How to convince politicians that mental health is a priority
Authors: Rachel Jenkins
Journal: World Psychiatry (2013)

Politicians, especially ministers of health, are crucial to drive national policy and strategy, because they can bring political will to bear on decision making, speed up decision making, and steer decisions in a specific direction. Therefore it is important to persuade politicians that mental health should be a priority. One of the most helpful things a minister of health can do to make mental health a real priority is to ensure that mental health is well integrated into the national health sector strategic plan at each level (community, primary care, district, provincial and national). This will make it much more likely that community based and primary care health staff will see mental health as an integral part of their work, that district staff will see mental health as an essential part of their support responsibilities to primary care alongside other health priorities, and that provincial level staff will see it as a priority to support the districts within each province to deliver local mental health services. Similarly, it is helpful for the minister to facilitate liaison between health and other relevant sectors (e.g., education, social welfare, criminal justice), so that mental health is appropriately integrated with each of their strategic plans 1, 2. Within the health sector itself, it is likely to be better for population health outcomes to focus on integrating mental health into the general health system rather than seeking a parallel vertical funding and delivery system 3, in the light of growing evidence that other well-funded vertical programmes for communicable diseases have often weakened health systems' capacity to address broader health needs 4. Politicians are not necessarily health professionals, let alone mental health professionals, and do not have detailed knowledge of mental health issues. They frequently only last a few months to a year or two in one specific ministerial post; at best around three years. There may be tensions between different stakeholders, and careful background dialogue is helpful so that the main stakeholders carry a concerted message. Politicians usually want to see progress; and they want to have ownership, particularly things they can announce to the public for which they can take political credit. Therefore, it is helpful to establish a steady stream of developments that politicians can announce and take credit for. This is often a good way of briefing politicians, as they will need their speeches to be drafted and these can be used to set out the arguments for priority status. The general arguments used to try and persuade politicians are that mental illness is common, disabling, accompanied by significant physical illness and mortality 5-8, that effective interventions are available, and that it is important to address the human rights of people with mental illness. If these arguments were enough to persuade politicians, mental health would have long been a major priority in all countries, as the evidence has been available for several decades 9. Therefore mental illness also needs to be placed in the context of critical concerns for politicians, which include overall improvement of national economic productivity; achievement of economic, health, education, social and environmental targets, including those set in the Millennium Development Goals; and the issues that trouble their constituents, families and friends. Politicians are concerned with the whole functioning of government: not just health, but also the other sectors of the economy, employment, education, social welfare, housing, criminal justice, as well as defence. Within the health system itself, the politicians are concerned with the overall structure and financing of the general health system, and the way in which it may deliver improved health outcomes for child health, reproductive health, and communicable as well as non-communicable diseases. It therefore helps to place the arguments within the political context in which the politician is functioning, so he/she can see how mental health matters to his/her other political concerns, and how it will assist achievement of the goals of other health targets and non-health sector goals. The politicians are influenced by government economists and external economic advisors. There are also government information technology experts who influence the data which is collected by governments, and this data collection influences the information available to governments on which decisions may be based. It is often particularly difficult to establish appropriate mental health data collection at community and primary care levels in low- and middle-income countries 10, resulting in a dearth of information for planning purposes. Politicians are, of course, also operating within the context of daily bombardment by the media about current topics of concern, and sometimes by daily advice from close political advisors about the likely electoral impact of any decision. Politicians may make the crucial decisions, but their implementation is undertaken by civil servants and professionals in the relevant sectors, who also need to be persuaded of the need to make mental health a priority, if implementation is to proceed successfully with serious impact. Political life spans are generally too short to rely on the support of a politician without also engaging the support of his/her civil servants. It is helpful for politicians to be briefed about the wider picture of mental health in their country, if they are to consider it a priority. Therefore, some understanding is required of the broad concepts of positive mental health, mental illness, disability, premature physical mortality, and suicide; of the different broad categories of illness and how common they are; of risk and protective factors; of impact on other illnesses; of wider impact on education, employment, productivity of individuals and countries; of the levels of health care relevant to mental health including household and community, primary care, secondary care, and tertiary care; and of the intersectoral aspects of mental health, including education, social welfare, employment and criminal justice. Without such a multilevel multisectoral understanding, political solutions to meeting population needs for mental health are likely to be insufficient. Politicians can be found and influenced in a variety of places, such as within their ministry, at public events, when invited to a health care setting, in dialogue in the media, at social gatherings and chance encounters. The core principles for oral encounters in each setting are similar, namely to be brief, unambiguous, balanced, memorable and clearly related to context. The length of the conversation will have to be tailored to the setting and situation, and any oral briefing needs to be accompanied by a written note. It is not always clear how long one will have with the minister, so it is often best to start with a summary and then expand further if time permits. It is helpful to link the briefing to current media and political concerns, to the special interests and concerns of the minister, to overall government strategy, and to overall resource availability. Crises should be used as an opportunity, not just to solve the immediate problems, but also to promote the long-term agenda for mental health, to explain complex issues, and to instigate the next research steps. As well as oral briefings and written briefings by a single person or organization to a single politician, there can also be major cross-government commissioned reviews which influence politicians. For example, the Foresight Report on Mental Capital and Wellbeing commissioned by the UK Government Chief Scientist in 2006, reported to the whole of government in 2008 11, directly encouraged action across government departments since then 12, and the US Institute of Medicine Report on Neurological, Psychiatric and Developmental Disorders 13 resulted in increased prioritization and research investment in mental health by major international donors. The final point, but perhaps the most important, is never to give up. Progress inevitably tends to ebb and flow, but as long as the dialogue with and pressure on politicians is maintained, overall progress over ten to twenty year time spans is generally significant. Too many psychiatrists become discouraged when politicians change post, instead of seeing each new incumbent as a new opportunity. The briefing given to the previous one about the conceptual framework and importance of mental health will never be wasted, as it will have relevance whatever the future post held, so that mental health can be considered in all policy making.