The WHO Special Initiative for Mental Health (2019-2023): Universal Health Coverage for Mental Health The WHO Special Initiative for Mental Health (2019-2023): Universal Health Coverage for Mental Health THEORY OF CHANGE THE PROBLEM : • There can be no health or sustainable development without mental health • Depression and anxiety disorders cost the global economy US$1 trillion per year • 800 000/year deaths from suicide, which is a leading cause of death in young people • Mental health conditions cause 1 in 5 years lived with disability • Common among people affected by communicable (e.g. HIV and TB) and non communicable diseases (e.g. cancer and cardiovascular disease) • Treatment coverage is extremely low • Especially common in populations affected by humanitarian crises and other forms of adversity (e.g. sexual violence) • People with mental health conditions often experience severe human rights violations, discrimination, stigma • Lack of sustained financing for services at scale • Effective evidence-based care is available but provision of services is lacking STRATEGIC ACTION 1: Advancing mental health policy, advocacy and human rights STRATEGIC ACTION 2: Scaling up interventions and services across community-based, general health and specialist settings GOAL: By 2023 universal health coverage (UHC) ensures access to quality and affordable care for mental health conditions in 12 priority countries to 100 million more people Contributes to WHOs GPW13 Triple Billion Targets to achieve: 1 billion more people benefiting from UHC 1 billion more people supported during emergencies 1 billion more people enjoying better health and well-being In partnership with WHO Member States and local, international and global implementing partners (e.g. UN, NGOs, user groups, professional associations) VISION: All people achieve the highest standard of mental health and well-being SPECIAL INITIATIVE TARGET: By 2023, access to mental health care for 100 million more people WHO GPW13 TARGET 1: Coverage of severe mental health conditions increased to 50% WHO GPW13 TARGET 2: Reduced suicide mortality by 15% SDG Target 3.4 when, by 2030, there is a one third reduction of premature mortality from NCDs through prevention, treatment and promotion of mental health and well-being SDG Target 3.5 to strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol “The world is accepting the concept of universal health coverage. Mental health must be an integral part of UHC. Nobody should be denied access to mental health care because she or he is poor or lives in a remote place.” Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization Mental health conditions contribute to poor health outcomes, premature death, human rights violations, and global and national economic loss. The WHO Director-General, Dr Tedros Adhanom Ghebreyesus, has identified mental health for accelerated implementation of the 13th General Programme of Work (GPW13), covering 2019-2023. The time to act is now to empower communities and individuals to attain the highest standard of health, which can only be achieved when their mental health and well-being is ensured, and their rights respected. The vision of the WHO Special Initative for Mental Health is that all people achieve the highest standard of mental health and well-being. To implement the WHO Special Initiative for Mental Health over 5 years, WHO aims to raise US$ 60 million. Anchored by a clear goal, the initiative seeks to ensure universal health coverage involving access to quality and affordable care for mental health conditions in 12 priority countries to 100 million more people. The WHO Special Initiative for Mental Health will advance mental health policies, advocacy and human rights, and scale up quality interventions and services for individuals with mental health conditions, including substance use and neurological disorders. For continued scale up and global learning, WHO will implement this work in 12 priority countries, working in partnership with Member States, local, and international partners, as well as organizations of people with lived experience. This WHO Special Initiative for Mental Health is summarized in Figure 1, which demonstrates how the programme will contribute towards the wider goals of the GPW13 and the Sustainable Development Goals (SDGs). Figure 1. The WHO Special Initiative for Mental Health Theory of Change Why a WHO Special Initiative for Mental Health? Health is a state of complete physical, mental, and social well- being, and not merely the absence of disease or infirmity1. However, mental health remains a neglected part of global efforts to improve health. People with mental health conditions experience widespread human rights violations, discrimination and stigma. More than 80% of people experiencing mental health conditions, including individuals experiencing neurological and substance use disorders, are without any form of quality, affordable mental health care. This is despite mental health conditions accounting for 1 in 5 years lived with disability globally, leading to more than US$ 1 trillion per year in economic losses. It is well known that people living with mental health conditions are more likely to face other physical health problems (e.g. HIV, TB, noncommunicable diseases), causing early mortality of 10-20 years. Suicide mortality is high (close to 800 000 deaths per year), disproportionately affecting young people and elderly women in low- and middle-income countries. Mental health conditions are especially common for people affected by humanitarian crises and other forms of adversity (e.g. sexual violence). To date, mental health care has had many advocates but there has been limited commitment and funding for sustained implementation and scale-up of services. For WHO to realise its 2019-2023 mission to Promote health, keep the world safe, serve the vulnerable, mental health has been flagged as a priority area for accelerated implementation. Such implementation will benefit from the many resources WHO has recently developed, including: evidence-based guidelines, technical packages of interventions, rights-based frameworks, implementation guidance and training resources. WHO staff have extensive field experience, informing what works for supporting quality and affordable mental health care, and what is needed for scaling up services. 1 Constitution of the World Health Organization. WHO, Geneva, 1948. 2 Mental Health Action Plan 2013-2020. WHO, Geneva, 2013. http://www.who.int/iris/handle/10665/89966 3 The Lancet Commission on Global Mental Health and Sustainable Development. Lancet, 2018, 392: 1553–1598. 4 This WHO Special Initiative will also contribute to WHO’s GPW13 targets 1, 4, 5, 6, 10, 16, 17, 19, 20, 21, 23, 35, 36, 39, and 41, covering a wide range of health priorities. What will the WHO Special Initiative for Mental Health do? Embedded in the GPW13 and contributing towards the SDGs, the WHO Special Initiative for Mental Health will work towards a vision where all people achieve the highest standard of mental health and well-being; and aligns with the global WHO Mental Health Action Plan 2013- 20202. The Goal of the WHO Special Initiative for Mental Health also corresponds with recommendations of the recently published Lancet Commission on Global Mental Health and Sustainable Development3. It centres on scaling-up mental health care as part of universal health coverage, leaving no one behind. By 2023, the WHO Special Initiative for Mental Health will support access to quality and affordable community- based mental health care for 100 million more people. In reaching the programme goal, WHO will contribute to (a) two GPW13 targets, coverage of severe mental health conditions increased to 50% and reduced suicide mortality by 15%4; and (b) two SDG indicators, suicide mortality (3.4.2) and treatment coverage for substance use disorders (3.5.1). Two strategic actions will be implemented, each with different expected outputs, shown in the table. Universal health coverage (UHC) means that all people receive quality health services that meet their needs, without exposing them to financial hardship in paying for them. Quality mental health care refers to care that is safe, effective, timely, efficient, equitable and people-centred. This includes ensuring interventions and services are evidence- based and respect human rights. STRATEGIC ACTION 1: ADVANCING MENTAL HEALTH POLICIES, ADVOCACY AND HUMAN RIGHTS STRATEGIC ACTION 2: SCALING UP INTERVENTIONS AND SERVICES ACROSS COMMUNITY-BASED, GENERAL HEALTH AND SPECIALIST SETTINGS 1. Globally, mental health is positioned high on the development and humanitarian agendas 2. Local champions, people who use mental health services, and their organizations are empowered to participate in the development and implementation of mental health policies, strategies, laws and services 3. Mental health policies, strategies and laws are developed and operationalized based on international human rights standards 4. Media and community awareness about the importance of mental health across the life course is raised 5. Human and financial resources for mental health are brought in line with the needs 1. Quality, affordable mental health care is scaled up across health and social services 2. Quality, affordable mental health care is integrated in relevant programmes (e.g. for HIV, gender-based violence, disabilities) 3. Mental health and psychosocial support is included for preparedness, response and recovery in emergencies 4. Priority interventions for groups in positions of vulnerability (e.g. women, children, youth, older people, staff) are developed and implemented 5. Implementation is documented, monitored and evaluated to improve services Mental health conditions include mental, neurological and substance use disorders, suicide risk and associated psychosocial, cognitive and intellectual disabilities. How will the WHO Special Initiative for Mental Health be implemented? The WHO Special Initiative for Mental Health will scale up these key strategic actions in 12 priority countries. With support from WHO, each country will assess the current situation for mental health care needs across the life course, and design approaches for context- specific implementation. There is a need for this type of special initiative in all or almost all countries of the world. In the selection of the 12 countries, precedence will be given to the many Member States who prioritized the GPW13 target “increased coverage of mental health conditions” during WHO’s 2018 country prioritization exercise.5 These will include countries with large, medium and small size populations with the aim of achieving access to quality, affordable mental health care of 100 million more people across the 12 countries. At least four of the countries will have so-called fragile, conflict, or vulnerable (FCV) settings, where mental health issues are among the humanitarian concerns. WHO country-by-country approach to the WHO Special Initiative for Mental Health The status of mental health care varies widely from country to country. Many countries already have policies to deliver services for mental health conditions in primary care settings but require system strengthening to achieve integration. Many countries deliver care mainly in institutional settings and need dedicated advocacy and support in phasing out long-stay institutions and developing community-based alternatives. Some countries may require support for policy development or to implement mental health reform efforts. By taking a country-by-country approach, WHO can help formulate a tailored approach for each priority country, building on existing strengths and needs. A key advantage to a country by-country approach is sustainability. Over recent decades, there has been a focus on small mental health initiatives that have had only short-term funding. This limits impact and has not paved the way for sustainable scale up to reach whole populations. Further, it has led to ad-hoc learning about the facilitators and barriers to scaling up effective interventions or strengthening systems to embed mental health care. By focusing on countries (or large regions within countries) and supporting them consistently for up to five years, WHO can glean systematic learnings to inform scale up in additional countries. 5 More than 90 countries and territories have thus far prioritized the target “increased coverage of mental health conditions” across six regions, including: African Region: Burundi; Botswana; Central African Republic; Comoros; Cabo Verde; Algeria; Eritrea; Ethiopia; Guinea Bissau; Kenya; Mali; Mauritania; Malawi; Namibia; Nigeria; Sierra Leone; South Sudan; Sao Tome and Principe; Uganda; South Africa; Eastern Mediterranean Region: Afghanistan; Djibouti; Egypt; Iraq; Jordan; Lebanon; Libya; occupied Palestinian territory; Qatar; Syrian Arab Republic; United Arab Emirates; Yemen; European Region: Bulgaria; Croatia; Czech Republic; Estonia; Kyrgyzstan; Lithuania; Malta; Republic of Moldova; Russian Federation; Turkmenistan; Turkey; Uzbekistan; South-East Asia Region: Democratic People’s Republic of Korea; Indonesia; Maldives; Myanmar; Nepal; Sri Lanka; Timor-Leste; Western Pacific Region: China; Fiji; Niue; Nauru; Philippines; Tonga; Viet Nam, and Region of the Americas: Countries from the Region of the Americas will be added to this list on completion of their regional country prioritization process in 2019. 6 Funding allocation per country may differ depending on size, needs and costs of services. With guidance from WHO regional and country offices, a country-level WHO focal person for mental health and substance abuse will be appointed in each of the 12 countries. Their role will be to adapt and disseminate WHO normative guidance and technical packages to local contexts, to work closely with relevant government departments and coordinate with other implementing partners. Local service providers, NGOs, WHO’s global network of collaborating centres, organizations of persons with lived experience, professional associations (e.g. societies for social work/psychology/ psychiatry), universities and fellow United Nations (UN) organizations will all be involved. Such collaboration and coordinated activities will enable WHO to support governments to lead substantial scale up of care for mental health conditions. What budget is needed to implement the WHO Special Initiative for Mental Health? The WHO Special Initiative for Mental Health requires US$ 60 million over five years for full implementation6. This can be supported by contributions to individual countries for some or for the full 5-year special initiative. • Average cost per country per year = US$ 1 million • Average cost per country over five years = US$5 million • Total WHO Special Initiative for Mental Health for 12 priority countries over five years = US$ 60 million How will the budget for the WHO Special Initiative for Mental Health be used? Combined regional office and headquarters costs are calculated at 30% of the annual total, leaving 70% of all costs for targeted in-country work. Regional Office and headquarters costs will contribute significantly towards ensuring that mental health is positioned on the highest political agenda in each region and globally. • Country offices will ensure adequate staffing coverage to support implementation; engage with strategic partners to advance policy dialogue, advocacy and human rights in mental health for implementation; provide technical support to the government and partners to plan and implement activities; manage financial support for implementation; and document, monitor and evaluate the activities. • Regional Offices will assess priority needs under the strategic actions in the countries; technically support and oversee country work; provide technical support to facilitate country-to-country learning within each region; and be active in regional advocacy, particularly with the media, to promote effective mental health messaging. • WHO headquarters will oversee and be accountable for the WHO Special Initiative for Mental Health; provide technical inputs based on regional and country needs; oversee data collection and monitoring and evaluation needs across regions; and lead the development of new normative guidance, technical packages, and information products. Examples of the types of services countries will implement include mental health care in primary health centres, community-based mental health centres, mental health units in general hospitals, day centres, mobile clinics, and outreach services for home-based support— offering evidence-based treatment, rehabilitation, care and recovery. How will the success of the WHO Special Initiative for Mental Health be measured? By 2023, the WHO Special Initiative for Mental Health is aiming to increase treatment coverage for mental health conditions by ensuring access to mental health care for 100 million more people over its 5-year plan. Within this aim is to contribute to the broader GPW13 targets for increasing service coverage for severe mental health conditions to 50% and reducing suicide mortality by 15%. The high-level indicators of service coverage and suicide mortality are aligned with the indicators of the WHO Mental Health Action Plan 2013-2020, which WHO reports on every two years through the Mental Health Atlas.7 Each country, following assessment and determination of priority actions, will establish a country-specific monitoring and evaluation framework. This will enable regular assessment of each country office being on track to achieve their overall 5-year plans under the special initiative. 7 Mental Health Atlas 2017. WHO, Geneva, 2018. http://www.who.int/mental_health/evidence/atlas/mental_health_atlas_2017/en/ Assumptions for the success of the WHO Special Initiative for Mental Health This special initiative is designed with multiple assumptions. These include: • Priority efforts being needed to integrate mental health care across all levels of health care, including community, primary, non-specialist hospital, and specialist services. Such integration of care will be critical to achieving universal health coverage and ensures optimal reach to as many individuals, families and communities as possible. • Affordable services and interventions for mental health conditions refers to care that does not expose people using services to financial hardship. • Focusing across the life-course, leaving no-one behind. This includes women, men, girls and boys across cultures, contexts, health conditions and in all phases of life. • Respecting international human rights standards, particularly the UN Convention on the Rights of Persons with Disabilities, and the principles of legal capacity, liberty, non- discrimination, participation and inclusion of people with mental health conditions. • Respecting humanitarian principles of humanity, neutrality, impartiality and independence; in addition to other global frameworks and standards for mental health and psychosocial support implemented in emergency settings. • Being adaptable to local context and their available resources, culture, language, social structures, gender and ability; and in response to social, environmental and economic determinants of health. • Commitment to a multi-sectoral approach, which may mean the need to work with individuals, families and communities on a prioritized set of interventions at critical phases based on country-specific needs. • Commitment to collaboration with Member States’ ministries of health and other relevant government entities, in addition to other local stakeholders. • Commitment to collaborating with governments, UN organisations and NGOs, research institutions, global partnerships, and donors. For further information, please contact: Dévora Kestel, Director, Department of Mental Health and Substance Abuse, World Health Organization, Geneva (kesteld@who.int) WHO/MSD/19.1 © WHO 2019. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. PA H O /W H O c op yr ig ht
The WHO Special Initiative for Mental Health (2019-2023): Universal Health Coverage for Mental Health The WHO Special Initiative for Mental Health (2019-2023): Universal Health Coverage for Mental Health THEORY OF CHANGE THE PROBLEM : • There can be no health or sustainable development without mental health • Depression and anxiety disorders cost the global economy US$1 trillion per year • 800 000/year deaths from suicide, which is a leading cause of death in young people • Mental health conditions cause 1 in 5 years lived with disability • Common among people affected by communicable (e.g. HIV and TB) and non communicable diseases (e.g. cancer and cardiovascular disease) • Treatment coverage is extremely low • Especially common in populations affected by humanitarian crises and other forms of adversity (e.g. sexual violence) • People with mental health conditions often experience severe human rights violations, discrimination, stigma • Lack of sustained financing for services at scale • Effective evidence-based care is available but provision of services is lacking STRATEGIC ACTION 1: Advancing mental health policy, advocacy and human rights STRATEGIC ACTION 2: Scaling up interventions and services across community-based, general health and specialist settings GOAL: By 2023 universal health coverage (UHC) ensures access to quality and affordable care for mental health conditions in 12 priority countries to 100 million more people Contributes to WHOs GPW13 Triple Billion Targets to achieve: 1 billion more people benefiting from UHC 1 billion more people supported during emergencies 1 billion more people enjoying better health and well-being In partnership with WHO Member States and local, international and global implementing partners (e.g. UN, NGOs, user groups, professional associations) VISION: All people achieve the highest standard of mental health and well-being SPECIAL INITIATIVE TARGET: By 2023, access to mental health care for 100 million more people WHO GPW13 TARGET 1: Coverage of severe mental health conditions increased to 50% WHO GPW13 TARGET 2: Reduced suicide mortality by 15% SDG Target 3.4 when, by 2030, there is a one third reduction of premature mortality from NCDs through prevention, treatment and promotion of mental health and well-being SDG Target 3.5 to strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol “The world is accepting the concept of universal health coverage. Mental health must be an integral part of UHC. Nobody should be denied access to mental health care because she or he is poor or lives in a remote place.” Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization Mental health conditions contribute to poor health outcomes, premature death, human rights violations, and global and national economic loss. The WHO Director-General, Dr Tedros Adhanom Ghebreyesus, has identified mental health for accelerated implementation of the 13th General Programme of Work (GPW13), covering 2019-2023. The time to act is now to empower communities and individuals to attain the highest standard of health, which can only be achieved when their mental health and well-being is ensured, and their rights respected. The vision of the WHO Special Initiative for Mental Health is that all people achieve the highest standard of mental health and well-being. To implement the WHO Special Initiative for Mental Health over 5 years, WHO aims to raise US$ 60 million. Anchored by a clear goal, the initiative seeks to ensure universal health coverage involving access to quality and affordable care for mental health conditions in 12 priority countries to 100 million more people. The WHO Special Initiative for Mental Health will advance mental health policies, advocacy and human rights, and scale up quality interventions and services for individuals with mental health conditions, including substance use and neurological disorders. For continued scale up and global learning, WHO will implement this work in 12 priority countries, working in partnership with Member States, local, and international partners, as well as organizations of people with lived experience. This WHO Special Initiative for Mental Health is summarized in Figure 1, which demonstrates how the programme will contribute towards the wider goals of the GPW13 and the Sustainable Development Goals (SDGs). Figure 1. The WHO Special Initiative for Mental Health Theory of Change Why a WHO Special Initiative for Mental Health? Health is a state of complete physical, mental, and social well- being, and not merely the absence of disease or infirmity1. However, mental health remains a neglected part of global efforts to improve health. People with mental health conditions experience widespread human rights violations, discrimination and stigma. More than 80% of people experiencing mental health conditions, including individuals experiencing neurological and substance use disorders, are without any form of quality, affordable mental health care. This is despite mental health conditions accounting for 1 in 5 years lived with disability globally, leading to more than US$ 1 trillion per year in economic losses. It is well known that people living with mental health conditions are more likely to face other physical health problems (e.g. HIV, TB, noncommunicable diseases), causing early mortality of 10-20 years. Suicide mortality is high (close to 800 000 deaths per year), disproportionately affecting young people and elderly women in low- and middle-income countries. Mental health conditions are especially common for people affected by humanitarian crises and other forms of adversity (e.g. sexual violence). To date, mental health care has had many advocates but there has been limited commitment and funding for sustained implementation and scale-up of services. For WHO to realise its 2019-2023 mission to Promote health, keep the world safe, serve the vulnerable, mental health has been flagged as a priority area for accelerated implementation. Such implementation will benefit from the many resources WHO has recently developed, including: evidence-based guidelines, technical packages of interventions, rights-based frameworks, implementation guidance and training resources. WHO staff have extensive field experience, informing what works for supporting quality and affordable mental health care, and what is needed for scaling up services. 1 Constitution of the World Health Organization. WHO, Geneva, 1948. 2 Mental Health Action Plan 2013-2020. WHO, Geneva, 2013. http://www.who.int/iris/handle/10665/89966 3 The Lancet Commission on Global Mental Health and Sustainable Development. Lancet, 2018, 392: 1553–1598. 4 This WHO Special Initiative will also contribute to WHO’s GPW13 targets 1, 4, 5, 6, 10, 16, 17, 19, 20, 21, 23, 35, 36, 39, and 41, covering a wide range of health priorities. What will the WHO Special Initiative for Mental Health do? Embedded in the GPW13 and contributing towards the SDGs, the WHO Special Initiative for Mental Health will work towards a vision where all people achieve the highest standard of mental health and well-being; and aligns with the global WHO Mental Health Action Plan 2013- 20202. The Goal of the WHO Special Initiative for Mental Health also corresponds with recommendations of the recently published Lancet Commission on Global Mental Health and Sustainable Development3. It centers on scaling-up mental health care as part of universal health coverage, leaving no one behind. By 2023, the WHO Special Initiative for Mental Health will support access to quality and affordable community- based mental health care for 100 million more people. In reaching the programme goal, WHO will contribute to (a) two GPW13 targets, coverage of severe mental health conditions increased to 50% and reduced suicide mortality by 15%4; and (b) two SDG indicators, suicide mortality (3.4.2) and treatment coverage for substance use disorders (3.5.1). Two strategic actions will be implemented, each with different expected outputs, shown in the table. Universal health coverage (UHC) means that all people receive quality health services that meet their needs, without exposing them to financial hardship in paying for them. Quality mental health care refers to care that is safe, effective, timely, efficient, equitable and people-centered. This includes ensuring interventions and services are evidence- based and respect human rights. STRATEGIC ACTION 1: ADVANCING MENTAL HEALTH POLICIES, ADVOCACY AND HUMAN RIGHTS STRATEGIC ACTION 2: SCALING UP INTERVENTIONS AND SERVICES ACROSS COMMUNITY-BASED, GENERAL HEALTH AND SPECIALIST SETTINGS 1. Globally, mental health is positioned high on the development and humanitarian agendas 2. Local champions, people who use mental health services, and their organizations are empowered to participate in the development and implementation of mental health policies, strategies, laws and services 3. Mental health policies, strategies and laws are developed and operationalized based on international human rights standards 4. Media and community awareness about the importance of mental health across the life course is raised 5. Human and financial resources for mental health are brought in line with the needs 1. Quality, affordable mental health care is scaled up across health and social services 2. Quality, affordable mental health care is integrated in relevant programmes (e.g. for HIV, gender-based violence, disabilities) 3. Mental health and psychosocial support is included for preparedness, response and recovery in emergencies 4. Priority interventions for groups in positions of vulnerability (e.g. women, children, youth, older people, staff) are developed and implemented 5. Implementation is documented, monitored and evaluated to improve services Mental health conditions include mental, neurological and substance use disorders, suicide risk and associated psychosocial, cognitive and intellectual disabilities. How will the WHO Special Initiative for Mental Health be implemented? The WHO Special Initiative for Mental Health will scale up these key strategic actions in 12 priority countries. With support from WHO, each country will assess the current situation for mental health care needs across the life course, and design approaches for context- specific implementation. There is a need for this type of special initiative in all or almost all countries of the world. In the selection of the 12 countries, precedence will be given to the many Member States who prioritized the GPW13 target “increased coverage of mental health conditions” during WHO’s 2018 country prioritization exercise.5 These will include countries with large, medium and small size populations with the aim of achieving access to quality, affordable mental health care of 100 million more people across the 12 countries. At least four of the countries will have so-called fragile, conflict, or vulnerable (FCV) settings, where mental health issues are among the humanitarian concerns. WHO country-by-country approach to the WHO Special Initiative for Mental Health The status of mental health care varies widely from country to country. Many countries already have policies to deliver services for mental health conditions in primary care settings but require system strengthening to achieve integration. Many countries deliver care mainly in institutional settings and need dedicated advocacy and support in phasing out long-stay institutions and developing community-based alternatives. Some countries may require support for policy development or to implement mental health reform efforts. By taking a country-by-country approach, WHO can help formulate a tailored approach for each priority country, building on existing strengths and needs. A key advantage to a country by-country approach is sustainability. Over recent decades, there has been a focus on small mental health initiatives that have had only short-term funding. This limits impact and has not paved the way for sustainable scale up to reach whole populations. Further, it has led to ad-hoc learning about the facilitators and barriers to scaling up effective interventions or strengthening systems to embed mental health care. By focusing on countries (or large regions within countries) and supporting them consistently for up to five years, WHO can glean systematic learnings to inform scale up in additional countries. 5 As per 10 May 2019, more than 70 countries and territories have thus far prioritized coverage of mental health conditions across six regions, including: African Region: Algeria, Burundi; Botswana; Central African Republic; Comoros; Cabo Verde; Eritrea; Ethiopia; Ghana, Guinea Bissau; Kenya; Mali; Mauritania; Malawi; Namibia; Nigeria; Sierra Leone; South Sudan; Sao Tome and Principe; Uganda; South Africa; Eastern Mediterranean Region: Afghanistan; Djibouti; Egypt; Iraq; Jordan; Lebanon; Libya; Pakistan, occupied Palestinian territory; Qatar; Syrian Arab Republic; Tunisia, United Arab Emirates; Yemen; European Region: Bosnia and Herzegovina, Bulgaria; Croatia; Czech Republic; Estonia; Greece, Kyrgyzstan; Lithuania; Kosovo, Malta; Republic of Moldova; Poland, Russian Federation; Turkmenistan; Turkey; Ukraine, Uzbekistan; South-East Asia Region: Bangladesh, Democratic People’s Republic of Korea; India, Indonesia; Maldives; Myanmar; Nepal; Sri Lanka; Timor-Leste; Western Pacific Region: Cambodia, China; Fiji; Niue; Nauru; Philippines; Tonga; Viet Nam, and Region of the Americas: Countries from the Region of the Americas will be added to this list on completion of their regional country prioritization process in 2019. 6 Funding allocation per country may differ depending on size, needs and costs of services. With guidance from WHO regional and country offices, a country-level WHO focal person for mental health and substance abuse will be appointed in each of the 12 countries. Their role will be to adapt and disseminate WHO normative guidance and technical packages to local contexts, to work closely with relevant government departments and coordinate with other implementing partners. Local service providers, NGOs, WHO’s global network of collaborating centres, organizations of persons with lived experience, professional associations (e.g. societies for social work/psychology/ psychiatry), universities and fellow United Nations (UN) organizations will all be involved. Such collaboration and coordinated activities will enable WHO to support governments to lead substantial scale up of care for mental health conditions. What budget is needed to implement the WHO Special Initiative for Mental Health? The WHO Special Initiative for Mental Health requires US$ 60 million over five years for full implementation6. This can be supported by contributions to individual countries for some or for the full 5-year special initiative. • Average cost per country per year = US$ 1 million • Average cost per country over five years = US$5 million • Total WHO Special Initiative for Mental Health for 12 priority countries over five years = US$ 60 million How will the budget for the WHO Special Initiative for Mental Health be used? Combined regional office and headquarters costs are calculated at 30% of the annual total, leaving 70% of all costs for targeted in-country work. Regional Office and headquarters costs will contribute significantly towards ensuring that mental health is positioned on the highest political agenda in each region and globally. • Country offices will ensure adequate staffing coverage to support implementation; engage with strategic partners to advance policy dialogue, advocacy and human rights in mental health for implementation; provide technical support to the government and partners to plan and implement activities; manage financial support for implementation; and document, monitor and evaluate the activities. • Regional Offices will assess priority needs under the strategic actions in the countries; technically support and oversee country work; provide technical support to facilitate country-to-country learning within each region; and be active in regional advocacy, particularly with the media, to promote effective mental health messaging. • WHO headquarters will oversee and be accountable for the WHO Special Initiative for Mental Health; provide technical inputs based on regional and country needs; oversee data collection and monitoring and evaluation needs across regions; and lead the development of new normative guidance, technical packages, and information products. Examples of the types of services countries will implement include mental health care in primary health centres, community-based mental health centres, mental health units in general hospitals, day centres, mobile clinics, and outreach services for home-based support— offering evidence-based treatment, rehabilitation, care and recovery. How will the success of the WHO Special Initiative for Mental Health be measured? By 2023, the WHO Special Initiative for Mental Health is aiming to increase treatment coverage for mental health conditions by ensuring access to mental health care for 100 million more people over its 5-year plan. Within this aim is to contribute to the broader GPW13 targets for increasing service coverage for severe mental health conditions to 50% and reducing suicide mortality by 15%. The high-level indicators of service coverage and suicide mortality are aligned with the indicators of the WHO Mental Health Action Plan 2013-2020, which WHO reports on every two years through the Mental Health Atlas.7 Each country, following assessment and determination of priority actions, will establish a country-specific monitoring and evaluation framework. This will enable regular assessment of each country office being on track to achieve their overall 5-year plans under the special initiative. 7 Mental Health Atlas 2017. WHO, Geneva, 2018. http://www.who.int/mental_health/evidence/atlas/mental_health_atlas_2017/en/ Assumptions for the success of the WHO Special Initiative for Mental Health This special initiative is designed with multiple assumptions. These include: • Priority efforts being needed to integrate mental health care across all levels of health care, including community, primary, non-specialist hospital, and specialist services. Such integration of care will be critical to achieving universal health coverage and ensures optimal reach to as many individuals, families and communities as possible. • Affordable services and interventions for mental health conditions refers to care that does not expose people using services to financial hardship. • Focusing across the life-course, leaving no-one behind. This includes women, men, girls and boys across cultures, contexts, health conditions and in all phases of life. • Respecting international human rights standards, particularly the UN Convention on the Rights of Persons with Disabilities, and the principles of legal capacity, liberty, non- discrimination, participation and inclusion of people with mental health conditions. • Respecting humanitarian principles of humanity, neutrality, impartiality and independence; in addition to other global frameworks and standards for mental health and psychosocial support implemented in emergency settings. • Being adaptable to local context and their available resources, culture, language, social structures, gender and ability; and in response to social, environmental and economic determinants of health. • Commitment to a multi-sectoral approach, which may mean the need to work with individuals, families and communities on a prioritized set of interventions at critical phases based on country-specific needs. • Commitment to collaboration with Member States’ ministries of health and other relevant government entities, in addition to other local stakeholders. • Commitment to collaborating with governments, UN organisations and NGOs, research institutions, global partnerships, and donors. For further information, please contact: Dévora Kestel, Director, Department of Mental Health and Substance Abuse, World Health Organization, Geneva (kesteld@who.int) WHO/MSD/19.1 © WHO 2019. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. PA H O /W H O c op yr ig ht
The WHO Special Initiative for Mental Health (2019-2023): Universal Health Coverage for Mental Health The WHO Special Initiative for Mental Health (2019-2023): Universal Health Coverage for Mental Health THEORY OF CHANGE THE PROBLEM : • There can be no health or sustainable development without mental health • Depression and anxiety disorders cost the global economy US$1 trillion per year • 800 000/year deaths from suicide, which is a leading cause of death in young people • Mental health conditions cause 1 in 5 years lived with disability • Common among people affected by communicable (e.g. HIV and TB) and non communicable diseases (e.g. cancer and cardiovascular disease) • Treatment coverage is extremely low • Especially common in populations affected by humanitarian crises and other forms of adversity (e.g. sexual violence) • People with mental health conditions often experience severe human rights violations, discrimination, stigma • Lack of sustained financing for services at scale • Effective evidence-based care is available but provision of services is lacking STRATEGIC ACTION 1: Advancing mental health policy, advocacy and human rights STRATEGIC ACTION 2: Scaling up interventions and services across community-based, general health and specialist settings GOAL: By 2023 universal health coverage (UHC) ensures access to quality and affordable care for mental health conditions in 12 priority countries to 100 million more people Contributes to WHOs GPW13 Triple Billion Targets to achieve: 1 billion more people benefiting from UHC 1 billion more people supported during emergencies 1 billion more people enjoying better health and well-being In partnership with WHO Member States and local, international and global implementing partners (e.g. UN, NGOs, user groups, professional associations) VISION: All people achieve the highest standard of mental health and well-being SPECIAL INITIATIVE TARGET: By 2023, access to mental health care for 100 million more people WHO GPW13 TARGET 1: Coverage of severe mental health conditions increased to 50% WHO GPW13 TARGET 2: Reduced suicide mortality by 15% SDG Target 3.4 when, by 2030, there is a one third reduction of premature mortality from NCDs through prevention, treatment and promotion of mental health and well-being SDG Target 3.5 to strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol “The world is accepting the concept of universal health coverage. Mental health must be an integral part of UHC. Nobody should be denied access to mental health care because she or he is poor or lives in a remote place.” Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization Mental health conditions contribute to poor health outcomes, premature death, human rights violations, and global and national economic loss. The WHO Director-General, Dr Tedros Adhanom Ghebreyesus, has identified mental health for accelerated implementation of the 13th General Programme of Work (GPW13), covering 2019-2023. The time to act is now to empower communities and individuals to attain the highest standard of health, which can only be achieved when their mental health and well-being is ensured, and their rights respected. The vision of the WHO Special Initiative for Mental Health is that all people achieve the highest standard of mental health and well-being. To implement the WHO Special Initiative for Mental Health over 5 years, WHO aims to raise US$ 60 million. Anchored by a clear goal, the initiative seeks to ensure universal health coverage involving access to quality and affordable care for mental health conditions in 12 priority countries to 100 million more people. The WHO Special Initiative for Mental Health will advance mental health policies, advocacy and human rights, and scale up quality interventions and services for individuals with mental health conditions, including substance use and neurological disorders. For continued scale up and global learning, WHO will implement this work in 12 priority countries, working in partnership with Member States, local, and international partners, as well as organizations of people with lived experience. This WHO Special Initiative for Mental Health is summarized in Figure 1, which demonstrates how the programme will contribute towards the wider goals of the GPW13 and the Sustainable Development Goals (SDGs). Figure 1. The WHO Special Initiative for Mental Health Theory of Change Why a WHO Special Initiative for Mental Health? Health is a state of complete physical, mental, and social well- being, and not merely the absence of disease or infirmity1. However, mental health remains a neglected part of global efforts to improve health. People with mental health conditions experience widespread human rights violations, discrimination and stigma. More than 80% of people experiencing mental health conditions, including individuals experiencing neurological and substance use disorders, are without any form of quality, affordable mental health care. This is despite mental health conditions accounting for 1 in 5 years lived with disability globally, leading to more than US$ 1 trillion per year in economic losses. It is well known that people living with mental health conditions are more likely to face other physical health problems (e.g. HIV, TB, noncommunicable diseases), causing early mortality of 10-20 years. Suicide mortality is high (close to 800 000 deaths per year), disproportionately affecting young people and elderly women in low- and middle-income countries. Mental health conditions are especially common for people affected by humanitarian crises and other forms of adversity (e.g. sexual violence). To date, mental health care has had many advocates but there has been limited commitment and funding for sustained implementation and scale-up of services. For WHO to realise its 2019-2023 mission to Promote health, keep the world safe, serve the vulnerable, mental health has been flagged as a priority area for accelerated implementation. Such implementation will benefit from the many resources WHO has recently developed, including: evidence-based guidelines, technical packages of interventions, rights-based frameworks, implementation guidance and training resources. WHO staff have extensive field experience, informing what works for supporting quality and affordable mental health care, and what is needed for scaling up services. 1 Constitution of the World Health Organization. WHO, Geneva, 1948. 2 Mental Health Action Plan 2013-2020. WHO, Geneva, 2013. http://www.who.int/iris/handle/10665/89966 3 The Lancet Commission on Global Mental Health and Sustainable Development. Lancet, 2018, 392: 1553–1598. 4 This WHO Special Initiative will also contribute to WHO’s GPW13 targets 1, 4, 5, 6, 10, 16, 17, 19, 20, 21, 23, 35, 36, 39, and 41, covering a wide range of health priorities. What will the WHO Special Initiative for Mental Health do? Embedded in the GPW13 and contributing towards the SDGs, the WHO Special Initiative for Mental Health will work towards a vision where all people achieve the highest standard of mental health and well-being; and aligns with the global WHO Mental Health Action Plan 2013- 20202. The Goal of the WHO Special Initiative for Mental Health also corresponds with recommendations of the recently published Lancet Commission on Global Mental Health and Sustainable Development3. It centers on scaling-up mental health care as part of universal health coverage, leaving no one behind. By 2023, the WHO Special Initiative for Mental Health will support access to quality and affordable community- based mental health care for 100 million more people. In reaching the programme goal, WHO will contribute to (a) two GPW13 targets, coverage of severe mental health conditions increased to 50% and reduced suicide mortality by 15%4; and (b) two SDG indicators, suicide mortality (3.4.2) and treatment coverage for substance use disorders (3.5.1). Two strategic actions will be implemented, each with different expected outputs, shown in the table. Universal health coverage (UHC) means that all people receive quality health services that meet their needs, without exposing them to financial hardship in paying for them. Quality mental health care refers to care that is safe, effective, timely, efficient, equitable and people-centered. This includes ensuring interventions and services are evidence- based and respect human rights. STRATEGIC ACTION 1: ADVANCING MENTAL HEALTH POLICIES, ADVOCACY AND HUMAN RIGHTS STRATEGIC ACTION 2: SCALING UP INTERVENTIONS AND SERVICES ACROSS COMMUNITY-BASED, GENERAL HEALTH AND SPECIALIST SETTINGS 1. Globally, mental health is positioned high on the development and humanitarian agendas 2. Local champions, people who use mental health services, and their organizations are empowered to participate in the development and implementation of mental health policies, strategies, laws and services 3. Mental health policies, strategies and laws are developed and operationalized based on international human rights standards 4. Media and community awareness about the importance of mental health across the life course is raised 5. Human and financial resources for mental health are brought in line with the needs 1. Quality, affordable mental health care is scaled up across health and social services 2. Quality, affordable mental health care is integrated in relevant programmes (e.g. for HIV, gender-based violence, disabilities) 3. Mental health and psychosocial support is included for preparedness, response and recovery in emergencies 4. Priority interventions for groups in positions of vulnerability (e.g. women, children, youth, older people, staff) are developed and implemented 5. Implementation is documented, monitored and evaluated to improve services Mental health conditions include mental, neurological and substance use disorders, suicide risk and associated psychosocial, cognitive and intellectual disabilities. How will the WHO Special Initiative for Mental Health be implemented? The WHO Special Initiative for Mental Health will scale up these key strategic actions in 12 priority countries. With support from WHO, each country will assess the current situation for mental health care needs across the life course, and design approaches for context- specific implementation. There is a need for this type of special initiative in all or almost all countries of the world. In the selection of the 12 countries, precedence will be given to the many Member States who prioritized the GPW13 target “increased coverage of mental health conditions” during WHO’s 2018 country prioritization exercise.5 These will include countries with large, medium and small size populations with the aim of achieving access to quality, affordable mental health care of 100 million more people across the 12 countries. At least four of the countries will have so-called fragile, conflict, or vulnerable (FCV) settings, where mental health issues are among the humanitarian concerns. WHO country-by-country approach to the WHO Special Initiative for Mental Health The status of mental health care varies widely from country to country. Many countries already have policies to deliver services for mental health conditions in primary care settings but require system strengthening to achieve integration. Many countries deliver care mainly in institutional settings and need dedicated advocacy and support in phasing out long-stay institutions and developing community-based alternatives. Some countries may require support for policy development or to implement mental health reform efforts. By taking a country-by-country approach, WHO can help formulate a tailored approach for each priority country, building on existing strengths and needs. A key advantage to a country by-country approach is sustainability. Over recent decades, there has been a focus on small mental health initiatives that have had only short-term funding. This limits impact and has not paved the way for sustainable scale up to reach whole populations. Further, it has led to ad-hoc learning about the facilitators and barriers to scaling up effective interventions or strengthening systems to embed mental health care. By focusing on countries (or large regions within countries) and supporting them consistently for up to five years, WHO can glean systematic learnings to inform scale up in additional countries. 5 As per 10 May 2019, more than 70 countries and territories have thus far prioritized coverage of mental health conditions across six regions, including: African Region: Algeria, Burundi; Botswana; Central African Republic; Comoros; Cabo Verde; Eritrea; Ethiopia; Ghana, Guinea Bissau; Kenya; Mali; Mauritania; Malawi; Namibia; Nigeria; Sierra Leone; South Sudan; Sao Tome and Principe; Uganda; South Africa; Eastern Mediterranean Region: Afghanistan; Djibouti; Egypt; Iraq; Jordan; Lebanon; Libya; Pakistan, occupied Palestinian territory; Qatar; Syrian Arab Republic; Tunisia, United Arab Emirates; Yemen; European Region: Bosnia and Herzegovina, Bulgaria; Croatia; Czech Republic; Estonia; Greece, Kyrgyzstan; Lithuania; Kosovo, Malta; Republic of Moldova; Poland, Russian Federation; Turkmenistan; Turkey; Ukraine, Uzbekistan; South-East Asia Region: Bangladesh, Democratic People’s Republic of Korea; India, Indonesia; Maldives; Myanmar; Nepal; Sri Lanka; Timor-Leste; Western Pacific Region: Cambodia, China; Fiji; Niue; Nauru; Philippines; Tonga; Viet Nam, and Region of the Americas: Countries from the Region of the Americas will be added to this list on completion of their regional country prioritization process in 2019. 6 Funding allocation per country may differ depending on size, needs and costs of services. With guidance from WHO regional and country offices, a country-level WHO focal person for mental health and substance abuse will be appointed in each of the 12 countries. Their role will be to adapt and disseminate WHO normative guidance and technical packages to local contexts, to work closely with relevant government departments and coordinate with other implementing partners. Local service providers, NGOs, WHO’s global network of collaborating centres, organizations of persons with lived experience, professional associations (e.g. societies for social work/psychology/ psychiatry), universities and fellow United Nations (UN) organizations will all be involved. Such collaboration and coordinated activities will enable WHO to support governments to lead substantial scale up of care for mental health conditions. What budget is needed to implement the WHO Special Initiative for Mental Health? The WHO Special Initiative for Mental Health requires US$ 60 million over five years for full implementation6. This can be supported by contributions to individual countries for some or for the full 5-year special initiative. • Average cost per country per year = US$ 1 million • Average cost per country over five years = US$5 million • Total WHO Special Initiative for Mental Health for 12 priority countries over five years = US$ 60 million How will the budget for the WHO Special Initiative for Mental Health be used? Combined regional office and headquarters costs are calculated at 30% of the annual total, leaving 70% of all costs for targeted in-country work. Regional Office and headquarters costs will contribute significantly towards ensuring that mental health is positioned on the highest political agenda in each region and globally. • Country offices will ensure adequate staffing coverage to support implementation; engage with strategic partners to advance policy dialogue, advocacy and human rights in mental health for implementation; provide technical support to the government and partners to plan and implement activities; manage financial support for implementation; and document, monitor and evaluate the activities. • Regional Offices will assess priority needs under the strategic actions in the countries; technically support and oversee country work; provide technical support to facilitate country-to-country learning within each region; and be active in regional advocacy, particularly with the media, to promote effective mental health messaging. • WHO headquarters will oversee and be accountable for the WHO Special Initiative for Mental Health; provide technical inputs based on regional and country needs; oversee data collection and monitoring and evaluation needs across regions; and lead the development of new normative guidance, technical packages, and information products. Examples of the types of services countries will implement include mental health care in primary health centres, community-based mental health centres, mental health units in general hospitals, day centres, mobile clinics, and outreach services for home-based support— offering evidence-based treatment, rehabilitation, care and recovery. How will the success of the WHO Special Initiative for Mental Health be measured? By 2023, the WHO Special Initiative for Mental Health is aiming to increase treatment coverage for mental health conditions by ensuring access to mental health care for 100 million more people over its 5-year plan. Within this aim is to contribute to the broader GPW13 targets for increasing service coverage for severe mental health conditions to 50% and reducing suicide mortality by 15%. The high-level indicators of service coverage and suicide mortality are aligned with the indicators of the WHO Mental Health Action Plan 2013-2020, which WHO reports on every two years through the Mental Health Atlas.7 Each country, following assessment and determination of priority actions, will establish a country-specific monitoring and evaluation framework. This will enable regular assessment of each country office being on track to achieve their overall 5-year plans under the special initiative. 7 Mental Health Atlas 2017. WHO, Geneva, 2018. http://www.who.int/mental_health/evidence/atlas/mental_health_atlas_2017/en/ Assumptions for the success of the WHO Special Initiative for Mental Health This special initiative is designed with multiple assumptions. These include: • Priority efforts being needed to integrate mental health care across all levels of health care, including community, primary, non-specialist hospital, and specialist services. Such integration of care will be critical to achieving universal health coverage and ensures optimal reach to as many individuals, families and communities as possible. • Affordable services and interventions for mental health conditions refers to care that does not expose people using services to financial hardship. • Focusing across the life-course, leaving no-one behind. This includes women, men, girls and boys across cultures, contexts, health conditions and in all phases of life. • Respecting international human rights standards, particularly the UN Convention on the Rights of Persons with Disabilities, and the principles of legal capacity, liberty, non- discrimination, participation and inclusion of people with mental health conditions. • Respecting humanitarian principles of humanity, neutrality, impartiality and independence; in addition to other global frameworks and standards for mental health and psychosocial support implemented in emergency settings. • Being adaptable to local context and their available resources, culture, language, social structures, gender and ability; and in response to social, environmental and economic determinants of health. • Commitment to a multi-sectoral approach, which may mean the need to work with individuals, families and communities on a prioritized set of interventions at critical phases based on country-specific needs. • Commitment to collaboration with Member States’ ministries of health and other relevant government entities, in addition to other local stakeholders. • Commitment to collaborating with governments, UN organisations and NGOs, research institutions, global partnerships, and donors. For further information, please contact: Dévora Kestel, Director, Department of Mental Health and Substance Abuse, World Health Organization, Geneva (kesteld@who.int) WHO/MSD/19.1 © WHO 2019. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. PA H O /W H O c op yr ig ht