown to be scalable
and eective.31 There is also a growing body of
evidence demonstrating that non-specialist
workers in primary care and community
settings can deliver these treatments with great
eectiveness to a variety of populations.32
Drug therapies
There are several major groups of
antidepressants in common use today, including
tricyclic antidepressants, selective serotonin
reuptake inhibitors (SSRIs), and serotonin-
norepinephrine reuptake inhibitors (SNRIs).
Studies have found strong evidence for the
ecacy of antidepressant pharmacotherapy and
no evidence of an advantage for any specic
drug over another.33 Antidepressants generally,34
and SSRIs in particular,35 have well-documented
ecacy in the treatment of anxiety disorders and
other disorders related to depression.
Treatment of severe and refractory conditions
The combination of structured psychological
treatments with antidepressants enhances
the recovery rates in people with medication-
resistant depression. Patients with severe or
treatment-resistant depression and older patients
with depression have been shown to respond
to electroconvulsive therapy (ECT).36 This is,
however, typically the last line of treatment, as
it must be administered in specialized settings
because it requires the use of anesthesia and
muscle relaxants. One side eect of continued
ECT is memory loss; therefore, it is used as a
maintenance therapy only for those patients
who were unable to sustain improvements after
switching from ECT to available antidepressants.
OUT OF THE SHADOWS
10
III. Treatment settings and integration
Mental health system
Eective care of depression and anxiety requires a
comprehensive mental health system encompassing
governance, healthcare institutions, and community
settings. This involves building a multi-sectorial
consensus backed by strong political will to enact
holistic mental health plans. Mental health planners
and policy makers need to develop, through public
awareness and community engagement, care
delivery systems that are sensitive to local social,
economic, and cultural contexts; this will ensure
that services are appropriately sought out and
utilized. There is published evidence that national-
level health system reforms, such as those in Brazil,37
Chile,38 Italy,39 and the UK,40 have transformed the
lives of people with mental disorders, and there
is anecdotal evidence reporting similar eects in
places as varied as Afghanistan, Jamaica,41 India,42
and Peru.43
Integrated care for depression in primary,
maternal, and pediatric care
In addition to its impact on overall physical health,
depression can negatively aect management of
common co-occurring diseases, such as diabetes,
hypertension, cardiovascular disease, and cancer.
Collaborative care—an evidence-based approach
to care for chronic illness applied in primary care
settings—guides the eective use of resources
for delivery of quality mental health care. It
emphasizes systematic identication of patients,
self-care, and active care management by clinical
providers, blended with other medical, mental
health, and community supports. Collaborative
care emerges as an eective way to address co-
morbid conditions and commonly co-occurring
risk factors while improving overall health
outcomes.44 The approach has proven eective
in general population samples and vulnerable
sub-populations in high-income countries, and
increasingly in LMICs.45 Evidence from low-income
countries demonstrates the eectiveness of care
delivery by community or lay health workers,
STORIES FROM THE FIELD:
A 59-YEAR-OLD PAINTER AND FARMER
FROM INDIA
Recently I was bed-ridden due to kidney
stones. I lost almost a month’s salary due to
this problem. I was not able to go to our farm;
all the work in the eld was piled up. The pain
was so unbearable and I didn't feel like talking
to anyone. I was constantly getting disturbing
thoughts about my life, my children’s future,
and my family situation. I had no money and felt
embarrassed to ask for money from my kids.
After surgery to remove the kidney stones,
I met with a counselor during one of my visits to
the health center. He understood my situation
and explained to me that I needed to reduce
worrying. He visited me four times at home
and gave me a booklet about depression and
explained it to me. He also suggested I talk to
family members, watch television, and read
books. These things helped me to divert my bad
thoughts. With the support of the counselor and
my family members, I started doing household
work and then started going to work on the
farm as well.
working alongside primary care providers (e.g.
nurses, clinical ocers, doctors) in community
settings, in reducing symptoms of depression.46
Anxiety and depression also play large roles
in the health of expectant and new mothers
and their progeny: A 2007 review and meta-
analysis found that more than one-half (54%) of
pregnant women suered from symptoms of
anxiety and more than one-third (37%) suered
from symptoms of depression.47 Antenatal
depression has been shown to increase the
likelihood of preterm birth, low birth weight, and
Making Mental Health a Global Development Priority
11
cognitive disturbances.48 In addition, 10-15% of
new mothers suer from perinatal depression.
Substantial investments in maternal and
newborn health render maternal care settings
a viable and desirable platform for delivery
of depression care, where early and eective
intervention for maternal depression can be
implemented. Studies in both low- and high-
income countries have shown that antenatal
and postnatal interventions are eective in
reducing depressive symptoms and improving
infant outcomes.49
Depression and anxiety disorders also have a
negative eect on the ability of students to learn
and study. This has been shown to be true for
children in elementary school50 all the way up
to young adults in college.51 What’s more, 75%
of lifetime mental disorders have rst onset by
ages 18-24.52 Integrating mental health treatment
into standard pediatric and adolescent health
care would not only improve students’ learning
outcomes, it would also present an opportunity
to establish a treatment regimen that could allow
children and young adults to get what could be a
lifelong aiction under control.
HIV care services
The frequent co-occurrence of depression with
HIV infection warrants integrated approaches
to management of both disorders.53 Depression
is associated with poor adherence to HIV care,
as well as greater morbidity and mortality
due to HIV-related disease.54 On the ip side,
psychological and psychotropic interventions
for depression have shown to be eective for
people with HIV. What’s more, non-specialists
with adequate support can deliver eective
psychological interventions in low-resource
contexts, as demonstrated in Zimbabwe
and Uganda.55
Information and communications technology
(ICT)-based platforms
ICT oers alternative modes of mental health
care delivery when resources are scarce, while
also addressing long-standing obstacles in
mental health delivery, such as transportation
barriers, stigma associated with visiting mental
health clinics, clinician shortages, and high
costs.56 These platforms, especially mobile mental
health interventions, can oer remote screening,
diagnosis, monitoring, and treatment; remote
training for non-specialist healthcare workers;
and can be used to develop and deliver highly
specic, contextualized interventions.57 Cognitive
behavioral therapy has been successfully
implemented through information technology
platforms, demonstrating improvement in
depressive symptoms, reduced costs, patient
acceptance, and enhanced primary care
workow.58 In addition, patient participation
is rapidly expanding in peer-to-peer social
networks where patients can access around the
clock support with demonstrable improvements
in depression symptoms.59
Platforms outside the health sector
Anti-stigma campaigns
Stigma associated with mental disorders
can result in social isolation, low self-esteem,
and more limited chances in areas such as
employment, education and housing. It can also
hinder patients seeking help, thereby increasing
the treatment gap for mental disorders.60 What’s
more, stigma can result in a general reluctance
to invest resources in mental health care61 and
discrimination among medical professionals,
with negative consequences on the quality of
mental health services delivered.62 For all of these
reasons, anti-stigma campaigns can be powerful
tools in confronting mental disorders.
OUT OF THE SHADOWS
12
School-based interventions
Primary and secondary schools are well-
established platforms for community-based
health surveillance and health interventions
across virtually all clinical domains, including
infectious diseases, non-communicable diseases
and risk behaviors,63 and mental health.64 Key
strengths of school-based health screening
and care delivery include a decentralized
infrastructure that can be utilized to achieve high
coverage for school age children and adolescents.
Potential benets of school-based programs
include broad positive impact on healthy
development and resilience, improved academic
performance, and opportunities to integrate
school and clinic-based services.65 School-based
life skills programs have also been shown to
improve students’ learning outcomes and help
establish eective treatment regimens.66
Workplace interventions
There is a robust body of evidence showing that
investment in workplace wellness programs
is not only good for employees but also for
the bottom line of companies.67 In addition
to obesity and smoking cessation programs,
workplace interventions commonly focus on
stress management, nutrition, alcohol abuse, and
blood pressure, and on preventive care such as
the administration of the u vaccine.
Workplace mental health interventions focused
on individuals can be centered on either
treatment or mental health promotion such
as cognitive-behavioral approaches targeting
stress reduction.68 Organizational-level workplace
interventions can include policies that address
prevention and early intervention. There is
some evidence that an integrated approach
to workplace mental health, involving harm
prevention through reducing workplace risks,
mental health promotion, and treatment of
existing illness, provides the most comprehensive
management of mental health needs.69
Interventions related to conicts and
natural disasters
Conict exposes civilian populations and
refugees to violence and high levels of stress,70
resulting in dramatic rises in mental illness71 that
can continue for decades after armed conict has
ceased. Cambodians, for example, continue to
suer widespread mental illness and poor health
almost four decades after the Khmer Rouge-led
genocide of the late 1970s.72
Part of the rebuilding eorts in post-conict
and post-disaster societies, therefore, should
be on building out mental health services
that are well integrated into primary care and
public health eorts. A series of catastrophic
earthquakes in Japan, including the 1995
Hanshin-Awaji Earthquake, the 2006 Niigata
Chuetsu Earthquake, and the 2011 Great East
Japan Earthquake, has provided evidence that
mental health and psychosocial support can be
eectively integrated as part of humanitarian
response and disaster risk management.73
At present, sectoral projects funded by the World
Bank Group (WBG) and other organizations
utilize a bottom-up, multidisciplinary approach
to re-integrate displaced population groups after
conicts and natural disasters. Incorporating
treatment for mental illness into these existing
projects would help overcome barriers to
securing employment among the poor and
vulnerable. Further investment in education,
social protection, and employment training
would help prevent social exclusion an build
social resilience by serving the unique needs of
vulnerable groups.
Making Mental Health a Global Development Priority
13
IV. Resource gaps, funding options, and
proposals for the future
Resource gaps
Just because a given intervention represents good
value does not mean that there is money available
to fund it. In order to be relevant from a public
policy perspective, an intervention has to be both
cost-eective and aordable.
The annual cost of a scaled up, basic package of
cost-eective mental health care interventions
is estimated at US$2 per capita for low-income
countries; US$3–US$4 for lower-middle-income
countries; and US$7-US$9 for Latin America and
the Caribbean.74 For low- and lower-middle-
income countries, this corresponds, on average,
to between 10% and 14% of public expenditures
on health and between 4% and 6% of total health
expenditures; in Latin America and the Caribbean,
it translates to between 3% and 4% of public
expenditures on health and roughly 2% of total
health expenditures. A key reason why these
costs are low is the relatively low price of essential
psychotropic medications, many of which are now
o patent. As noted previously, current public
spending on mental disorders in LMICs is well
below what would be required to fund a cost-
eective package of interventions. The already
discussed health and welfare consequences of
mental disorders provide ample evidence as to
why governments and government resources
should play a major role in the funding of
mental health.75
Between 2007 and 2013, less than 1% of
international health aid went to mental health; as a
result, total spending on mental health—domestic
public spending plus external aid—came to only
US$0.25 per person in low-income countries and
to $US0.61 in lower-middle-income countries.76
This means that funding for mental health would
have to increase from ve to eight times its current
value in order to support a basic package of cost-
eective interventions in low-income countries.
Those gures allow us to estimate the magnitude
of the resource gap for mental health: US$1.6
billion for low-income countries and US$6.6–
US$9.3 billion for lower-middle-income
countries.77 Tackling this problem will require
ambitious and strategic nancing policies, which
will need to take into account not only how
resources are mobilized and pooled but also how
they are channeled, allocated, and implemented.78
Potential funding options
Create a dedicated pool of funding based on sin taxes
A potential source of dedicated funding may
come from the taxes raised from alcohol or other
addictive substances, such as tobacco, that are
disproportionately used by the mentally ill. Data
from the World Health Organization for the 77
countries from which information is available
indicate that the annual tax revenue from excise
taxes on alcohol could be substantial. Price and
tax measures on tobacco and alcohol can be an
eective and important means to reduce tobacco
consumption, alcohol abuse and health care costs,
and represent a revenue stream for nancing for
development in many countries.79 Besides the
potential health benets of this scal measure, it
could help broaden the tax base and generate
additional revenue to support budgetary capacity
to nance universal health coverage (UHC) and
mental health scale-up.
A potentially innovative nancing model could
combine the resource-pooling experience of
UNITAID, which receives resources from a small
tax on airfare tickets in nine countries, with some
combination of the strategies implemented by
Gavi: The Vaccine Alliance and The Global Fund to
Fight AIDS, Tuberculosis, and Malaria. These last
two funding sources allow for the channeling of
resources to a country’s health system, and have
introduced performance-based mechanisms
to generate incentives aimed at improving
OUT OF THE SHADOWS
14
implementation. Accordingly, a portion of the
revenues generated from specic sources, such as
alcohol taxes, could be pooled into a fund aimed
at nancing context-specic packages of cost-
eective mental health interventions channeled to
primary or community care services. This nancing
instrument could potentially adopt multi-
stakeholder participation for resource allocation
and performance-based incentives to improve
service delivery.
Resources from mineral wealth
Many developing countries are rich in mineral
resources. Unfortunately, those resources are not
typically used to promote equitable growth and
social development. The experiences from countries
like Botswana, Chile, and Malaysia demonstrate
that the combination of sound economic policies,
strong institutions, and a commitment to social
development can reduce poverty and build human
capital. A similar approach could be used in other
developing countries to nance UHC and mental
health programs.
It should be stressed, however, that while innovative
nancing mechanisms may contribute to the
promotion of mental health and interventions in
the short term, they are not a substitute for the
role of governments and development assistance.
Consistent with the Financing for Development
Action Document that was adopted at the
Third International Conference on Financing for
Development in Addis Ababa in July 2015, and
endorsed at as part of the United Nation’s recent
Sustainable Development Goals initiative, it
should be recognized that for all countries, public
policies and the mobilization and eective use of
domestic resources are central to the common
pursuit of sustainable development. Building on the
considerable achievements in many countries since
the adoption of the Monterrey Consensus in 2002
and the Doha Declaration in 2008, countries need
to strengthen the mobilization and eective use of
domestic resources.
Scaling up mental health coverage
The challenge to nancing mental health lies in
the fact that interventions should not be seen
as being isolated from one another; rather, they
should be incorporated into dierent delivery
platforms, such as primary care and community
health.80 This means that if these platforms do not
function well, or are not appropriately structured
and funded, mental health interventions will
also be ineective. In the long term, earmarking
or creating funding mechanisms dedicated
exclusively to funding mental health interventions
without also ensuring other aspects of patient
care and health coverage are unlikely to be
successful. In the short term, however, dedicated
sources of nancing are necessary to break the
cycle of neglect that aects mental health policies
and programs, alongside eorts to improve
service delivery, platforms, and quality of care.
The emergence in recent years of a strong Global
Mental Health movement provides a base of
evidence-based knowledge and capacity to
promote and support these eorts, but funding is
needed to expand its reach in LMICs where mental
health capacities have been chronically limited.81
Include mental health in universal health
coverage packages
Mechanisms used to prioritize interventions for
nancing and payment within UHC policies, such
as national health benets plans or essential
medicines lists, are an opportunity to focus LMICs’
domestic public spending on cost-eective
mental health interventions, and to structure
development donor support in this direction.
Including the treatment of common mental
disorders within primary care has been one of the
most accessible means of achieving progress, and
can be reected in UHC benets plans. (Successful
eorts in Chile, Colombia, Cuba, and Ghana
provide lessons on how to integrate, scale up,
and sustain service provision.) This is particularly
important as some countries are explicitly
Making Mental Health a Global Development Priority
excluding some mental health conditions from
their plans. The UHC package is the opportunity to
bring policy and funding together.
Build on results-based funding initiatives
Results-based funding between donors and
health systems in developing countries may oer
innovative ways to fund mental health programs
and pay providers within health systems, existing
as an alternative and complement to traditional
development assistance for global health.
There are a number of ways this could occur:
For example, natural synergies exist between
mental health and other non-communicable
diseases, and there is a growing awareness of
the importance of mental health in the elds of
maternal and child health. Cooperation across
sectors also provides an opportunity for funders,
including multilateral nance institutions such
as WBG; regional development banks such as
the Inter-American Development Bank, the
Asian Development Bank, and the African
Development Bank; regional bodies such as the
European Commission; bilateral agencies such as
the Department for International Development,
the Japan International Cooperation Agency,
and the United States Agency for International
Development; and philanthropies such as the
Bill & Melinda Gates Foundation, Bloomberg
Philanthropies, the Nippon Foundation, and the
Rockefeller Foundation, to use existing service
platforms to support the scaling up of mental
health treatment and care. For example, a bilateral
donor or philanthropy could contribute to the
WBG’s Global Financing Facility’s support of Every
Woman Every Child with funding earmarked
for mental health prevention and treatment.
Investment in other areas, including education,
social protection, and labor and employment,
could also be utilized to respond to the unique
needs of vulnerable groups. Multi-sector packages
of services used for the reintegration of displaced
populations in post-conict and post-disaster
societies could help mainstream mental health
services. Another opportunity for scaling up
global mental health in the near future could be
found in social impact bonds and development
impact bonds, which would provide upfront
funding from private investors who would earn a
return if evidence showed that programs achieve
pre-agreed outcomes.82
15
OUT OF THE SHADOWS
16
Key Policy Actions
• Mental health matters: Visibly increase the attention given to mental
disorders at the national and international levels (including migration
and humanitarian aid; social inclusion and poverty reduction; and
human rights protection and universal health coverage). Strong
leadership is needed to make mental health a priority, to commit to
innovative and quality services, to channel resources toward mental
health systems, and to strengthen community services.
• Mental health works: Introduce or strengthen programs that promote
and protect mental well-being into general health services (integrated
care), school curricula (life skills), and occupational health schemes
(wellness at work); and promote better coordination across these
platforms and sectors.
• Mental health needs: Devote additional resources from development
assistance donors and domestic health budgets towards implementing
community-based mental-health programs and strengthening the
overall treatment of mental disorders as part of the progressive
realization of universal health coverage.
Making Mental Health a Global Development Priority
17
Endnotes
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71 Bolton, P., et al. (2002): “Prevalence of depression in rural
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72 Mollica, R.F., et al. (2014) “The enduring mental health
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73 Kim, I. (2015). “Beyond Trauma: Post-resettlement Factors and
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76 Gilbert, B.J., et al. (2015).
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79 See, for instance, the Philippines’ 2015 report on its sin tax
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80 Patel, V., et al. (2015).
81 “Global Mental Health 2011,” The Lancet, October 18, 2011.
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82 Center for Global Development and Social Finance (2013).
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21
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