The past two decades have seen an unprecedented increase in efforts to address global inequalities in physical health care, particularly as part of the UN's Millennium Development Goals (MDGs) initiative. Resources targeting HIV/AIDS, tuberculosis, malaria, and maternal and child health have increased substantially. Development assistance for health grew from US$5·6 billion in 1990 to $21·8 billion in 2007,1 and there have been similar increases in education and social development activities. Less progress has been seen in the response to mental, neurological, and substance misuse disorders, despite the identification of the large treatment gap2, 3 and a consensus that improved access to mental health care could provide new hope for people with these disorders, especially in the poorest countries of the world.4, 5
Key messages
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There are many examples of mental health initiatives being developed worldwide.
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There is a need to scale up such services in low-income and middle-income countries so that more people can benefit; however, thus far very few innovative services have achieved this goal.
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Barriers to the scaling up of services should be strategically and systematically considered and addressed. Key to this process is to involve all stakeholders, including decision makers to ensure their support and to facilitate sustainability of services, as well as people using mental health services.
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Services should be both evidence-based and locally relevant, ensuring that they take into account all aspects of existing systems.
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Assessment of examples of scaling up is important so that conclusions can be implemented in a practical way. These conclusions should be disseminated in a format that is accessible to implementers of services.
In 2007, The Lancet presented a Series of papers on global mental health that reviewed the global state of mental health systems,5, 6 summarised the evidence for effective treatments,7 identified barriers to service improvement,8 and examined existing and required resources for mental health care.9 The series concluded with a call for global action to increase access to mental health services—a process referred to as scaling up.10 In this report, we assess global progress in scaling up of mental health care in low-income and middle-income countries since 2007.
Definitions of scaling up typically refer to an objective with several common components: an increase in the number of people receiving services (coverage); an increase in the range of services offered; services that are built on a scientific evidence base, usually with a service model that has been shown to be effective in a similar context; services made sustainable through policy formulation, implementation, and financing (strengthening of health systems).
Scaling up has also been used to refer to a process, which includes mobilisation of political will, human resource development, an increase in the availability of essential medicines, and monitoring and evaluation.11 WHO has described scaling up as “deliberate efforts to increase the impact of health service innovations successfully tested in pilot or experimental projects so as to benefit more people and to foster policy and programme development on a lasting basis”.12
Much research on scaling up focuses on resource availability, identification of barriers, and service delivery issues.11 We have followed this outline in our report. Progress in scaling up of services could most accurately be measured by comparing change in effective coverage—ie, the proportion of people with a mental disorder who receive appropriate treatment.13 However, such information relating to coverage is not widely published in governmental or scientific literatures, particularly from low-income and middle-income countries.14, 15 The absence of available baseline prevalence and service use data in these countries makes accurate measurement of coverage impossible, although recent data suggest that across the range of mental disorders, only a third of people with mental health disorders are treated in high-resource countries, and as few as 2% of people with such conditions are treated in some low-income and middle-income countries.16, 17
We therefore used a combination of a systematic review of published literature and a survey of key informants (panel 1). We aimed to gather as comprehensive and up-to-date a view as possible of the extent of scaling up of mental health services in countries with low and middle incomes. Additionally, we have been able to identify many programmes from which we drew out themes related to challenges and practical solutions for making progress in scaling up of services.
The literature review and survey identified many examples of services being scaled up (see webappendix pp 10–19), but few met all of our criteria. There were some published descriptions of services that were scaled up to cover increased population numbers (eg, in Brazil,20 Chile,21 and China22), but most reports described early stages of reorganisation of services23, 24, 25 or preparation of policy and legislation.26 This outcome could in part be attributable to the length of time needed to plan, implement, and evaluate programmes. Almost half the respondents to the survey reported that progress in their country towards scaling up of services since 2007 had been “good” or “very good” (figure 2A).