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Mental illness: Still the Cinderella of global health systems research

By Angeli Rawat
on December 9, 2016

After attending the Fourth Symposium on Global Health Systems Research (Vancouver, Canada) themed “Resilient and responsive health systems for a changing world” we could not help but search for our lost glass slipper. Influenced by the catastrophic Ebola and Zika outbreaks, this flagship initiative of Health Systems Global (HSG) was immensely successful, if success can be measured by financial investment alone. With support from aid luminaries such as the Rockefeller Foundation, Bill and Melinda Gates Foundation, the Wellcome Trust, backed by the World Health Organization, more than 2000 participants attended hundreds of presentations on health system challenges and responses. The Symposium shifted thinking towards resilience and sustainability within health systems and revisited failures and successes of current health system strengthening efforts. Nonetheless there was a glaring oversight: the Symposium programme included little or no focus on mental health and the health system responses towards mental illness as a global health burden.

“No health without mental health”?

Approaching health systems holistically and accepting there cannot be health without mental health, we must consider the importance of mental health in health systems. Mental health is defined as “a state of well-being in which every individual realizes his or her own potential, 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”. Health system concepts like resilience and responsiveness – the overarching themes of the Vancouver symposium – are not exclusively macro terms. Within frameworks lie individuals and their dynamic interactions with social and political ecologies. Both health system processes and outcomes – whether resilience, responsiveness, or integration (the usual buzzwords) – are inextricably tied to structure and agency. While resilience and responsiveness focus on the collective, neither individual agency, nor its complex relationship with resilience and responsiveness as collective constructs should be overlooked. It is at this intersection where mental health research is vital. How can we foster resilient and responsive systems without resilient and responsive individuals? For a system to respond to crises (e.g., HIV, Ebola Virus Disease) individual participation in the response is required. However, mental illnesses often renders some incapable of such engagement. Improved population mental health is linked to poverty reduction and improved development outcomes, improved economic health system returns, and improved antiretroviral treatment adherence. Mental health, linked to seven of the Sustainable Development Goals (SDGs), is intertwined with the triple helix of sustainable development – economic, social, and environmental outcomes.

Mental Health: a fundamental but forgotten aspect of health systems research

We can only speculate on the reasons why mental health continues to be the Cinderella of important global health dialogues. Stigma can take on different dimensions, including peril or “otherness”, a condition one can control, concealability, course and stability, and social disruptiveness. These perceptions not only unfold in neighbourhoods and communities, but often in health facilities, amongst health care professionals. Mental health stigma is a profound barrier to care and treatment, and perhaps also to research.

Susan Sontag pointedly remarked, “Any important disease whose causality is murky, and for which treatment is ineffectual, tends to be awash in significance”. The causes, diagnoses, and treatment for the loosely knitted together spectrum of disorders that we know as “mental illness” remains devoid of coherence and consensus. The anti-psychiatry movement during the 1960s and 1970s – while sharpening our focus on the power disparities in psychiatric practice and the negative effects of institutionalisation – arguably also diluted global mistrust in scientific disciplines dedicated to mental illness. With no biological markers, the nebulous nature of mental illness makes it more challenging to explain, measure, research and treat compared to conditions with clear biological markers and those which directly cause death, such as tuberculosis, especially for funders.

In responding to health system shocks, we often myopically focus on survival to the detriment of well-being. Health system shocks (including outbreaks and natural, economic, political disasters) result in those who have experienced death and suffering being forgotten by the health system research and development communities. Ensuring a holistic (and arguably more effective and sustainable) response is an almost impossible ideal to guarantee if health systems are not attuned to the complex social determinants and intricacies of mental illness. Health system researchers must meet this ideal, both as a core function of responsive, resilient and equitable health systems, and by way of moral imperative. It is – from a scientific-moral point of view – less relevant to search for simple answers than to search for difficult ones: where the added value of health systems research lies.

HSR 2018 Liverpool: A call to action

Despite impressive recent strides made to bring mental health in global health dialogues, the omission of mental health at the Symposium highlights disconnect between mental health system discussions, and the more general health system discussion – especially in an era of integrative care. Well-integrated ties among global mental health actors, and policy makers and international governance structures are vital. The almost complete neglect of mental health in the MDGs and its tokenistic inclusion in the SDGs further underwrites the potential contributions that HSG can bring on a global level. Liverpool, home of the Fifth Global Symposium for Health Systems Research and some of the first dedicated mental health facilities by James Currie in the 18th century (as well as some local football teams that tend to challenge most fans’ nerves!), provides impetus for prioritising mental illness in global health systems research. We call on the 2018 organisers to include a strong mental health focus in Liverpool focusing on the following broad themes:

  1. The link between individual and population mental health and health system processes and outcomes (such as strengthening, resilience, responsiveness, functioning)
  2. Regional and country responses to mental illness
  3. Building integrated mental health systems in a global climate where mental illness is often disregarded as a serious priority

In its Vancouver statement, resulting from the recent Symposium, HSG concludes with the main objectives of the organisation, namely “improving the science needed to accelerate Universal Health Coverage (UHC); to be more inclusive and innovative towards achieving UHC; and to make health systems more people-centred”. We strongly feel that these ambitious goals are only attainable with sufficient attention for the mental health aspects of health systems. Left aside, we fear that the golden carriages presented at the next ball in Liverpool 2018 might turn out to be simple pumpkins after all…

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