Mental health policies in Commonwealth countries
Authors: Dinesh Bhugra, Soumitra Pathare, Rajlaxmi Joshi, Antonio Ventriglio
Journal: World Psychiatry (2018)

The large global burden of mental health conditions1 has led to an increased emphasis on improving access to mental health services in countries across the world. There is clear recognition that improving mental health governance is key to improving access to and quality of mental health services, and the existence of a mental health policy is an important component of improving mental health governance2. The World Health Organization (WHO)'s Mental Health Atlas 2014 found that 68% of countries had a mental health policy3, while the WHO Mental Health Action Plan 2013-2020 set a target that 80% of countries should have developed or updated their mental health policies/plans in line with international and regional human rights instruments by 20202. The Commonwealth is a voluntary association of 52 independent and sovereign states part of the erstwhile British Empire which, in spite of their geographical variations, generally have similar political, legal and governance systems. We reviewed the mental health policies of Commonwealth countries in order to compare them to standards developed by the WHO and to assess their compliance with international recommendations. We identified and downloaded mental health policies of Commonwealth countries from WHO MINDbank4. If a mental health policy was not found there, we extended our search to official government websites of countries. In the case of federal countries such as Canada and Australia, we relied on a federal mental health policy and, if this was absent, we used the most recent mental health policy from any of the provinces or, if there were two policies from the same year, the mental health policy from the province with the larger population. We used WHO's Mental Health Policy checklist5 to assess compliance of country mental health policies with international recommendations. Eleven countries (21.1%) did not have a mental health policy. We were unable to find a mental health policy in 16 (30.8%) additional countries, although we found references in various documents to such a policy. We found a mental health policy in 25 countries (48.1%), of which Naaru and Zambia had a “final draft” policy and Uganda and St. Lucia had a draft policy. Of the countries with a mental health policy, only seven (28.0%) had adopted it after 2011. In only two (8.0%), the policies contained an explicit reference to country data and research informing policy development. While 15 policies (60.0%) indicated how funding would be used for financing mental health services, only four (16.0%) had a clear statement on providing equitable funding between mental and physical health, and only five (20.0%) explicitly stated that mental health should be included in health insurance. Seventeen policies (68.0%) promoted human rights, while only 14 (56.0%) specifically mentioned developing human rights oriented mental health legislation. Only one policy (4.0%) had detailed intersectoral collaboration outlined, while four (16.0%) had it to some extent. Fourteen policies (56.0%) included a process to measure and improve the quality of mental health services. Only three policies (12.0%) either significantly or to some extent made a commitment to putting in place suitable working conditions for mental health providers. Twenty-one policies (84.0%) did, however, recognize that training in core competencies and skills was important for human resource development. Fourteen policies (56.0%) promoted integration of mental health services into general health services, but only 11 policies (44.0%) promoted deinstitutionalization. Nearly half of the policies had provisions for promotion of mental health, prevention of mental disorders and rehabilitation of persons with mental illness. Only half of the policies emphasized the need for research and evaluation of services and assessment of the policy and strategic plan. Thus, while the WHO reported that 68% of countries globally had a mental health policy, we were only able to find such a policy in 48% of Commonwealth countries. Most (72%) of the Commonwealth mental health policies were adopted prior to 2011. Thus, these countries were behind the global average of 47% of countries having adopted a mental health policy after 20103. There are many possible reasons for these findings, including failure of mental health sector to advocate effectively, lack of technical skills in mental health policy development, and limited political interest due to stigma and discrimination. Financing of mental health remains a concern. Although 60% of policies recognized the role of funding in equitable mental health services, only a tiny minority explicitly addressed equitable funding between services for mental and physical health. We know anecdotally that in many countries health insurance from private (and at times also public) insurance providers excludes treatment of mental illness. It is a matter of serious concern that policies in only a fifth of the countries have a commitment to including mental health in general health insurance. As we said, the WHO Mental Health Action Plan sets a global target for 80% of countries to develop or update their mental health legislation in line with international human rights instruments by 20202. Although half of the Commonwealth country policies identify the development of new mental health legislation as a key policy action, the reality lies in actual delivery and whether countries which have new legislation as a key policy action do succeed in delivering equity. It is now well accepted that addressing mental health problems requires intervention across many different sectors including health, social welfare, education, justice, employment to name just a few. It is therefore surprising to note the near total absence of any emphasis on intersectoral collaboration in these policies in Commonwealth countries. We were also concerned to note that only half of the policies promoted integration of mental health with physical health services, deinstitutionalization, promotion of mental health, prevention of mental disorders and rehabilitation. The lack of emphasis on improving quality of mental health services in the policies of half of the countries is equally disconcerting, because it allows poor quality services to continue without change and perpetuates poor outcomes. Only half of the policies mentioned the need for research and evaluation of policies and services, indicating a general lack of interest in an important component of future policy development. The absence of systematic evaluation of existing policies may result in ineffective services continuing to be offered and consequent failure to achieve policy goals. In conclusion, our findings indicate that there is still some way to go in bringing about equity between physical and mental health care but also equity between Commonwealth countries. The informal links between these countries indicate the strength of the relationship and perhaps high-income countries need to consider mentoring and supporting low-income countries to ensure that mental health policies are developed appropriately in order to deliver best care which our patients need, deserve and will utilize. Dinesh Bhugra1, Soumitra Pathare2, Rajlaxmi Joshi2, Antonio Ventriglio3 1Institute of Psychiatry, King's College London, London, UK; 2Centre for Mental Health Law and Policy, Indian Law Society, Pune, Maharashtra, India; 3University of Foggia, Foggia, Italy The study was funded by the WPA while D. Bhugra was the President.