Elsevier

The Lancet

Volume 370, Issue 9590, 8–14 September 2007, Pages 878-889
The Lancet

Series
Resources for mental health: scarcity, inequity, and inefficiency

https://doi.org/10.1016/S0140-6736(07)61239-2Get rights and content

Summary

Resources for mental health include policy and infrastructure within countries, mental health services, community resources, human resources, and funding. We discuss here the general availability of these resources, especially in low-income and middle-income countries. Government spending on mental health in most of the relevant countries is far lower than is needed, based on the proportionate burden of mental disorders and the availability of cost-effective and affordable interventions. The poorest countries spend the lowest percentages of their overall health budgets on mental health. Most care is now institutionally based, and the transition to community care would require additional funds that have not been made available in most countries. Human resources available for mental health care in most low-income and middle-income countries are very limited, and shortages are likely to persist. Not only are resources for mental health scarce, they are also inequitably distributed—between countries, between regions, and within communities. Populations with high rates of socioeconomic deprivation have the highest need for mental health care, but the lowest access to it. Stigma about mental disorders also constrains use of available resources. People with mental illnesses are also vulnerable to abuse of their human rights. Inefficiencies in the use of available resources for mental health care include allocative and technical inefficiencies in financing mechanisms and interventions, and an overconcentration of resources in large institutions. Scarcity of available resources, inequities in their distribution, and inefficiencies in their use pose the three main obstacles to better mental health, especially in low-income and middle-income countries.

Introduction

Mental health is an integral and essential component of health.1 Human, social, and financial resources will be needed to achieve the World Health Report objective of adequate access to effective and humane treatment for those who suffer from a mental disorder.2 We review here the availability, distribution, and use of such resources for mental health care worldwide. We have summarised available evidence, including from the relevant WHO publications and databases. The limitations of our review include its selective, rather than systematic, nature and its focus on mental health services, rather than on prevention and promotion, which have been discussed elsewhere.3, 4 The scope of our review is global but data show that the severest examples of scarcity of resources, inequity of distribution, and inefficiency of resource-use are in low-income and middle-income countries (as per the World Bank's classification).

These three themes—of scarcity, inequity and inefficiency—are inter-related and often seem to accentuate each other. For example, countries with fewer mental health resources commonly distribute them less equitably because they rely on private rather than collective financing mechanisms. In turn, the general neglect of mental disorders in under-resourced health systems can affect not only national productivity, but also individual quality of life.

Section snippets

Scarcity of resources

Information on resources for mental health care has been scant compared with information on prevalence, type, and burden of mental disorders. However, analysis of data from WHO's Atlas project (panel 1) shows widespread, systematic, and long-term neglect of resources for mental health care in low-income and middle-income countries.5, 6

Inequities in access to mental health care

Not only are resources for mental health scarce, but they are also distributed inequitably: between countries, between regions, and within local communities. Need and access tend to vary inversely—those with highest need have least access to care. The rate of mental disorders and the need for care are highest in poor people, those who are least educated, women, young people, and rural communities; yet these groups have low access to appropriate services. Within communities, disadvantaged

Inefficiencies in use of resources

Inefficiencies characterise all health systems, but are perhaps most visible when resources are already scarce and inequitably distributed. If mental health systems are analysed from the perspective of allocative efficiency (ie, whether the distribution of resources best meets a society's needs) the extent of untreated psychiatric morbidity and the high associated burden of disability suggest that resources for mental health are not distributed efficiently. Most low-income and middle-income

Implications for policy and practice

Scarcity of resources for mental health, inequity in access to them, and inefficiencies in their use have serious consequences, the most direct of which is that people who need care get none. The treatment gap—the proportion of those who need but do not receive care—is too high for some mental disorders. As many as one in three individuals with schizophrenia and other non-affective psychoses do not receive any treatment.142 The treatment gaps for depression and dysthymia, bipolar illness,

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