Inequitable and Ineffective: Exclusion of Mental Health from the Post-2015 Development Agenda


article has not abstract


Published in the journal: . PLoS Med 12(6): e32767. doi:10.1371/journal.pmed.1001846
Category: Editorial
doi: 10.1371/journal.pmed.1001846

Summary

article has not abstract

The Millennium Development Goals (MDGs), adopted at the turn of the century, represented a milestone in global development by committing United Nations member states to eradicating extreme poverty and achieving specific targets over the subsequent decade and a half. At this time the world's attention is increasingly focused on the post-2015 development agenda, which will be unveiled in September of this year in the form of Sustainable Development Goals (SDGs). Given that mental health and other non-communicable diseases were conspicuously omitted from the MDGs, and have only been weakly mentioned in draft SDG targets, in this essay we argue for a place for mental health on the post-2015 development agenda. Its continued exclusion will not only contribute to the failure of the SDGs given the centrality of mental health in most aspects of human development and well-being but also formalize our collective failure to care for the most vulnerable among us.

Impact of Omitting Mental Health from the MDGs

The eight MDGs were broadly focused on extreme poverty but also supported improvements in education, public health, and biodiversity—with three health-focused MDGs, related to child mortality; maternal health; and HIV, malaria, and tuberculosis. Although mental disorders [1] and other noncommunicable diseases [2] are substantial contributors to the global burden of disease, they were not formally acknowledged. This omission was a critical oversight, given that interventions to improve mental health likely play an important role in spurring progress on the health-related MDGs [3], including child health [4], maternal health [5], and HIV [6].

Few countries will ultimately achieve the MDG targets for reducing child mortality and improving maternal health [7]. Overall, however, it appears that the MDG platform has been successful in building consensus around, and mobilizing funding for, particular development agendas. Global attention to the issues of newborn survival and maternal health, for example, was facilitated in part by the policy windows created by MDGs 4 and 5 [8,9]. However, the progress that has been made on improving child survival has not been matched by an equivalent focus on ensuring that those that survive also thrive. This oversight has prompted agencies such as the World Health Organization to call for a focus on early child development in the SDGs [10]. Mental health, like early child development, is a cross cutting phenomenon that has the potential to bring together health ministries and diverse actors in a synergistic way that we argue will be essential to achieving the SDGs.

In contrast to the issues of newborn survival and maternal health, the conspicuous exclusion of mental health from the MDGs is thought to have played a significant role in explaining its failure to achieve prominence on the global agenda [11]. Not unrelatedly, most countries in Africa and southeastern Asia devote less than 1% of their health budgets to mental health services [12]. These amounts are supplemented by a paltry amount of development assistance for health, of which less than 1% is earmarked specifically for the care of persons with mental disorders [13].

Fortunately, new initiatives have begun to redress this imbalance of attention, including the PLOS Medicine series on Packages of Care [14], Global Mental Health Practice [15], and Integrating Mental Health [16], as well as the 2007 and 2011 Lancet series on global mental health [17,18]. Concomitantly, recent initiatives from Grand Challenges Canada, the United Kingdom Department for International Development, and the United States National Institute of Mental Health have begun to redress the imbalance of funding [1921]. And finally, as indicated in a recent blog posting, World Bank Group President Jim Yong Kim and World Health Organization Director-General Margaret Chan will be cohosting a major event on mental health in the spring of 2016 [22].

Why Mental Health Should Be Central to the SDGs

The SDG Open Working Group has described poverty eradication as the greatest challenge facing the world. Fittingly, “End poverty in all its forms everywhere” has been designated goal 1 of the proposed SDGs. At this point, there are now 17 proposed goals, of which only one is directly related to health (goal 3, “Ensure healthy lives and promote well-being for all at all ages”), and 169 proposed targets, of which only one is directly related to mental health (target 3.4, “By 2030 reduce by one-third premature mortality from noncommunicable diseases through prevention and treatment, and promote mental health and well-being”). With some projections pegging the cumulative global impact of mental disorders at $16 trillion over the next two decades [23], the exclusion of mental disorders in the SDGs while attempting to eradicate poverty would likely render the SDGs, in Richard Horton’s caustic characterization, as something akin to “fairy tales, dressed in the bureaucratese of intergovernmental narcissism” [24]. The SDGs would then become yet another example of a broad promise in global health left unfulfilled [25].

The importance of recognizing mental health in the SDGs should be obvious. Mental disorders represent some of the most common and disabling sources of human suffering [1], and unmet needs for mental health treatment are pervasive, particularly in resource-limited settings [12,26]. A declared commitment to persons with mental disorders would be an initial step toward supporting those who are among the world’s most marginalized and vulnerable [27], consistent with the “leave no one behind” principle espoused in the UN High-Level Panel report on the post-2015 development agenda [28]. And finally, mental health is directly linked to seven of the proposed SDGs—either as an outcome or as a determinant—namely, those related to poverty, hunger, gender equality, sanitation, employment, inequality, and inclusivity. Mental health is so closely woven into the “triple helix” of sustainable development (economic, social, and environmental) that the continued underdiagnosis and undertreatment of mental disorders makes it highly unlikely that a truly shared and global prosperity will ever be sustainably achieved.

A More Explicit Commitment to Mental Health

As we count down to September 2015, we see a critical opportunity for the UN General Assembly to formally reaffirm what was recognized in the Political Declaration of the High-Level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases [29]: that the continued global burden of mental disorders undermines sustainable human development throughout the world and threatens the achievement of internationally agreed-upon development goals. Our colleagues have already suggested the inclusion of additional targets that would highlight the role of mental health in sustainable human development: avoiding premature deaths (including those from suicide) [30] and achieving parity in access to mental and physical health services [31]. These proposed revisions are substantive and consequential, because the SDGs are likely to have a critical influence on global health and development assistance for the next decade and a half. For a sector that already suffers from underfunding [12] and inattention [11], then, the stakes are exceptionally high.

In summary, mental disorders are common worldwide, can be extremely disabling, and pose grave threats to sustainable human development. Their burden is typically borne by the poorest and most excluded of society, further underscoring the need to “leave no one behind.” The current inequities in mental health service investments, both between and within countries, are unacceptable. Without due attention and formal commitment to the global burden of mental disorders, we fear that the post-2015 goal of ensuring healthy lives and promoting well-being for all will continue to elude us.


Zdroje

1. Whiteford HA, Degenhardt L, Rehm J, Baxter AJ, Ferrari AJ, Erskine HE, et al. (2013) Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. Lancet 382: 1575–1586. doi: 10.1016/S0140-6736(13)61611-6 23993280

2. Beaglehole R, Bonita R, Alleyne G, Horton R, Li L, Lincoln P, et al. (2011) UN High-Level Meeting on Non-Communicable Diseases: addressing four questions. Lancet 378: 449–455. doi: 10.1016/S0140-6736(11)60879-9 21665266

3. Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR, et al. (2007) No health without mental health. Lancet 370: 859–877. 17804063

4. Tsai AC, Tomlinson M (2012) Mental health spillovers and the Millennium Development Goals: The case of perinatal depression in Khayelitsha, South Africa. J Glob Health 2: 010302. doi: 10.7189/jogh.02.010302 23198127

5. Miranda JJ, Patel V (2005) Achieving the Millennium Development Goals: does mental health play a role? PLoS Med 2: e291. 16156692

6. Tsai AC, Weiser SD, Petersen ML, Ragland K, Kushel MB, Bangsberg DR (2010) A marginal structural model to estimate the causal effect of antidepressant medication treatment on viral suppression among homeless and marginally housed persons with HIV. Arch Gen Psychiatry 67: 1282–1290. doi: 10.1001/archgenpsychiatry.2010.160 21135328

7. Lozano R, Wang H, Foreman KJ, Rajaratnam JK, Naghavi M, Marcus JR, et al. (2011) Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis. Lancet 378: 1139–1165. doi: 10.1016/S0140-6736(11)61337-8 21937100

8. Shiffman J (2010) Issue attention in global health: the case of newborn survival. Lancet 375: 2045–2049. doi: 10.1016/S0140-6736(10)60710-6 20569844

9. Shiffman J, Smith S (2007) Generation of political priority for global health initiatives: a framework and case study of maternal mortality. Lancet 370: 1370–1379. 17933652

10. Chan M (2013) Linking child survival and child development for health, equity, and sustainable development. Lancet 381: 1514–1515. doi: 10.1016/S0140-6736(13)60944-7 23642687

11. Tomlinson M, Lund C (2012) Why does mental health not get the attention it deserves? An application of the Shiffman and Smith framework. PLoS Med 9: e1001178. doi: 10.1371/journal.pmed.1001178 22389632

12. Saxena S, Thornicroft G, Knapp M, Whiteford H (2007) Resources for mental health: scarcity, inequity, and inefficiency. Lancet 370: 878–889. 17804062

13. Gilbert BJ, Patel V, Farmer PE, Lu C (2015) Assessing development assistance for mental health in developing countries: 2007–2013. PLoS Med 12: e1001834.

14. Patel V, Thornicroft G (2009) Packages of care for mental, neurological, and substance use disorders in low- and middle-income countries: PLoS Medicine Series. PLoS Med 6: e1000160. doi: 10.1371/journal.pmed.1000160 19806180

15. Patel V, Jenkins R, Lund C, the PLoS Medicine Editors (2012) Putting evidence into practice: The PLoS Medicine Series on Global Mental Health Practice. PLoS Med 9: e1001226.

16. Collins PY, Insel TR, Chockalingam A, Daar A, Maddox YT (2013) Grand challenges in global mental health: integration in research, policy, and practice. PLoS Med 10: e1001434. doi: 10.1371/journal.pmed.1001434 23637578

17. Patel V, Garrison P, de Jesus Mari J, Minas H, Prince M, Saxena S, et al. (2008) The Lancet's series on global mental health: 1 year on. Lancet 372: 1354–1357. doi: 10.1016/S0140-6736(08)61556-1 18929907

18. Patel V, Boyce N, Collins PY, Saxena S, Horton R (2011) A renewed agenda for global mental health. Lancet 378: 1441–1442. doi: 10.1016/S0140-6736(11)61385-8 22008422

19. Collins PY, Patel V, Joestl SS, March D, Insel TR, Daar AS, et al. (2011) Grand challenges in global mental health. Nature 475: 27–30. doi: 10.1038/475027a 21734685

20. Lund C, Tomlinson M, De Silva M, Fekadu A, Shidhaye R, Jordans M, et al. (2012) PRIME: A programme to reduce the treatment gap for mental disorders in five low- and middle-income countries. PLoS Med 9: e1001359. doi: 10.1371/journal.pmed.1001359 23300387

21. Becker AE, Kleinman A (2013) Mental health and the global agenda. N Engl J Med 369: 66–73. doi: 10.1056/NEJMra1110827 23822778

22. Evans T, Marquez PV, Saxena S (2015) "The zero hour" for mental health. http://blogs.worldbank.org/health/zero-hour-mental-health. Last accessed May 15, 2015.

23. Bloom DE, Cafiero ET, Jané-Llopis E, Abrahams-Gessel S, Bloom LR, Fathima S, et al. (2011) The global economic burden of noncommunicable diseases. Geneva: World Economic Forum.

24. Horton R (2014) Offline: why the Sustainable Development Goals will fail. Lancet 383: 2196.

25. Panter-Brick C, Eggerman M, Tomlinson M (2014) How might global health master deadly sins and strive for greater virtues? Glob Health Action 7: 23411. doi: 10.3402/gha.v7.23411 24685169

26. Wang PS, Aguilar-Gaxiola S, Alonso J, Angermeyer MC, Borges G, Bromet EJ, et al. (2007) Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys. Lancet 370: 841–850. 17826169

27. Kleinman A (2009) Global mental health: a failure of humanity. Lancet 374: 603–604. 19708102

28. United Nations (2013) A new global partnership: eradicate poverty and transform economies through sustainable development. The report of the High-Level Panel of Eminent Persons on the Post-2015 Development Agenda. New York: United Nations Publications.

29. United Nations General Assembly (2012) Political declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases (A/RES/66/2). New York: United Nations.

30. Norheim OF, Jha P, Admasu K, Godal T, Hum RJ, Kruk ME, et al. (2015) Avoiding 40% of the premature deaths in each country, 2010–30: review of national mortality trends to help quantify the UN sustainable development goal for health. Lancet 385: 239–252. doi: 10.1016/S0140-6736(14)61591-9 25242039

31. Thornicroft G, Patel V (2014) Including mental health among the new sustainable development goals. BMJ 349: g5189. doi: 10.1136/bmj.g5189 25145688

Štítky
Interní lékařství

Článek vyšel v časopise

PLOS Medicine


2015 Číslo 6

Nejčtenější v tomto čísle

Tomuto tématu se dále věnují…


Kurzy

Zvyšte si kvalifikaci online z pohodlí domova

Jistoty a nástrahy antikoagulační léčby aneb kardiolog - neurolog - farmakolog - nefrolog - právník diskutují
nový kurz
Autoři: doc. MUDr. Štěpán Havránek, Ph.D., prof. MUDr. Roman Herzig, Ph.D., doc. MUDr. Karel Urbánek, Ph.D., prim. MUDr. Jan Vachek, MUDr. et Mgr. Jolana Těšínová, Ph.D.

Léčba akutní pooperační bolesti
Autoři: doc. MUDr. Jiří Málek, CSc.

Nové antipsychotikum kariprazin v léčbě schizofrenie
Autoři: Prof. MUDr. Cyril Höschl, DrSc., FRCPsych.

Familiární transthyretinová periferní polyneuropatie
Autoři: MUDr. Radim Mazanec, Ph.D.

Diabetes mellitus a kardiovaskulární riziko, možnosti jeho ovlivnění
Autoři:

Všechny kurzy
Kurzy Doporučená témata Časopisy
Přihlášení
Zapomenuté heslo

Nemáte účet?  Registrujte se

Zapomenuté heslo

Zadejte e-mailovou adresu se kterou jste vytvářel(a) účet, budou Vám na ni zaslány informace k nastavení nového hesla.

Přihlášení

Nemáte účet?  Registrujte se