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June 2010
WPA guidance on steps, obstacles and mistakes to avoid in the implementation of community mental health care

GRAHAM THORNICROFT1, ATALAY ALEM2, RENATO ANTUNES DOS SANTOS3, ELIZABETH BARLEY1, ROBERT E. DRAKE4, GUILHERME GREGORIO3, CHARLOTTE HANLON2, HIROTO ITO5, ERIC LATIMER6, ANN LAW1, JAIR MARI3, PETER MCGEORGE7, RAMACHANDRAN PADMAVATI8, DENISE RAZZOUK3, MAYA SEMRAU1, YUTARO SETAYA5, RANGASWAMY THARA8, DAWIT WONDIMAGEGN2

1Health Service and Population Research Department, Institute of Psychiatry, King’s College London, UK; 2Department of Psychiatry, Faculty of Medicine, Addis Ababa University, Addis Ababa, Ethiopia; 3Department of Psychiatry, Universidade Federal de São Paulo, Brazil; 4Dartmouth Psychiatric Research Center, Lebanon, NH, USA; 5National Institute of Mental Health, National Centre of Neurology and Psychiatry, Tokyo, Japan; 6Douglas Mental Health University Institute and McGill University, Montreal, Canada; 7New Zealand Mental Health Commission, Wellington, New Zealand; 8Schizophrenia Research Foundation (SCARF), Chennai, India

This paper provides guidance on the steps, obstacles and mistakes to avoid in the implementation of community mental health care. The document is intended to be of practical use and interest to psychiatrists worldwide regarding the development of community mental health care for adults with mental illness. The main recommendations are presented in relation to: the need for coordinated policies, plans and programmes, the requirement to scale up services for whole populations, the importance of promoting community awareness about mental illness to increase levels of help-seeking, the need to establish effective financial and budgetary provisions to directly support services provided in the community. The paper concludes by setting out a series of lessons learned from the accumulated practice of community mental health care to date worldwide, with a particular focus on the social and governmental measures that are required at the national level, the key steps to take in the organization of the local mental health system, lessons learned by professionals and practitioners, and how to most effectively harness the experience of users, families, and other advocates.

Key words: Community mental health care, balanced care model, mental health services, human rights, community awareness, human resources, psychiatrists, training, quality assurance

(World Psychiatry 2010;9:67-77)

In 2008 the WPA General Assembly approved the Action Plan of the Association for the triennium of the Presidency of Professor Mario Maj. One of the items of the Plan is the production of guidelines on practical issues of interest to psychiatrists worldwide (1,2). The present document, providing guidance on lessons learned and mistakes to avoid in the implementation of community mental health care, is part of that project. In subsequent publications we shall describe in more detail the particular challenges and solutions identified in the various regions worldwide.

Mental health problems are common, with over 25% of people worldwide developing one or more mental disorders at some point in their life (3). They make an important contribution to the global burden of disease, as measured by disability-adjusted life years (DALYs). In 2004, neuropsychiatric disorders accounted for 13.1% of all DALYs worldwide, with unipolar depressive disorder alone contributing 4.3% towards total DALYs. In addition, 2.1% of total deaths worldwide were directly attributed to neuropsychiatric disorders. Suicide contributed a further 1.4% towards all deaths, with 86% of all suicides being committed in low- and middleincome countries (LAMICs) each year (4). A systematic review of psychological autopsy studies reported a median prevalence of mental disorder in suicide completers of 91% (5). Life expectancy is lower in people with mental health problems than in those without (in some countries dramatically so) also due to their higher levels of physical illnesses (6). Mental health problems, therefore, place a substantial burden on individuals and their families worldwide, both in terms of diminished quality of life and reduced life expectancy. The provision of high-quality mental health care is vital in reducing some of this burden (7).

In this context, the aim of this report is to present guidance on the steps, obstacles and mistakes to be avoided in the implementation of community mental health care, and to make realistic and achievable recommendations for the development and implementation of community-oriented mental health care worldwide over the next ten years. It is intended that this guidance will be of practical use to psychiatrists and other mental health and public health practitioners at all levels, including policy makers, commissioners, funders, non-governmental organizations (NGOs), service users and carers. Although a global approach has been taken, the focus is mainly upon LAMICs, as this is where challenges are most pronounced.

WHAT IS COMMUNITY-ORIENTED MENTAL HEALTH CARE?

There are wide inconsistencies between, and even within, countries in how community-oriented care is defined and interpreted. Historically speaking, in the more economically developed countries, mental health service provision has been divided into three periods (8):

  • The rise of the asylum (from around 1880 to 1955), which was defined by the construction of large asylums that were far removed from the populations they served.
  • The decline of the asylum or “deinstitutionalization” (after around 1955), characterized by a rise in community-based mental health services that were closer to the populations they served.
  • The reform of mental health services according to an evidence-based approach, balancing and integrating elements of both community and hospital services (8-10).

Within a “balanced care model”, most services are provided in community settings close to the populations served, with hospital stays being reduced as far as possible, and usually located in acute wards in general hospitals (11). Differing priorities apply to low, medium and high resource settings:

  • In low-resource settings, the focus is on establishing and improving the capacity of primary health care facilities to deliver mental health care, with limited specialist back-up. Most mental health assessment and treatment occurs, if at all, in primary health care settings or in relation to traditional/religious healers. For example, in Ethiopia, most care is provided within the family/close community of neighbours and relatives: only 33% of people with persistent major depressive disorder reach either primary health care or traditional healers (12,13).
  • In medium-resource settings, in addition to primary care mental health services, an extra layer of general adult mental health services can be developed as resources allow, in five categories: outpatient/ambulatory clinics; community mental health teams; acute inpatient services; communitybased residential care; and work, occupation and rehabilitation services.
  • In high-resource countries, in addition to the above-mentioned services, more specialized ones dedicated to specific patient groups and goals may be affordable in the same five categories described for medium-resource settings. These may include, for instance, specialized outpatient and ambulatory clinics, assertive community treatment teams, intensive case management, early intervention teams, crisis resolution teams, crisis housing, community residential care, acute day hospitals, day hospitals, non-medical day centres, recovery / employment / rehabilitation services.

It is this balanced care model approach that has been taken here in considering community-oriented care. In lowresource settings, community-oriented care will be characterized by:A focus on population and public health needs.

  • Case finding and detection in the community.
  • Locally accessible services (i.e., accessible in less than half a day).
  • Community participation and decision-making in the planning and provision of mental health care systems.
  • Self-help and service user empowerment for individuals and families.
  • Mutual assistance and/or peer support of service users.
  • Initial treatment by primary care and/or community staff.
  • Stepped care options for referral to specialist staff and/or hospital beds if necessary.
  • Back-up supervision and support from specialist mental health services.
  • Interfaces with NGOs (for instance in relation to rehabilitation).
  • Networks at each level, including between different services, the community, and traditional and/or religious healers.

Community-oriented care, therefore, draws on a wide range of practitioners, providers, care and support systems (both professional and non-professional), though particular components may play a larger or lesser role in different settings depending on the local context and the available resources, especially trained staff.

FUNDAMENTAL VALUES AND HUMAN RIGHTS

Underpinning the successful implementation of community-oriented mental health care is a set of principles that relate on the one hand to the value of community and on the other to the importance of self-determination and the rights of people with mental illness as persons and citizens (14,15). Community mental health services emphasize the importance of treating and enabling people to live in the community in a way that maintains their connection with their families, friends, work and community. In this process it acknowledges and supports the person’s goals and strengths to further his/her recovery in his/her own community (16).

A fundamental principle supporting these values is the notion of people having equitable access to services in their own locality in the “least restrictive environment”. While recognizing the fact that some people are significantly impaired by their illness, a community mental health service seeks to foster the service user’s self-determination and his/her participation in processes involving decisions related to his/her treatment. Given the importance of families in providing support and key relationships, their participation (with the permission of the service user) in the processes of assessment, treatment planning and follow-up is also a key value in a community model of service delivery.

Various conventions identify and aim to protect the rights of service users as persons and citizens, including the recently ratified United Nations (UN) Convention on the Rights of Persons with Disability (UNCRPD) (17) and more specific charters such as the UN Principles for the Protection of Persons with Mental Illness and for the Improvement of Mental Care adopted in 1991 (18).

The above-mentioned and other international, regional and national documents specify the right of the person to be treated without discrimination and on the same basis as other persons; the presumption of legal capacity unless incapacity can be clearly proven; and the need to involve persons with disabilities in policy and service development and in decision-making which directly affects them (18). This report has been written to explicitly align with the requirements of the UNCRPD and associated treaties and conventions.

METHODS USED BY THE WPA TASK FORCE

This guidance has been produced by taking into account the key ethical principles, the relevant evidence, and the combined experience of the authors and their collaborators. In relation to the available evidence, systematic literature searches were undertaken to identify peer-reviewed and grey literature concerning the structure, functioning and effectiveness of community mental health services or obstacles to their implementation. These literature searches were organized for most of the World Health Organization (WHO) Regions, reflecting the context of the report’s main authors. There are limitations to this approach, in particular the WHO Eastern Mediterranean Region was not fully represented, and this report focuses upon adult mental health services. Accordingly, this guidance does not address the service needs of people with dementia or intellectual impairment, and of children with mental disorders.

Searches varied according to local expertise and resources. Medline was searched for every region. Other databases searched were EMBASE, PsycINFO, LILACS, SciELO, Web of Knowledge (ISI), WorldCat Dissertations and Theses (OCLC) and OpenSigle. Searches, adapted for each database, were for M.E.S.H. terms and text words relating to community mental health services and severe mental illness.

Other electronic, non-indexed sources, such as the WHO, Pan American Health Organization (PAHO), WPA, other mental health associations, and country-specific Ministry of Health websites, were also searched. Google was searched for PDFs published in European and African countries which contained the words “community mental health”. Searches were limited to articles published in the languages spoken by the authors covering each WHO Region, and authors sought relevant advice from WHO Regional Advisors.

Electronic searches were supplemented by searches of the reference lists of all selected articles. Hand searches of issues from the past five years of three key journals relevant to Africa (African Journal of Psychiatry, South African Journal of Psychiatry, and International Psychiatry) were also conducted. In addition, key texts were identified: these included relevant papers and book chapters published by authors of the current work (19-24) and a special edition of the Lancet on Global Mental Health (25-29). WHO publications which provide information regarding community mental health services worldwide were also sourced (7,31-33).

For the Africa Region, original research was conducted in order to supplement published data. Twenty-one regional experts completed a semi-structured, self-report questionnaire concerning their experience in implementing community mental health care in sub-Saharan Africa (34). The experts were from 11 countries and one NGO active in several countries across sub-Saharan Africa.

COMMON ISSUES IDENTIFIED IN IMPLEMENTING COMMUNITY MENTAL HEALTH SERVICES

International and inter-cultural differences can play a significant role in shaping what mental health services are needed and possible within local settings (most particularly, the level of financial resources available (28)). Nevertheless, in preparing this report, we have been surprised to find that the most fundamentally important themes (both in terms of challenges and lessons learned) apply to many countries and regions. We therefore discuss next each of these key themes in turn.

Policies, plans and programmes

One challenge common to many countries worldwide is the difficulty in putting community mental health intentions into practice. We distinguish here between:

  • National policy (or provincial or state policy in countries where health policy is set at that level): an overall statement of strategic intent (e.g., over a 5-10 year period) that gives direction to the whole system of mental health care.
  • Implementation plan: an operational document setting out the specific steps needed to implement the national policy (e.g., what tasks are to be completed, by whom, by when, with which resources, and identifying the reporting lines, and the incentives and sanctions if tasks are completed or not completed).
  • Mental health programmes: specific plans either for a local area (e.g., a region or a district) or for a particular sector (e.g., primary care) that specify how one component of the overall care system should be developed.

According to WHO’s Mental Health Atlas (31), 62.1% of countries worldwide had a mental health policy, and 69.6% had a mental health programme in place in 2005 (with 68.3% and 90.9% of the global population covered respectively). Many of the countries without such policies were LAMICs. Even where comprehensive evidence-based mental health policies are in place, problems in implementing these policies are common (33,35). Some of the reasons may include health staff not complying with policies due to difficulties in accepting and implementing changing roles (33), the lack of accessible evidence-based information or guidelines for health staff, inadequate funding mechanisms, inadequate  training of health care personnel, the lack of mechanisms for training and coaching health staff, poor supervision and support, and an overall lack of human resources (35). Detailed and highly practical implementation plans (taking into account available resources) are therefore necessary in enabling effective community mental health care provision.

Scaling up services for whole populations

A further challenge that needs to be addressed worldwide is the massive gap between population needs for mental health care (true prevalence of mental illness) and what is actually provided in mental health care (treated prevalence) (7), highlighting the importance of scaling up services for whole populations. The evidence concerning the substantial burden of mental disorders has not been translated into adequate investments in mental health care (29). The treatment gap is particularly pronounced in LAMICs, where commonly over 75% of people with mental disorders receive no treatment or care at all, and less than 2% of the health budget is spent on mental health (7). Whilst the high-income countries of the world have an average of 10.50 psychiatrists and 32.95 psychiatric nurses per 100,000 population (median figures), in low-income countries there are only 0.05 and 0.16 respectively (31). Furthermore, even within countries, the quality and level of services often vary greatly according to, for instance, patient group, location (with service provision usually being higher in urban areas), or socio-economic factors (3).

Similarly, only 10% of global mental health research is directed to the health needs of the 90% of population living in LAMICs, and only a fraction of this research activity is concerned with implementing and evaluating interventions and services (36). Methods to estimate resource needs are necessary in scaling up services. A systematic methodology for setting priorities in child health research has been developed taking into consideration that interventions should be effective, sustainable and affordable to reduce the burden of disease (37). A similar methodology was applied by the Lancet Global Mental Health Group, which focused on four groups of disorders whilst setting priorities for global mental health research: depressive, anxiety and other common mental disorders; alcohol- and other substance-abuse disorders; child and adolescent mental disorders; and schizophrenia and other psychotic disorders (30). It was recommended that interventions should be delivered by non-mental health professionals within existing routine care settings, and specialists should play a role in capacity building and supervision (38). A comprehensive review of packages of care for six leading neuropsychiatric disorders − attention/deficit hyperactivity disorder (ADHD), alcohol abuse, dementia, depression, epilepsy and schizophrenia − have also recently been proposed as means to extend treatment in LAMICs (20-24). An extensive set of treatment guidelines, also suitable for LAMICs, will be published by the WHO in 2010 as a part of their mhGAP programme. A survey of availability and feasibility of various treatments for the most prevalent mental disorders in the various age groups has been recently carried out by the WPA with its Member Societies (39).

Community awareness about mental illness

A further common barrier in identifying and treating mental disorders worldwide is the lack of awareness about them within communities, with stigma towards, and discrimination against, people with mental health problems being widespread. This is important, because effective awareness-raising campaigns can result in increased presentation of persons with mental illness to primary health care (40).

Three main strategies have been used to reduce public stigma and discrimination: protest, education, and social contact (41). Protest, by stigmatized individuals or members of the public who support them, is often applied against stigmatizing public statements, such as media reports and advertisements. Many protest interventions, for instance against stigmatizing advertisements or soap operas, have successfully suppressed negative public statements and for this purpose they are clearly very useful (42). However, it has been argued (41) that protest is not effective for improving attitudes toward people with mental illness.

Education interventions aim to diminish stigma by replacing myths and negative stereotypes with facts, and have reduced stigmatizing attitudes among members of the public. However, research on educational campaigns suggests that behaviour changes are often not evaluated.

The third strategy is personal social contact with persons with mental illness (43). For example, in a number of interventions in secondary schools, or with the police, education and personal social contact have been combined (44,45). Social contact appears to be the more efficacious part of the intervention. Factors that create an advantageous environment for interpersonal contact and stigma reduction may include equal status among participants, a cooperative interaction, and institutional support for the contact initiative (46).

For both education and contact, the content of programmes against stigma and discrimination matters. Biogenetic models of mental illness are often highlighted because viewing mental illness as a biological, mainly inherited, problem may reduce shame and blame associated with it. Evidence supports this optimistic expectation (i.e., that a biogenetic causal model of mental illness will reduce stigma) in terms of reduced blame. However, focusing on biogenetic factors may increase the perception that people with mental illness are fundamentally different, and thus biogenetic interpretations have been associated with increased social distance (47). Therefore, a message of mental illness as being “genetic” or “neurological” may be overly simplistic and unhelpful for reducing stigma. Indeed, in many LAMICs, conveying a message emphasizing the heritable nature of mental illness fuels stigma, for instance making marriage more difficult.

Anti-stigma initiatives can take place nationally as well as locally. National campaigns often adopt a social marketing approach, whereas local initiatives usually focus on target groups. An example of a large multifaceted national campaign is Time to Change in England (48). It combines massmedia advertising and local initiatives. The latter try to facilitate social contact between members of the general public and mental health service users as well as target specific groups such as medical students and teachers. The programme is evaluated by public surveys assessing knowledge, attitudes and behaviour, and by measuring the amount of experienced discrimination reported by people with mental illness. Similar initiatives in other countries, such as See Me in Scotland (49), Like Minds, Like Mine in New Zealand (50), or the WPA anti-stigma initiative (51), along with similar programmes in other countries, including Japan, Brazil, Egypt and Nigeria, have reported positive outcomes (40).

In sum, there is evidence for the effectiveness of measures against stigma and against discrimination (52). On a more cautious note, individual discrimination, structural discrimination and self-stigma lead to innumerable mechanisms of stigmatization. If one mechanism of discrimination is blocked or diminished through successful initiatives, other ways to discriminate may emerge (53,54). Therefore, to substantially reduce discrimination, stigmatizing attitudes and behaviours of influential stakeholders need to change fundamentally.

Developing powerful consensus for engagement

The collaborative engagement of a wide variety of supportive stakeholders is critical to successful implementation of community-oriented mental health care. It is important to have a systemic view of the change process. The support is needed of politicians, board members and health managers whose primary focus may not be on mental health, clinicians, key members of the community including NGO providers, service users and their families, and traditional and religious healers. To involve them in the imperative for change will require different strategies and a change management team that includes people with a variety of expertise. Overall, having clear reasons and objectives for the shift to community oriented care is essential. Messages should be concise, backed by evidence and consistent.

Developing consensus for change requires a lot of work in meeting and communicating with people. The main means of communication need to include written material and opportunities to meet with stakeholder groups. Politicians and administrators will require a compelling business case. However, others will need summaries of plans, slide presentations and the opportunity to meet and work through proposals and concerns. E-mails and website information and surveys are now valuable supplements to the process. The emphasis must be on a willingness to communicate in good faith and to do so openly and honestly doing “what it takes” to convince people of the benefits of the change process.

It is important to bear in mind that in some cases prejudice and self-interest will have to be confronted. It is helpful, at the beginning of the process, to identify both those who are likely to support change, and those who are likely to oppose it. A willingness to listen to concerns and to find ways of incorporating them, if possible, into the planning and implementation process is essential because, when such an attitude is communicated, there is an opportunity for people to feel included in the process. That done, boldness and firmness will communicate to remaining detractors the seriousness of the intent to implement change; it will also encourage supporters to believe that their aspirations for better mental health care will be realized, and thus embolden them in turn.

Engaging stakeholders requires both formal and informal opportunities to meet, receive advice and work through issues. The establishment of reference groups early on in the change process is a key formal mechanism to achieving this. These should include all the key stakeholders, in particular service users, families, clinicians and service providers, with the latter being essential to facilitate integrated systems of care further on in the process. While it is important to structure the overall process with formal meetings and communications, it is also important to be willing to convene informal meetings upon request to “trouble-shoot” situations of concern. The consultation process should result in an amalgam of “bottom-up” and “top-down” contributions to the change process. Reports on progress are an essential way of maintaining trust and building excitement to the process of successful implementation.

It is also important to bear in mind that good mental health services have established processes for ensuring that the voices of service users, their families and community providers are heard on an ongoing basis. The aim is not simply to achieve discontinuous change, but to promote an ongoing quality improvement in which consumers of mental health services know they have a major stake. Without such effective and united consortia, policy makers may find it easy to disregard the different demands of a fragmented mental health sector, and instead respond positively to health domains (e.g., HIV/AIDS) which demonstrate the self-discipline of united approach with a small number of fully agreed priorities.

Mistakes to be avoided

Several key mistakes are commonly made in the process of attempting to implement community mental health care. First, there needs to be a carefully considered sequence of events linking hospital bed closure to community service development. It is important to avoid closing hospital-based services without having successor services already in place to support discharged patients and new referrals, and also to avoid trying to build up community services while leaving hospital care (and budgets) intact. In particular, there needs to be at each stage of a reform process a workable balance between enough (mainly acute) beds and the provision of other parts of the wider system of care that can support people in crisis.

A second common mistake is to attempt system reform without including all the relevant stakeholders. Such initiatives especially need to include psychiatrists, who may otherwise feel subject to “top-down” decision making and react, either in the interests of patients or in their own interests, by attempting to delay or block any such changes. Other vital stakeholders to be directly included in the process will often include policy makers and politicians, health service planners, service users and carers, service providers including those in state and private practice, national and international NGOs, and those working in alternative, complementary, indigenous and religious healing traditions, and relevant national and professional associations. Typically, those groups not fully involved in a reform process will make their views known by seeking to undermine the process.

A further common mistake is linking inappropriately the reform of mental health care with narrow ideological or party political interests. This tends to lead to instability, as a change of government may reverse the policies of their predecessors. Such fault lines of division or fragmentation may also occur, for example, between service reforms proposed by psychologists and psychiatrists, or between socially and biologically oriented psychiatrists, or between clinicians and service user/consumer groups. Whatever the particular points of schism, such conflicts weaken the chance that service reforms will be comprehensive, systemic and sustainable, and they also run the risk that policy makers will refuse to adopt proposals that are not fully endorsed by the whole mental health sector.

Additional issues that may compromize the integrity of community based services include: a) an exclusive focus of community services on psychotic conditions, so that the vast majority of people with mental disorders are neglected or dealt with by professionals who do not have the appropriate expertise; and b) the neglect of patients’ physical health.

Payment for services

A fundamental component in the successful implementation of mental health service provision is that of funding (10). As indicated above, funding for mental health services in LAMICs tends to be very low. This may be due in part to a stigmatizing attitude toward mental disorders, and to an absence of the recognition of the economic benefits that can accrue from improved mental health care. Ideally, the share of its health funding that a country devotes to mental health care will be informed by careful consideration of the comparative health benefits of spending on alternative forms of care. The data needed to carry out such an analysis are, however, typically not available in LAMICs.

Furthermore, whatever funding there is also tends to be concentrated on inpatient services. Correcting this is, initially, a matter of budgetary re-allocation: using resources that could have been used for other purposes to increase funding for community-oriented care.

The issue then arises of how to pay public providers (hospitals, stand-alone programs, and possibly independent individual providers such as psychiatrists) for the services that they render. The simplest forms of payment are global budgets for facilities and programs, which may be carried over from year to year with minor adjustments for inflation, and salaries for individual providers. These simple payment mechanisms have the advantage of administrative simplicity. At the same time, they have at least two important drawbacks. First, they provide no incentive for increasing either the quantity or the quality of service provision. Second, population shifts are likely to cause the demand for the services of different providers to evolve and, without taking changes in local demand into account, inequities in payment across providers are likely to emerge and grow over time. This in turn will compromize access to overburdened providers, while possibly resulting in overprovision (e.g., excessive lengths of stay) by other providers. Accordingly, countries with the technical and administrative capacity to introduce more complex payment systems should consider doing so.

For hospitals, a fairly simple alternative which is applicable where care is sectorized is to modulate budgets on the basis of the population of the facility’s catchment area. Countries with the technical capacity to do so may wish to adjust the payment level per person on the basis of socio-demographic variables known to be related to the need for inpatient mental health care (for example, poverty).

For hospitals that have overlapping catchment areas, a combination of prospective payment (payment on the basis of number of admissions) and retrospective payment (payment on the basis of bed-days actually provided) may be preferable to exclusive reliance on one or the other. Pure retrospective payment encourages overprovision of services; pure prospective payment, given the difficulty of assessing reliably the degree of need for care of a person admitted for a psychiatric condition, may encourage underprovision.

For stand-alone programs or individual providers, the two main options beyond a fixed budget or a salary are fee-forservice and capitation. Fee-for-service payment encourages a higher volume of services without regard to outcomes. If certain services (e.g., prescription of medications) are paid at a higher rate per unit time than others (e.g., psychotherapy), then fee-for-service payment will also influence the mix of services provided. In addition, fee-for-service payment tends to maximize contacts with patients who are less ill, more compliant, and easier to treat. Difficult or more severely ill patients receive less care unless payments are adjusted by severity − so-called case-mix adjustments. Efficient uses of clinical time such as telephone or computer contacts are ignored because they are not reimbursed.

Capitation payment encourages increasing the number of people served. It may lead to greater accountability for the care of specific patients. In and of itself, however, unless there is competition for patients across providers, it provides no incentive for quality. Furthermore, programmes often fill up to capacity and have difficulty shifting patients to less intensive services.

Countries with the technical and administrative capacity (and political leeway) to do so should consider introducing incentives for increasing quality, either for hospitals, programs, or individual providers. Following Donabedian’s seminal work, quality is commonly conceptualized as related to structure, process and outcomes (55). Adjusting payments to hospitals, programs or individual providers on the basis of structure or process indicators (e.g., formal qualifications of staff, achievement of a certain score on a model fidelity scale) assumes that these indicators actually predict quality. To the extent that they do, providing incentives for achieving a high score on those indicators is likely to be beneficial, with a neutral effect on which types of patients the provider will seek to serve. Adjusting payments based on outcomes (for example, physiological indicators of metabolic syndrome, rehospitalisation rates, employment rates) has the advantage of being directly related to a system’s ostensible goals. It encourages, however, selection of less ill patients. More research is needed on how to design effective systems for encouraging quality of community-oriented mental health care that are practicable in countries with more or less developed technical and administrative capabilities.

In sum, payment systems influence patient selection, quality and amount of treatments, and outcomes, in more or less favourable ways, and different ones require varying degrees of technical and administrative capacity to be implemented successfully. Determining the optimal system or combination of systems for a particular health care setting probably depends heavily on history, infrastructure, financial resources, human resources, and other factors.

Training staff, human resources and roles of psychiatrists

Human resources are the most critical asset in mental health service provision. The gradual transformation to community-based care has resulted in changes in the ways human resources have been utilized (56). The essential changes have been a reallocation of staff from hospital to communitybased service settings, the need for a new set of competencies which include recovery and rehabilitation, and the training of a wider range of workers, including informal community care workers, within the context of the practical needs of a country (57). Further, in many LAMICs, trained psychiatrists work under conditions of heavy and relentless clinical activities, and may not have dedicated time during the week for any service development duties.

Another perspective to human resource development has been the increasing emphasis on integration of mental health into a primary care setting, thereby increasing access to the vast majority of the underserved. This has necessitated the training of general health staff in basic skills in mental health care such as detection of mental disorders, provision of basic care, and referral of complex problems to specialist care. In most developing countries, there is a need for a well-rounded generalist who is capable of coping with most psychiatric problems with little access to any mental health practitioner. Further important issues are lack of insurance, out of pocket expenses, and the economic burden falling on families.

The broadening scope and the shift to community-based mental health services introduce greater levels of complexity, affecting the role of psychiatrists, broadening it to areas such as promotion and social inclusion. Psychiatrists need to work in more settings, with more staff groups. Planning and management will take a more central place. Psychiatrists are seen to possess a unique expertise, and occupy leading positions in most countries, functioning as advisers to governments and chairing drafting groups that are responsible for the production of policies and action plans. There are countries where such groups comprise only psychiatrists. They have therefore a unique opportunity to shape the process of reform in the best interest of patients, families and carers, the public and staff.

While psychosocial rehabilitation is an important part of the overall process of successful management of chronic mental disorders, its practice is still rare compared to the use of medicines (58). In many developing countries, training is scarce for occupational therapists, psychologists or social workers. In countries with few psychiatrists, numerous medical, administrative and leadership duties leave psychiatrists little time to work with rehabilitation units. Even so, in many LAMICs other resources are available − e.g., strong family and community networks, faith groups, informal employment opportunities − that might be mobilized to support the rehabilitation of people with longer-term mental disorders.

Organization development, quality assurance and service evaluation

Initiation of community mental health care services generally requires strong leadership among stakeholders based on community-oriented care concepts. It is practical to learn from successful models by using basic tools including timetables, assessment forms, job descriptions, and operational policies (9).

Coaching and maintenance activities are needed to make services robust and sustainable. Manualization of operational procedures, reference materials and ongoing supervision are essential. As community-oriented care becomes established in several regions, service components are gradually standardized, and manualized standard care becomes available.

Quality assurance is feasible even in settings with limited resources. Quality monitoring can be incorporated into routine activities by selecting target services, collecting data, and using the results for system problem-solving and future direction. External evaluation takes place at different levels. Local government checks whether service providers meet the requirement of laws or acts, while payers focus on examining the necessity of services provided. Professional peers and consumers also participate in independent evaluation.

Since the primary purpose of mental health services is to improve outcomes for individuals with mental illness, it is crucial to assess outcomes of treatments and services. Also, the results can be used to justify the use of resources. More research is, therefore, needed to provide the best possible services that would directly link to better outcomes for those in need of care.

RECOMMENDATIONS

Drawing upon the literature reviewed by our WPA Task Force, and by our own accumulated experience, we have recognized a series of commonly occuring challenges and obstacles to implementing a community-oriented system of mental health care. At the same time we have identified related steps and solutions which may work in responding positively and effectively to these barriers (19,27), as set out in Table 1.

We recommend that people interested in planning and implementing systems of mental health care which balance community-based and hospital-based service components give careful consideration to anticipating the challenges identified here, and to learning the lessons from those who have grappled with these issues so far.

Table 1 Obstacles, challenges, lessons learned and solutions in implementing community-oriented mental health care

  Obstacles and challenges Lessons learned and solutions
Society Disregard for, or violation of, human rights
of people with mental illness
- Oversight by: civil society and service user groups, government inspectorates, international
NGOs, professional associations.
- Increase population awareness of mental illness and of the rights of people with mental illness
and available treatments.
  Stigma and discrimination, reflected in
negative attitudes of health staff
- Encourage consumer and family/carer involvement in policy making, medical training, service
provision (e.g., board member, consumer provider), service evaluation (consumer satisfaction
survey).
  Need to address different models of
abnormal behavior
- Traditional and faith-based paradigms need to be amalgamated, blended, or aligned as much as
possible with medical paradigms.



Government Low priority given by government to mental
health
- Government task force on mental illness outlines mission as a public health agenda.
- Mission can encompass values, goals, structure, development, education, training, and quality
assurance for community-oriented mental health system from a public health perspective.
- Establish cross-party political support for the national policy and implementation plan.
- Effective advocacy on mental health gap, global burden of disease, impact of mental health
conditions, cost-effectiveness of interventions, reduced life expectancy.
- Use of WHO and other international agencies for advocacy, linking with priority health
conditions and funds, positive response to untoward events.
- Identifying champions within government who have administrative and financial authority.
  Absent or inappropriate mental health
policy
- Advocate for and formulate policy based upon widespread consultation with the full range of
stakeholder groups, incorporating a rationalized public health perspective based on
population needs, integration of service components.
- Consumer involvement in policy making.
  Absent, old or inappropriate mental health
legislation
- Create powerful lobby and rationale for mental health law.
- Modernize mental health law so that it is relevant to community-oriented care.
- Watchdog or inspectorate to oversee proper implementation of mental health law.
  Inadequate financial resources in relation to
population level needs
- Help policy makers to be aware of the gap between burden of mental illness and allocated
resources, and that effective treatments are available, and affordable.
- Advocate for improved mental health expenditure using relevant information, arguments and
targets, e.g. global burden of disease, mhGAP unmet needs.
- Recruit key political and governance champions to advocate for adequate funding of
initiatives.
  Lack of alignment between payment
methods and expected services and
outcomes
- Design a system that directly relates required service components and financially reimbursable
categories of care, e.g., for evidence-based practices.
- Provide small financial incentives for valued outcomes.
- Create categories of reimbursement consistent with system strategy.
- Develop and use key performance indicators.
- Reserve transitional cost to reallocate hospital staff to move to community.
  Need to address infrastructure - Government to plan and finance efficient use of buildings, essential supplies and electronic
information systems and other to direct, monitor, and improve the system and outcomes.
  Need to address structure of community oriented
service system
- Design the mental health system from local primary care to regional care to central specialty
care and fill in gaps with new resources as funding grows.
  Inadequate human resources for delivery of
mental health care in relation to the level of
need in the population
- Assessment of population level needs for primary care and specialist mental health care
services.
- Build capacity of health workers engaged in providing general health care and mental health
care in community.
- Training current health and mental health professionals in community-oriented mental health
care.
  Brain drain, failure to retain talent, staff
retention, and weak career ladders
- UN agencies/international NGOs assure sustainability of their projects/programmes.
- Exchange programmes between countries.
- Set period of time medical students/registrars have to serve in their countries or rural areas.
- Task shifting/function differentiating of psychiatrists to use their ability in their area of
speciality.
- Create financial incentives and reputation systems for psychiatrists who engage in community
mental health.
- Train other (less “brain drainable”) health professionals to deliver mental health care.
- Payment for education may be attached to the allocation and preservation of resources to
address equitable distribution and to prevent emigration without appropriate reimbursement.
  Non-sustainable, parallel programmes by
international NGOs
- Close relations with ministries and other stakeholders and international NGOs.
- Mental health plan in place, so NGOs can help achieve these goals sustainably.
- Government to be proactive in collaborating with NGOs and private-public partnership.



Organization
of the local
mental health
system
Need to design, monitor, and adjust
organization of mental health system
- This includes plan for local, regional, and central mental health services based on public
health need, full integration with primary care, rational allocation of multi-disciplinary
workforce, development of information technology, funding, and use of existing facilities. All
stakeholder groups can be involved in developing, monitoring, and adjusting plan.
- Set implementation plan with clear coordination between services.
- Development of policy/implementation plan with number of service needed per population.
- Role differentiation of the hospital, community and primary care services, and private and public
services, using catchment area/capitation system with flexible funding system.
- Prioritization of target groups, especially people with severe and persistent mental illness.
  Lack of a feasible mental health programme
or non-implementation of mental health
programme
- Make programme highly practical by identifying resources available, tasks to be completed,
allocation of responsibilities, timescales, reporting and accountability arrangements, progress
monitoring/evaluation systems.
  Need to specify developmental phases - Planners and professional leaders to design 5 and 10 year plans.
  Poor utilization of existing mental health
facilities
- Improve awareness of benefits of facilities and services.
- Specify pathways to care.
- Inbuilt monitoring quality of care, especially process and outcome phases.
  Need to include non-medical services - Include families, faith-based social services, NGOs, housing services, vocational services, peersupport
services, and self-help services. All stakeholders involved in designing system.
- Moving key tasks such as initial assessment and prescribing using a limited and affordable
formulary to specially trained staff who are available at the appropriate local level.
- Identify leaders to champion and drive the process.
- More involvement in planning, policy making and leadership and management.
  Lack of multi-sectoral collaboration, e.g.,
including traditional healers, housing,
criminal justice, or education sectors
- Development of clear policy/implementation plan by all stakeholders.
- Collaborate with other local service to identify and help people with mental illness.
- Provision of information/training to all practitioners.
- Establish multi-sectoral advisory and governance groups.
- Familiarization sessions between practitioners in the Western and local traditions.
  Poor availability or erratic supplies of
psychotropic medication
- Educate policy makers and funders about the costs/benefits of specific medications.
- Provide infrastructure for clozapine monitoring.
- Monitoring prescribing patterns of psychotropic medication.
- Drug revolving funds, public-private partnerships.



Professionals
and
practitioners
Need for leadership - Psychiatrists and other professionals need to be involved as experts in planning, education,
research, and overcoming inertia and resistance in the current environment.
  Difficulty sustaining in-service training/
adequate supervision
- Training of the trainers by staff from other regions or countries.
- Shifting of some psychiatric functions to trained and available practitioners.
- Lobby hard to ensure this is a priority and integral to the mental health plan.
  High staff turnover and burnout, or low
staff morale
- Introduction of recovery oriented services.
- Collect case examples of recovery.
- Build trust by involving staff leaders in oversight and decision making committees.
- Sponsor social events to enable staff to team build in non-work situations.
- Emphasize career-long continuing training programmes.
- Training of supervisors.
- Provide opportunities for attending out of area professional meetings.
- Equip with sufficient skills and support.
  Poor quality of care/concern about staff
skills
- Ongoing training and supervision.
- Create and disseminate guidelines for professionals.
- Cultivate psychiatrists’ clinical skills, so that they are preserved in spite of the variety of new
commitments.
- Third party evaluation.
- Encourage and reward quality by awards and similar processes.
  Professional resistance, e.g., to communityoriented
care and service user involvement
- Government and professional societies promote the importance of community-oriented care
and service user involvement.
- Task shifting/function differentiating of psychiatrists to use their abilities more broadly in their
area of speciality and work with a range of stakeholders including consumers and carers/
families.
- Develop training in recovery-oriented psychosocial rehabilitation as part of training of new
psychiatrists, including at medical schools in LAMICs.
- Collect case examples of recovery and successfully implemented community mental health
initiatives.
  Dearth of relevant research to inform costeffective
services and lack of data on mental
health service evaluation
- More funding on research, for both qualitative and quantitative evidence of successfully
implemented examples of community-oriented care.
  Failure to address disparities (e.g., by
ethnic, economic groups)
- All key stakeholders involved; advocacy for under-represented groups to develop policies and
implementation plans.



Users, families,
and other
advocates
Need for advocacy - Users and other advocates may be involved in all aspects of social change, planning, lobbying
the government, monitoring the development and functioning of the service system, and
improving the service system.
  Need for self-help and peer support services - Users to lead these movements.
  Need for shared decision making - Users and other advocates must demand at all levels that the system shift to value the goals of
users and families and that shared decision making become the norm.
- Continuing professional education on human rights and staff attitudes emphasizing attention
to preferences of consumers and carers.

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