Healthy bodies cannot exist without healthy minds and, as such, the architecture for universal health coverage must be designed around the mental, as well as the physical
By Vikram Patel, Pershing Square professor of global health at Harvard Medical School, and Shekhar Saxena, visiting professor at Harvard T H Chan School of Public Health
Universal health coverage is a focus at this year’s G7 and G20 summits and the United Nations General Assembly in September. Therefore it is important to remind all those participating: there can be no universal health coverage without mental health. Mental health is not only an intrinsic part of a truly universal health system but universal health coverage is critical for significant improvement in mental health outcomes.
Long before the Sustainable Development Goals and the renewed push towards universal health coverage, the United Nations in 1966, declared that “the right of every human being to the enjoyment of the highest attainable standard of physical and mental health”. Yet health systems development and resources for health have never matched the parity mental and physical health were given in international law.
The world left mental health behind.
The impact of omitting mental health from health policies and budgets is stark (see bullet points) and the statistics demonstrate the immense burden of untreated mental disorders on individuals, families, communities and economies. For individuals, mental health may have the highest treatment gaps for any health condition in all countries. For countries, when it comes to mental health every country is a developing country.
Moreover, mental and physical health cannot be separated. Individuals with unsupported mental health conditions, such as depression, anxiety and substance use disorders, are less likely to seek testing for HIV, and less likely to follow advice following their test result.
Mental health conditions adversely affect medication adherence for HIV, tuberculosis and TB/HIV co-infection, and are significant risk factors for developing drug resistance, loss to follow up and death. It is hard to see how the global HIV target of 90-90-90 will be reached without investment in mental health services.
Replenishment for the Global Fund this year falls on World Mental Health Day – an appropriate moment to demonstrate the importance of integrating mental health to help achieve global HIV targets.
In the 2018 report of the Lancet Commission on global mental health and sustainable development, we argued that mental health must be reframed within the sustainable development framework and that mental health care is an essential component of universal health coverage.
Successfully incorporating mental health is core to the three principles of universal health coverage.
Universal health coverage is a rights-based approach to health. An equity approach will significantly improve mental health outcomes for sub-groups in populations – often the poorest and those most marginalised such as refugees or sexual minorities – who disproportionately experience mental health conditions.
Yet health system reform to achieve universal health coverage too often omits mental health services. These population groups are also less likely to use digital technology and more likely to experience discrimination, isolation and premature mortality, and so specific sensitive planning must be undertaken. Universal health coverage must include equitable access to mental health services.
Community-based services centred in primary healthcare systems provide the best opportunity to cover entire populations including those hardest to reach. This requires diversifying from the currently high proportion of spending on mental health institutions and other tertiary-level care. Without full integration, universal health coverage can never truly be achieved.
Universal health coverage means delivering an essential service package of adequate quality that meets the needs of the population.
If mental health services are not included, this cannot be achieved. An essential package must include the full range of mental disorders, particularly severely disabling conditions such as schizophrenia, alcohol dependence and dementia, while responding to the disease burden of the population.
Integration must also emphasise quality of care both for the mental disorder – in particular to abolish the use of coercive, harmful and abusive practices – as well as for co-existing physical health conditions, for these are common and significant contributors to premature mortality.
Not having the ability to pay should never be a barrier for accessing treatment. The vast majority of mental health services are low cost with a high return on investment – depression services alone return $5.3 for every $1 invested.
Universal health coverage will not be achieved unless national health budgets increase so that health systems are almost entirely financed by progressive, domestic funds.
However, mental health is so far behind that in many countries, international strategic financial stimulus is needed to kick start systemic change. Simply, $1 billion of global aid per year is needed, for 5% of health budgets allocated to mental health in low- and middle-income countries and 10% in high-income countries.
Ultimately, universal health coverage depends upon political will. So too does the inclusion of mental health. Much political will is attained, demonstrated and acted upon at global moments and 2019 is a significant year for universal health coverage – and therefore mental health.
The High Level Meeting on UHC in September is a key moment for national and international commitments to accelerate political and financial support for mental health as part of universal health coverage, as are the G7 and G20 meetings and the replenishment of the Global Fund.
This year can change the course for mental health if world leaders recognise the importance of good mental health and act to achieve parity of physical and mental health, starting with universal health coverage.