ARTICLES

 

Global mental health in an unequal world: An interview with Shekhar Saxena

 

 

Suntosh R. Pillay

King Dinuzulu Hospital Complex, Department of Clinical Psychology, Durban, 4015 Nelson R. Mandela School of Medicine, Department of Psychiatry, University of KwaZulu-Natal, Durban, 4001. suntoshpillay@gmail.com

 

 

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ABSTRACT

Inequities in access to psychosocial care are well documented and intersect with a range of sociopolitical determinants of health; in particular, poverty, unemployment, and stigma. 'Mental Health in an Unequal World' was therefore an appropriate and urgent theme for World Mental Health Day 2020, as an opportunity to trouble the status quo. Shekhar Saxena has been at the forefront of reducing the treatment gap for people living with mental illnesses and has contributed greatly to advancing an agenda for radical reform across the world. A psychiatrist by training, he is now Professor of the Practice of Global Mental Health at Harvard University's T. H. Chan School of Public Health and served as Director of the Department of Mental Health and Substance Abuse at the World Health Organisation (WHO) from 2010-2018. He was the editor of The Lancet Series on Global Mental Health in 2007 and 2011, and The Lancet Commission on Global Mental Health and Sustainable Development 2018. In this interview Prof Saxena reflects on the gains and challenges of advocating for a more just, equitable, and healthier world. In particular, he discusses why he is optimistic about the role played by global mental health initiatives, such as WHO's Mental Health Action Plan; that for universal health coverage to be successful it must integrate mental healthcare at all levels; and that people living with mental illnesses must have a voice in decision-making structures.

Keywords: global mental health; inequality; World Health Organisation; social determinants; universal health coverage

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SP Prof, thank you so much for making the time for this interview. The theme of World Mental Health Day 2021, set by the World Federation for Mental Health, is about mental health in an unequal world. Are you optimistic that we are making progress in terms of reducing the inequities in mental healthcare?

SS Thank you Suntosh. Mental health is an area that really cuts across many dimensions. Obviously, it's part of health, but it has very close connections with a number of social, demographic, and economic variables, and we do know that we live in a world that is highly unequal, and to some extent becoming even more unequal. So, the threat to mental health is very large. Fortunately, the awareness about inequality and its impact on mental health is also increasing. I'm hoping that increased awareness will actually give rise to more action by policy makers.

SP What exactly is global mental health and how does global health play a role in reducing health inequities in the world?

SS Global mental health is a relatively recent discipline. A few decades ago, mental health was equated with psychiatry, which is a medical discipline. But with the efforts of many people, this area has become much wider and comprehensive, transitioning from psychiatry as a medical discipline, to mental health as an essential component of our life, our health, and our development. Global mental health also includes the concept of learning from each other. If there is an advancement that is taking place in South Africa, then other countries need to learn from that, and see to what extent it is applicable in their setting, and vice versa. It is also about populations. We look at how public policies can improve mental health for all. It has a very clear connection with living in an unequal world because that is a significant threat to population health. Unless we take care of that we will be failing in our objectives. We need a focused concentration on the social, demographic, and economic determinants of mental health and how those are equally important together with providing care for people who are already living with mental disorders.

SP When you look back at your time at the World Health Organisation (WHO), do you feel like WHO has made a contribution towards reducing the inequities in global mental health?

SS I was fortunate enough to work for WHO for more than 20 years and I had an opportunity to work on a global scale. WHO, as a convener of Ministries of Health and governments, gave me an opportunity to really look at the world from a mental health lens. With countries being at different stages, although progressing towards similar objectives, they're starting from very different points. WHO's leadership made a major difference to how the world looks at mental health and how the countries act upon that. Mental Health Action Plan that was passed by the World Health Assembly in 2013 was the first international agreement by the Ministries of Health. Just imagine: the poorest and richest countries sat in the same room and agreed to the same objectives and the same indicators and targets for global mental health; it's simply amazing.

Obviously political commitment needs to be also translated into action and some countries are doing that better than others, but at least there is a common goal. There is at least a common strategy to move forward. And I think those are the kind of things which only an organisation like WHO could have done. So yes, I think there is a lot of improvement. There is a lot of action and hope that more people living with mental disorders will receive the kind of care that they need.

SP You've played quite a major role in developing that action plan. Do you feel like low- and middle-income countries (LMICs) have stepped up and actually made the kinds of commitments that were laid out?

SS The action plan has now been extended to 2030 by the World Health Assembly, so that's good news because the countries have reiterated their commitment to the goals and there is a renewed agenda for what the countries could do. It is very obvious that LMICs spend far less money on mental health compared to the other areas of health, and also that their health budgets are smaller. So, the investments in terms of money as well as in terms of human resources, in most LMICs are very small indeed.

WHO's effort is to provide technical guidance to them in two ways. Why should they invest more, and also how they should be able to utilise these resources in the most effective manner. So, the era of having large mental hospitals outside the main cities, and looking after patients on a custodial basis, is really over. Mental health services should be integrated within the overall health services, taking into account the commitments of universal health coverage. And many countries are actually doing it. You asked whether LMICs are moving forward. My clear answer is 'Yes, they are moving forward in a systematic manner making some progress'. Not as much as they committed for, but something is better than nothing. The proportion of people receiving care has increased, the quality of care has improved, and their human rights are better protected.

SP Social and political determinants of health play a large role in reducing inequities. In particular, South Africa is trying to pass a National Health Insurance bill through Parliament to create a central fund in order to improve universal health coverage (UHC) in this country. Based on your research and your work around UHC, if you were advising our health sector, what are some of the biggest lessons that you've learned in your work, around how to increase universal mental health coverage in specific countries?

SS Mental health should be an integral part of UHC. We're not living in times where specialised mental healthcare should be available on a segregated basis. We are living in a time where mental healthcare has to be included and integrated at all levels of healthcare, starting from basic primary care to highly specialised care. If that is the objective of the mental health policy within South Africa, which I understand it is, then the insurance strategy must follow that. If the financing mechanisms can take care of that, as a part of the state's endeavour, that will be a huge step forward.

SP I was reading an article you wrote, and one statistic really stuck out for me: you said that people living with major depression and schizophrenia are estimated to have a 40 to 60% greater chance of dying prematurely compared to the general population. That should be something to make any politician or health minister stand up and take notice of how important it is to increase mental health financing. But it does seem like politicians hold the purse strings tightly. What are some of the strategies that you've used to convince governments, in particular countries that don't see the reason to invest in mental health, to actually allocate a greater proportion of their health budget towards that?

SS Thank you for quoting those statistics because they are, of course, very useful for convincing the policymakers to invest more. On average, people with mental disorders die about 15 to 20 years earlier than the general population, largely because they have lifestyle risk factors. Often, they are obese, don't exercise, don't eat well, smoke more, and get chronic diseases, which eventually kill them. And so that is the other argument for integrating general healthcare with mental healthcare. When a person with depression or psychosis goes to their healthcare provider, the provider not only needs to take care of their mental health, but also the other factors which are leading to deterioration of physical health.

So, how do we convince policymakers to invest more in mental health? I often say that when it comes to mental health, all countries are developing countries, so there is not too much of a difference between South Africa and a country like USA. None of them have got it right. So, at all stages of a country's development for mental health, they can do a lot. And a country like South Africa, which already has, I believe, a good primary healthcare system, integration, and allocation of adequate resources for training can actually be the key to very quick success. Imagine a country which doesn't have primary care; what do you integrate mental health in? Which is not the case in South Africa; you have a robust primary care system and so it is much easier for a country like South Africa. When a politician says, for example, that mental health is something that doesn't give you enough return, there is now adequate evidence that the investments in mental health are cost effective and give you a return on investment, similar to many chronic diseases. So, when the healthcare system is investing in diabetes, cancers, or cardiovascular illness, the returns on treatment for depression, psychosis, and anxiety are very similar. There is no reason not to invest in this. Altogether, there are many arguments one can use; it depends on which ones are likely to work best in a particular country at a given time.

SP Have you seen any remarkable innovations that you wish more countries will roll out, or scale up, that you think perhaps is not being used enough?

SS The first innovation is actually provision of care by less trained and non-specialised workers, which includes general doctors and nurses, but also people even less trained than them, such as primary healthcare workers or peer counsellors. They can actually do an amazing job in providing care at that level. Of course, they cannot take care of everything, but they can contribute and decrease the burden on specialised staff.

Another innovation is the involvement of people living with mental disorders, which is absolutely critical. I am happy to know that South Africa is actually doing a lot of that. The Global Mental Health Peer Network is based in South Africa. When you decide on policies and services, you need to have people living with mental disorders around the table, because they will be able to give you good advice and suggestions. Mental health is too important a topic to be left just to professionals or to policymakers. The people who live with mental disorders and their families should be part of the decision-making process.

SP When you look into the next 10 years, if you could gaze into your crystal ball, what are the kinds of conversations that you are hoping we'll be having about mental health in the future, if we were having this conversation in 2031?

SS Thank you for asking that question. I see a lot of optimism around global mental health. The COVID-19 pandemic is a very major threat to the health of people, but the conversation around mental health has become more widespread and being talked about in the media, including social media. I hope that conversation will actually lead the way into more action and more investments. It's yet to happen, but I hope that in the coming years, we will be much more aware of mental health being important for all of us. We need to develop action plans at country level and community level, which will bridge the gap between what is needed and what is available. So, if we can see the opening up of dialogue and action from health facilities to communities, that is what I'm hoping for. I think the chances are high, especially with the advocacy that is going around for World Mental Health Day. There will definitely be more improvement in the coming years.

SP Prof, you obviously seem quite optimistic about the future, despite your long career in mental health, you don't sound like you are jaded or pessimistic about us moving forward in the world. How do you keep motivated in terms of your own work and how do you keep an optimistic attitude?

SS Well, I am an optimist by nature, but especially in this area. I think the confluence of newer stakeholders joining the mental health discussion is something that gives me a lot of hope and a lot of optimism because mental health now has become much more broad-based; it's not only the professionals but the general community is joining in and contributing to the effort. And I'm very especially happy with young people joining in; celebrities like sportspersons and film stars are talking about their own mental health and that is really a very positive development. So, some of these things really keep me working towards our objectives. We are at least strengthening our movement.

SP On a personal note, how do you take care of your mental health?

SS I think you're asking a very important question, because we need to ask ourselves that question all the time. Unfortunately, healthcare providers sometimes ignore their own mental health. The message is, if you don't look after your own health and mental health, you will be less effective in providing the care that you were supposed to provide to others. So yes, we do need to look after our mental health.

I personally do pay a lot of attention to my own mental health and many activities which give me resilience and motivation, which are part of my routine. Taking long walks to introspect about what has worked and what has not and learning from it. I also try to experience a sense of gratitude, which is very effective in promoting mental health.

SP Thanks Prof, that's really useful advice for everyone. Is there any new and exciting work that we should look out for from you?

SS Well, two things. United for Global Mental Health have published a report on suicide prevention, especially focusing on the decriminalisation of suicide. Twenty countries still have laws against people who attempt suicide and that is very sad and very harmful. I was involved in that report and I would suggest that this report attracts the attention of policymakers if they come from a country that still has some elements of criminalization of suicide. These should be removed immediately.

The second report is the Countdown Global Mental Health 2030, which is a follow-up step to the Lancet Commission on Global Mental Health and Sustainable Development from 2018. The countdown is going to have a set of indicators to compare countries as to where they are on mental health of children and caregivers. That's the kind of evidence base that we need to track progress in the future and also to compare across countries. That's the kind of work that I really enjoy because that gives us information for advocacy. That's the kind of evidence that we need to provide to policymakers.

Acknowledgements:

Thank you to Angie Mcintosh for transcribing this interview.

Declarations:

The author has no conflicts of interest.

 

 

This is an edited version of the interview originally done for the annual Durban Mental Health Symposium, a non-profit venture hosted annually by the KwaZulu-Natal Mental Health Advocacy Group. The full interview is available to watch online on Youtube.