Mental Health Financing in Africa: Building resources to overcome historical inequalities

The financing of mental health is a neglected priority in sub-Saharan Africa. According to the latest World Health Organization Atlas report, African countries spend $0.10 per capita on mental health (in contrast with $21.7 per capita in the European region)1. There is also weak financial risk protec-tion for mental health; in 43% of African countries, people pay mostly or entirely out of pocket for mental health services. These financing deficits are reflected in inadequate human resources to provide mental health care; there are 9 mental health workers for every million people in the African region. In turn this is reflected in a massive treatment gap; more than 90% of people living with a mental health condition receive no evidence-based care.

This dire situation is likely to have been worsened by the COVID pandemic, in at least three impor-tant ways. First, the pandemic has had a direct effect on the mental health of populations in low and middle-income countries (LMIC);2 second the economic impact of the pandemic on employ-ment rates, poverty and food insecurity, may in turn have adversely influenced mental health;3 and third the treasuries of African governments and international development agencies now have reduced fiscal space to invest in mental health care systems.

Nevertheless, the current crisis also brings new opportunities. Now, perhaps more than ever before, there is a growing public awareness of the importance of mental health, through discussion in the media and other public fora of the mental health consequences of COVID.

There is also growing evidence for how African countries can better invest in mental health. An example of a set of optimal financing models has been identified by the “Emerging mental health systems in low and middle-income countries” (Emerald) project.4 Emerald recommended the in-clusion of packages of care for mental health in ongoing universal health coverage (UHC) reforms, and suggested approaches for improving the efficiency of current spends and generating new resources.

While approaches to the integration of mental health within the health financing reform process will be unique to each context, core components of such an endeavor should include several com-mon features, as follows:

  • A comprehensive understanding of the burden of disease due to mental health conditions and extant treatment coverage is required for adequate needs assessment.
  • Developing context-specific investment or business cases for mental healthcare is essential to advocate for increased domestic and international resourcing.
  • A budgeted resource plan is needed that explicitly identifies a defined package of care drawing on the evidence base for cost-effective interventions to address mental health conditions.
  • Ensuring strong engagement across key governmental and non-governmental stakeholders is vital to ensure political buy-in and consensus. Enhanced governance and planning capacity, as well as improved monitoring and evaluation processes will be key to facilitating these process-es. [4].

In addition to financing models, there is also emerging evidence for how efficiencies can be im-proved to optimize expenditure in African countries. This includes addressing current inefficien-cies in the use of resources by shifting from hospital-based models of care to new investments in primary health care and community service provision; the integration of mental health in broader primary healthcare services, including task-shifting mental healthcare to non-specialist providers in tandem with increased training and strong specialist supervision structures; and the provision of early interventions for at-risk populations. [5]

In Ghana and South Africa, work has recently been conducted to develop national investment cases for mental health. In Ghana, preliminary work on an investment case was conducted as part of the Ghana Somubi Dwumadie programme . In South Africa, our investment case for mental health has involved three key steps: [6]

  • We calculated the current cost of mental health service expenditure.5 Among other things, this showed that the national Department of Health currently spends approximately 5% of its budget on mental health (provincial range: 2.1–7.7% of provincial health budgets); that most of this funding (86%) is spent on hospital services when it could be more efficiently and effectively spent on primary care and community-based services; and that 18% of the total mental health budget is spent on re-admissions to inpatient facilities, reflecting a highly inefficient revolving door pattern of care.
  • In consultation with a wide range of stakeholders at national and provincial level, we identified a core package of services, health system inputs and related infrastructure investments that need to be scaled up. This focused on modeling an increasingly decentralized system of care over a 15-year period, with new investments in primary care and community-based care. It also included investments in three other key sectors: (1) in the education sector, in the form of social and emotional learning programmes, to be delivered in schools to promote the mental health and well-being of children and adolescents, and to prevent mental health problems; (2) in the social development sector to address alcohol and substance-use; and (3) in the housing sector to ensure capital investments in community-residential care infrastructure.
  • Using an adapted version of the WHO Inter-UN OneHealth Tool, we calculated the return on investment, in terms of healthy life years, prevalent cases and mortality averted, as well as improved economic productivity over a 15-year period. This showed clearly that the cost of inaction to the South African economy far outweighed the cost of investing in the mental health of the population. When expressed as an annual amount, lost workforce productivity estimat-ed for South Africa translates to approximately US$ 10.9 billion annually; or approximately 4%of the country’s gross domestic product (GDP). This is in stark contrast to an average annual estimate of US$ 1.8 billion to scale-up mental health services in South Africa over the 15-year period. In short, investing in mental health is not only important from a human rights perspec-tive, but also makes good economic sense.

These new methodological innovations in calculating the costs and the return on investment for scaling up mental health care in South Africa can be adapted to other African countries. They rep-resent a new opportunity to mobilise finances from governments as well as International Develop-ment assistance from external organizations, in order to improve the mental health and well-being of African citizens. Recent analysis of international development assistance for mental health in LMIC shows that this assistance is not always well aligned with mental health needs in these coun-tries.7 The development of African-based mental health investment cases, tailored to the needs of African countries represent a step change, with the potential to fund mental health services in places where it is needed most.

To conclude, there has been growing global awareness about the importance of mental health as both a driver of social and economic development and a worthy goal of such development. The time is long overdue for improved and sustained investment, with the goal of building the mental health and resilience of African populations, particularly children and adolescents, who will face tomorrow’s social, environmental and economic challenges.

References

  1. WHO. Mental Health Atlas. Geneva: WHO; 2017.
  2. Kola L, Kohrt BA, Hanlon C, et al. COVID-19 mental health impact and responses in low-income and middle-income countries: reimagining global mental health. Lancet Psychiatry 2021; 8(6): 535-50.
  3. Lund C, Brooke-Sumner C, Baingana F, et al. Social determinants of mental disorders and the Sustainable Develop-ment Goals: a systematic review of reviews. Lancet Psychiatry 2018; 5(4): 357-69.
  4. Chisholm D, Docrat S, Abdulmalik J, et al. Mental health financing challenges, opportunities and strategies in low- and middle-income countries: findings from the Emerald project. BJPsych Open 2019; 5(5): e68.
  5. Docrat S, Besada D, Cleary S, Daviaud E, Lund C. Mental health system costs, resources and constraints in South Africa: a national survey. Health Policy and Planning 2019; 34(9): 706-19.
  6. Besada D, Docrat S, Lund C. Mental Health Investment Case for South Africa. Final Report of the Mental Health Investment Case Task Team. . Pretoria: Department of Health; 2021.
  7. Iemmi V. Global collective action in mental health financing: Allocation of development assistance for mental health in 142 countries, 2000-2015. Soc Sci Med 2021; 287: 114354.

Authors: CRICK LUND [1, 2], SUMAIYAH DOCRAT [3], DONELA BESADA [1, 4]

  1. Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s Global Health Institute, King’s College London
  2. Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town
  3. Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town
  4. Health Systems Research Unit, South African Medical Research Council

View or download the WFMH World Mental Health Day educational and campaign material