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Need for increased budgetary allocation for quality mental health in Ghana: Some reflections

The World Health Organisation defines Mental Health as “a state of well-being in which the individual realises his or her abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community”.

Mental health can also be said to be the level of psychological well-being or an absence of mental illness. It is the state of someone who is functioning at a satisfactory level of emotional and behavioural adjustment“.

It also helps determine how we handle stress, relate to others, and make choices. Mental health is important at every stage of life, from childhood and adolescence through adulthood.

The World Health Organization {WHO} estimates that one in four people will experience a mental health condition in their lifetime. There has been growing recognition that neurological health and mental wellness, or lack thereof, is both a cause of and solution to global issues like violence, poverty and overall health.

What is mental illness?

Mental illness according to the American Psychiatric Association (APA) are “health conditions involving changes in thinking, emotion or behaviour (or a combination of these). They are associated with distress and/or problems functioning in social, work or family activities.

 

 

Global Burden of Mental Disorder.

According to the WHO 2005 report, 31.7% of all years lived with disability is attributed to MNS conditions (19). MNS disorders in many countries are among the ten leading causes of disease burdens in LAMICs (15). The WHO in 2017 declared major depressive illness as a leading cause of disability worldwide (20), whiles schizophrenia, alcohol misuse were also identified as key causes of disability (21).

In discussing funding for mental health, it is relevant to point out that, as a country, a tremendous amount of visionary thinking, scientific research, governmental leadership and public readiness has led us to where we are today. And now there is a need to focus on concrete solutions and steps to integrating a mental health budget line into the work of achieving the Sustainable Development Goals (SDGs).

 

Understanding mental health

  • Mental health is more than just the absence of mental disorders or disabilities.
  • Mental health or psychological well-being makes up an integral part of an individual’s capacity to lead a fulfilling life, including the ability to form and maintain relationships, to study, work or pursue leisure interests, and to make day-to-day decisions about educational, employment, housing or other choices.
  • Disturbances of mental well-being can adversely compromise these capacities and choices, leading not only to diminish functioning at the individual level but also broader welfare losses at the household and societal level.

With respect to children, an emphasis is placed on the developmental aspects, for instance, having a positive sense of identity, the ability to manage thoughts, emotions, as well as to build social relationships, and the aptitude to learn and to acquire an education, ultimately enabling their full active participation in society.

 

 

The Need for greater focus on Mental Health

Despite the obvious importance of mental health, it continues to occupy the back seat when it comes to the allocation of resources. This is due to the burden of infectious and non-communicable diseases which are given priority over mental health.

There are fundamental reasons why mental health needs to be a greater priority in development. First is that copious reference can be made to studies which show that of people with disability, people with psychosocial disability are the poorest and the most unemployed. The rates of unemployment among people with mental illness who have stabilized in their conditions remain unacceptably high in many countries including Ghana.

Employers do not trust people with mental illness to work. They are not accepted to work because they are thought to be possessed or contagious. It’s partly the social justice issue of not employing people with a disability, but also it is not good for development. If 1 in 4 people in their lifetime have a mental health problem and if that is not dealt with properly, quickly, effectively, then it is likely to even affect their family’s income catastrophically. And it will also impact the capacity of a country’s economy to grow. In a nutshell, the development of this country has been held back by the level of cases of untreated mental illness. Meanwhile, pathetically, budget or funding allocations for mental health remain scandalous and it is broadly encapsulated by stigma and ignorance. We continue to still witness pitiful contribution of money to mental health care — less than 1 percent of health budgets. That needs to urgently change!

 

 Strategies and Justification for improving mental health financing.

Financing is a fundamental building block on which the other critical aspects of any system rests. Similarly, adequate and sustained financing is a critical factor for the translation of plans into action, towards realization of a viable mental health system.

It is imperative that funding or financial systems for mental health care should be aligned so that they maximize quality and do not become an obstacle to quality improvement; noting that the goal of quality improvement is ultimately to respect the rights of people with mental disorders ensuring that they are provided with the best available care, increase self-reliance and improve the quality of life.  Under the Millennium Development Goals, mental health was overlooked. But under the Sustainable Development Goals, goals for health include well-being. For advocates of better mental health support systems in developing countries, the SDG goals are opening the doors to build awareness on the diverse needs of people with mental health and the discrimination they face.

 

Why mental health budget?

It makes economic sense to invest more in mental health. This is so because when cost- effective community level treatment is available there is substantial improvement in workforce productivity. The WHO & World Economic Forum (WEF) estimate that the global impact of mental disorders will amount to loss of economic output of $16 billion!

Budgeting for mental health service / programme enable transparency and accountability into the utilization of scarce resources, and ensures that the provision of mental health service remains a priority and is sustainable. Besides, an improved mental health budget has the potential to  articulate what physical and human resources are required to deliver a mental health service that is effective, efficient and of acceptable quality. Budgetary allocations to mental health will honour the various perspectives in the field, while inspiring a united vision of a person’s right to dignity and right to care and facilitate effective development of policies, strategic plans and programmes. A good mental health budget will bring forward those marginalized by psychosocial disability and those who have worked beside them to share their own unique experiences and insights on the intersection between mental health and poverty, health and peace.

However, the immense benefits that adequate funding resources holds for the effective delivery of mental health service in the country appears to have eluded political leadership in Ghana, except to say that in recent years there have been some good focus on mental health in terms of legislation (the legislative instrument for the Mental Health Act,846, 2012, has just been approved) and  some commendable commitment to release of funds to address some of the age-long challenges of the psychiatric hospitals, but resources remain severely inadequate as relatively insignificant levels of total heath budget are provided mental health. The trend is in line with the observation made by Shekhar Saxena.  Shekhar Saxena (The Lancet, 2018) stated that “the seriousness with which mental health is taken at a political and societal level has certainly increased. Investment however does not match ambition. We have the knowledge and all the technical tools we need to scale up care, but we do not have enough financing mechanisms nationally or internationally. Most Lower and Middle Income Countries (LAMIC) spends less than 1% of their total health budget on mental health.”

The question therefore policy makers ought to ask is whether they can afford  not to invest in mental health but can you actually not to – it would be playing with the human capital of the country and communities”.(The Lancet, 2018 vol. 392).

In effect, those at the helm of affairs have no option but to focus on mental health!

It is however, important to note that it takes some advocacy and policy-influencing actions on the part of stakeholders to achieve a specific change objective. It is within this context that reference can be made to a currently on-going project titled “Accessible and Quality Mental Healthcare for Poor and Marginalized Persons with Mental Disorders”. The project, funded by Star Ghana Foundation[i], is being implemented by the Mental Health Society of Ghana[ii] in collaboration with BasicNeeds Ghana[iii]. As part of implementing this project the National Executive Committee of the Mental Health Society of Ghana (MEHSOG), met in Accra on Wednesday, 23rd of August, 2019. The purpose of that meeting was for the National Executive Committee of MEHSOG to deliberate, develop and implement a user/carer-led advocacy on financing community mental health. The meeting considered wide-ranging issues that ensure quality mental health services, focusing particularly on the relevance of funding to achieve the desired quality in mental health.

In any fair discussion on funding for mental health in Ghana, it is relevant to point out that a tremendous amount of visionary thinking, scientific research, governmental leadership, civil society advocacy and engagements, public readiness has led us to where we are today- truly, some remarkable achievements have been made! However, now there is perhaps an even more need to focus on concrete solutions and steps to integrating a mental health budget line into the work of achieving the Sustainable Development Goals (SDGs) 3.4 and 3.5 where the essence of mental health is succinctly and incontrovertibly captured as follows.

Whereas 3.4 stipulates that ‘by 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being’; 3.5, admonishes nations to ‘Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol’.

 

Human resource argument

There is the human resource argument to make in order to justify the need for an increased funding for mental health. With a greater budget the issue of inadequate training of mental health professionals to augment the few available could be addressed. For a total population of approximately 29 million, there are currently 28 psychiatrists (0.11 per 100,000 population), 22 psychiatrists working in hospitals and 6 in the community;   35 Clinical Psychiatric Officers (0.18 per 100,000);   1,598 mental health nurses (6.6 per 100,000),   with 585 are working in the community and 1013 in the three psychiatric hospitals; and 338 Community Mental Health Officers (1.69 per 100,000). There is a total of 19 Mental Health Nurses currently manning vast districts across the country. In effect, there is not only dearth of trained personnel; there is also a situation where the distribution of human resource and services is extremely inequitable. For example in the 5 northern regions( North East, Savannah, Northern, Upper East and Upper West) there is no psychiatrist, only 2 psychologists and only 3 clinical officers; and indeed most services are concentrated in the southern part of the country, especially inpatient service. This affects the quality and efficiency of care to the people considering the ever increasing demand for support.

Although there has been improvement in the care which has now been decentralised from the tertiary level to the secondary and primary health care levels, inadequacy of the needed expertise to support this integration remains a challenge.  The Mental Health Authority is unable to train more staff because it does not have much funds for the purpose.

 

Service delivery argument

Quality is important for all mental health systems, from a variety of perspectives. From the perspective of a person with mental disorder, quality ensures that that he or she receives the care he or she requires and that his symptoms and quality of life has improved. From the perspective of the family member or care-giver, quality provides support and helps preserve family integrity. From the perspective of the service provider, quality ensures effectiveness and efficiency, and from the perspective of the policy maker, quality is the key to improving the mental health of the population, ensuring value for monies and accountability.

In order to provide quality, efficient, effective and sustainable mental health services thereby achieving SDG3.4 and 3.5 as a country, there is the need to task shift. In this regard there is the need to build capacity of Community Volunteers, Community Health Workers, Faith Based/Traditional Healers and the General Community to support in providing care.  This cannot be achieved given the allocated budget of less than 3%. Meanwhile, there is still high stigma and people with mental health problems are not accessing care due to the lack of adequate knowledge and understanding. There is however limited awareness creation exercise in the various communities all due to inadequacy of funds.

The low budget for mental health has meant that continuing education on mental health for primary health care (PHC) and specialist staff has been a huge challenge that confronts mental health and with dire consequences for the delivery of quality mental health services. There is the need for system of trainers for continuing education.  In view of the low funding to mental health over the years, ad hoc trainings have been commonplace, but what is actually required is a systematic coordinated approach with appropriate emphasis on practical competencies and a sustainable continuing education on regular basis.

Research has shown that there is a link between Mental Health and the various health intervention programmes such as Malaria, Diabetes, Cancer, Tuberculosis, HIV/AIDs, Maternal and Child Health care, among others. All these services as outlined, have adequate funding base both locally and internationally. However, these cases have symptomatic relationship with one or more mental health disorder, mainly depression and addressing it would lead to improved health outcomes. Yet, pitifully, mental health continues to receive the least funding support from the Ministry of Health.

 

Low funding for mental health have meant that the supply of psychotropic medicines remains poor and intermittent.  Mental health facilities in Ghana report that they only have around 20% of their psychotropic medicine needs, thus supply  is intermittent, and the   content is erratic, so that  medication for the mentally ill is perforce frequently changed or even stopped , leading to frequent unnecessary relapses, with the potential and/or likelihood of making patients resort to crime.

The issue of lack of Lack of funds and Quality oversight is also worth touching on. The Mental Health Act 2012 envisages that the MHA would be responsible for quality oversight of services, inspections and follow up of recommendations. However, there is as yet no framework for appraisal of service structures, processes and outcomes, nor for procedures for inspections and follow up of recommendations for lack of adequate funding support to the Authority. For the same reason, the Mental Health Authority has not yet commenced continuing professional development for coordinators on service development and quality oversight, which is key to ensuring quality in mental health service delivery across the country.

 

Health Technology Argument

As pointed out earlier, the provision of adequate levels of psychotropic medicines remains a high challenge for mental health in Ghana. Services are free per the mental health law, yet there are very little provisions for replenishing of these medicines. Therefore shortages are prevalent. Ensuring their continuous availability for optimum care is far-fetched since the Mental Health Authority is unable to meet its budget yearly due to the low allocation. Local production of the medicines are not able to meet the demand. Patients’ relapses are mostly on the increase. Psychotropic medicines are not included in the Essential Medicines List thereby making them not qualify for Insurance cover; there is no reimbursement of mental health services by the National Health Insurance Authority (NHIA).

An underlying factor seems to be that other medicines are issued on a cost recovery basis, so health facilities are happy to order them as they know they will be reimbursed by patients, but psychotropic medicines are free, so facilities know they will not get reimbursed by patients, so they do not order in supplies.

This is a situation which requires clear policy dialogue between the Mental Health Authority, Ministry of Health and the Ghana Health Service to resolve, with allocation of adequate funding, followed by clear communication of the decisions to affected agencies, and monitoring to ensure implementation.

 

Conclusion

The Government, through the Ministry of Health, Departments and Agencies in collaboration with development partners is working towards attaining the universal health coverage by implementing the various sections of the Sustainable Development Goals. However, it is extremely important to stress that universal health coverage which is health for all, can only be attained when the mental health of the people are well catered for, per the WHO definition of health.

As we, in Ghana, strive to meet  the April 2001 Abuja declaration that enjoins countries in the sub-region to commit at least 15% allocation of national budget to health, it would be most laudable if the allocation of mental health is revised upwards from the current 1% to support  in meeting the mental health needs of the people. when looked at from whatever angle, there is a solid case for investing in mental health, whether on the grounds of enhancing individual and population health and well-being, reducing social inequalities, protecting human rights, or improving economic efficiency. Arguably, the wealth of every nation is dependent on the sound mind in body and soul of the people. As has been alluded to, mental health is the bedrock of all health interventions and should therefore be given the highest priority it deserves.

 

By Fatawu Iddrisu

The Autor is the Chairman of National Executive Committee (NEC) and President of MEHSOG

 

 

 

 

 

 

 

 

 

 

 

 

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