I have
seen the negative impact of the UN’s failure to incorporate mental health
within the millennium development goals (MDGs). Working on various mental
health projects in several African countries, I saw how the health budgets of
resource-strapped countries were diverted towards MDG projects. Many NGOs
providing essential community psychiatric support were near collapse, or forced
to alter their objectives to secure sufficient funds.
While
almost half of the MDGs focused on physical health, mental health was conspicuously
absent even though, at the time, approximately 450 million people worldwide
were living with a mental illness. The UN sidelined mental health even though
mental impairment falls within its own definition of “disability” in the
convention on the rights of persons with disability (CRPD).
By 2030,
the final year of the sustainable development goals (SDGs), depression is
predicted to be the world’s biggest medical burden, and over the next 20 years
the cumulative lost economic output due to mental illness will be $16tn
(£11tn). However, only a few countries devote more than 10% of their total
health budget to mental health.
Happily,
mental health is included in the new SDGs, even if the word “mental” does not
actually feature. Goal 3 seeks to “ensure healthy lives and promote wellbeing”
for everyone – a significant improvement. Unfortunately, this loose phraseology
will inevitably result in competition for international funding between mental
health NGOs and other organisations with missions in sport, nutrition or the
arts, for example.
It is
also disappointing that only two of the 13 targets under SDG3 – 3.4 and 3.5 –
relate to mental health, and that in the final global indicators (pdf) relating
to the goal, only two of 26 are specific to mental health. One of the
provisional indicators which would have required data collation on service use
by those with severe mental disorders, mirroring a provision in the WHO mental
health action plan (pdf), did not make the final cut. This was hardly the
parity those working in mental health had hoped for.
But
mental health has never had parity with physical health. Despite compelling
economic arguments for investing in mental health, stigma perpetuates the lack
of resources allocated.
So what
can be done? A mental health law which enshrines the rights of those with a
mental illness and gives them the right to treatment could help diminish stigma
by educating people about human dignity and rights, in addition to protecting
and empowering patients. A law can also frame policy, encourage prevention
strategies, and set minimum skills for accreditation of mental health
professionals and psychiatric facilities. While the UK’s 1983 Mental Health Act
is far from perfect, it has done much to realise the rights of the mentally
ill.
Nearly
two thirds of the world either has no mental health legislation or has a law
more than ten-years-old, and the 2030 agenda does not require the
implementation of mental health legislation to enforce obligations, such as the
right to access appropriate treatment.
Furthermore,
for mental health legislation to have any real effect, there must be the
political will to support it. It can be difficult to persuade low-resourced
countries to do this, especially when there are many other pressing health
problems.
Even
where legislation exists, a patient’s ill health may prevent access to legal
redress for human rights violations. Healthcare workers should inform patients
at regular intervals of their rights under a statute. The procedure for
challenging failures in implementation or non-compliance with legislation must
be simple and clear, and ideally free legal assistance should be provided. To
comply with international treaty obligations and best practice, an independent
body to hear inpatients’ appeals against the removal of their liberty must be
established.
Naturally,
this requires significant funds and the global community can make a huge impact
by funding the development or amendment of a law, legal expertise, training for
local lawyers, advocates and healthcare workers, as well as independent
monitoring and impact evaluation.
The good
news is that there is finally a real drive to move mental health from the
margins into the mainstream of the global development agenda. This month, the
World Bank and the WHO co-hosted a high level meeting on global mental health
(pdf) and development priorities, seeking parity between mental and physical
health (appropriately headed Out of the Shadows).
If
nations comply with the CRPD and other international human rights treaties,
we’ll be able to see evidence that SDG3 and SDG16 are being met. Meanwhile,
mental health lobbyists should press for additional indicators on SDG3 to
measure mental health improvements – in particular an indicator requiring the
introduction or updating of mental health legislation.
The
global community must ensure that those with mental illness are not left
behind. The world has a duty to spearhead positive change, and to prevent the
continued marginalisation of the mentally ill. Let’s not miss this opportunity.
Laura
Davidson
Laura Davidson is barrister and international
development consultant specialising in mental health and mental capacity law.
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