Soma&Psy interviews Michelle Funk, coordinator of Mental Health Policy and Service Development, Human Rights and Legislation at the World Health Organization (WHO) about the WHO and their recommendations on mental health policies.

What influence does the World Health Organization have on national agendas about mental health and what are its recommendations?

WHO is a specialised health agency and the major authoritative source of information concerning mental health in countries worldwide. WHO’s policies and recommendations are important in setting national agendas around mental health. Its key recommendations are laid out in the comprehensive mental health action plan 2013–2020, recently adopted on May 27, 2013 by the World Health Assembly.

The action plan identifies key actions for countries, national and international organizations, and the WHO Secretariat, in order to meet four key objectives:

  • “To strengthen effective leadership and governance for mental health,” for example by putting in place policies, strategies, and laws that are in line with international human rights standards;
  • “Provide comprehensive, integrated and responsive mental health and social care services in community-based settings”, that promote recovery and human rights
  • “Implement strategies for promotion and prevention in mental health,” for example by developing and implementing suicide prevention strategies;
  • “Strengthen information systems, evidence and research for mental health”[1]

 

How much of a priority is mental health in developing countries?

In much of the developing world, mental health is not given the attention it needs. Millions of people worldwide are affected by mental health conditions, and one in four people around the world will be affected by these conditions at some point in their lives. Globally, mental health conditions account for 13% of the total burden of disease, and 31% of all years lived with disability.

Despite the prevalence and negative impact of mental health conditions on people’s lives, countries all around the world do not adequately invest in the area of mental health. For instance, 30% of countries do not have a specified budget for mental health and in Africa, 70% of countries spend less than 1% of their health budget on mental health.

Mental health has not been prioritized partly due to the massive stigma associated with persons with mental health conditions and the misconceptions around mental health, including the belief that no effective care or treatments exist for these conditions. In addition competing priorities of important infectious diseases, such as HIV/AIDS and malaria, have also altered the landscape for investment in mental health.

 

What challenges or barriers exist for integrating mental health into health and social care systems?

In many low- and middle-income countries, stand-alone psychiatric hospitals, which are often associated with poor quality care and human rights violations, are the predominant means of delivering mental health services. WHO recommends that these services be replaced with a network of mental health and social care services within the community.  However, many countries are finding it extremely challenging to develop the necessary health and social care services that promote mental health and to close down the stand-alone psychiatric hospitals.

Some barriers and challenges to integrating mental health include:

  • Lack of investment of both financial and human resources
  • Overcoming the belief that mental health conditions are solely a medical issue requiring care in specialist settings
  • Lack of training among professionals working in the health and social care sector in how to identify and support people with psychosocial disabilities.
  • Stigmatising attitudes by professionals working in health and social sectors towards people with mental health conditions and a lack of knowledge and skills about human rights and  how to work collaboratively with service users to develop treatment and recovery plans.
  • Lack of understanding among key policymakers, planners, and providers that effective solutions to mental health conditions require multi-sectoral approaches involving not only the health sector, but also housing, education, employment and income generation, and social support
  • Overall weak national health care and social care systems

 

How can communication technologies (ICT) help integrated mental health?

A number of communication technologies (ICT) and other types of innovation have been integrated and developed to allow greater access to a wide range of mental health programs. Many technological features exist with the aim of helping providers diagnose mental health conditions, expand and improve mental health care, assist individuals with self-care, train health care workers, promote therapeutic interventions, and manage symptoms, among other areas. Technologies have ranged from chat and SMS features, to videoconferencing, the use of mobile phone and email applications, online forums, self-help programs, and websites.[2]

Early evaluations show promising results, however more research needs to be directed towards assessing the delivery of mental health services and supports through communication technologies. Programs also need to be evaluated and studied in different settings, with different populations, and for different mental health conditions, to measure both short-term and long-term impacts of ICT.

 

What can we do to fight human rights violations, discrimination and the stigma attached to mental health conditions?

  1. Change attitudes and raise awareness. Different stakeholders, such as Ministries of Health, persons with mental health conditions and family groups, health professionals, NGOs, should unify their efforts in educating and changing public attitudes towards mental health and in advocating for the rights of people with mental health conditions.
  2. Improve human rights in mental health facilities. Mechanisms to monitor human rights conditions should be established to protect against inhuman and degrading treatment and poor living conditions and to promote quality of care and human rights in inpatient and outpatient facilities. People should also have access to complaints mechanisms in cases of human rights violations.
  3. Empower people with mental health conditions and families. Governments should support the creation and/or strengthening of organizations of people with mental health conditions. Such groups are in the best position to highlight problems, specify their needs, and help find solutions to improving mental health in countries and have a crucial role to play in the design and implementation of policies, plans, laws and services.
  4. Replace psychiatric institutions with community care. Large institutions, which are so often associated with human rights violations, should be replaced by community mental health services, backed by psychiatric beds in general hospital and home care support. In addition people should have access to educational and employment opportunities as well as social support services including housing.
  5. Increase investment in mental health. Governments need to dedicate more of their health budget to mental health. In addition the mental health workforce needs to be developed and trained to ensure that all people have access to good quality mental health services which promote human rights, at each level of the health care system.
  6. Adopt policies, laws and services that promote human rights. Countries, with the participation and involvement of people with mental health conditions and other key stakeholders, should put in place mental health policies, laws and services that promote the rights of people with mental health conditions, empower them to make choices about their lives, provide them with legal protections, and ensure their full integration and participation into the community.
  7. Ratify and implement the UN Convention on the Rights of Persons with Disabilities (CRPD).  The Convention sets out key provisions critical to ending violations and promoting and protecting the rights of people with disabilities including people with mental health conditions.  Its coming into force marks a major milestone in establishing legal obligations on governments to ensure the full and equal enjoyment of all human rights for persons with disabilities.

 

Many groups around the world are talking about the WHO QualityRights Project. Could you tell us a little bit more about the project?

WHO launched the WHO QualityRights project in 2012. As a part of this project, WHO works with countries to assess and improve the quality of care and human rights conditions in mental health and social facilities and aims to empower people with psychosocial disabilities and their families to advocate for human rights. In addition, WHO developed the WHO QualityRights Toolkit which establishes the key standards that need to be met in all inpatient and outpatient services for people with psychosocial disabilities, under the framework of the Convention on the Rights of Persons with Disabilities.

The specific objectives of QualityRights are to:

  1. improve service quality and human rights conditions in inpatient and outpatient services and facilities;
  2. promote human rights, recovery and independent living in the community for children and adults with psychosocial disabilities;
  3. develop and strengthen organizations of people with mental health conditions, as well as peer and family support groups, in order to enable them to provide mutual support, conduct advocacy and influence decision-making processes on issues affecting them;
  4. reform national policies and legislation in line with international human rights standards, in particular the UN Convention on the Rights of Persons with Disabilities.

 

WHO QualityRights has already achieved results in countries. In Somaliland, in Northern Somalia, an assessment of Hargesia Hospital led to the establishment of specific measures to address poor standards of care, living conditions, understaffed facilities, and community integration. Assessments in a number of inpatient and outpatient facilities in Asturias, Spain, led to the development of a mental health strategic plan to improve services as well as a “bill of rights” for people with psychosocial disabilities. In Brazil and Greece, QualityRights assessments of facilities also led to the identification of gaps needing to be addressed in order to improve the quality of care and human rights conditions.

 

In India, the QualityRights project was launched in July 2014 by the Ministry of Health and Family Welfare of Gujarat. Activities are focused on assessment of quality of care and human rights conditions in facilities throughout Gujarat, and on developing an individualized improvement plan for each facility. Additionally wide-scale capacity-building (on the rights of people with psychosocial disabilities, quality care issues and on recovery) is being undertaken for health-care staff, service users and families. As part of the project, peer support groups for service users and families are being established throughout Gujarat as well.


 

[1]WHO. Draft comprehensive mental health action plan 2013–2020. May 16, 2013. http://apps.who.int/gb/ebwha/pdf_files/WHA66/A66_R8-en.pdf?ua=1.

[2] Boydell KM, Hodgins M, Pignatiello A, Teshima J, Edwards H, Willis D. Using Technology to Deliver Mental Health Services to Children and Youth: A Scoping Review. Journal of the Canadian Academy of Child and Adolescent Psychiatry. 2014;23(2):87-99.