12.2020 - UnitedGMH - UHC Report - No Health Without Mental Health

“NO
HEALTH
WITHOUT
MENTAL
HEALTH”:
THE URGENT NEED FOR
MENTAL HEALTH INTEGRATION IN
UNIVERSAL HEALTH COVERAGE
“NO
HEALTH
WITHOUT
MENTAL
HEALTH”:
THE URGENT NEED FOR
MENTAL HEALTH INTEGRATION IN
UNIVERSAL HEALTH COVERAGE
December 2020
Authors:
Maxim Polyakov, Senior Consultant, Policy, Advocacy and Financing, United for Global
Mental Health
James Sale, Policy and Advocacy Manager, United for Global Mental Health
Sarah Kline, Co-Founder and Deputy CEO, United for Global Mental Health
Shekhar Saxena, Professor of the Practice of Global Mental Health, Harvard TH Chan
School of Public Health
ACK
NOWL
EDGE
MENTS
The authors would like to thank the following for their advice and guidance through
the development of this report:
Prof Pamela Collins

University of Washington, USA
Alan Court
Office of the WHO Ambassador for Global Strategy and Health Financing, USA
Dr Julian Eaton
The London School of Hygiene and Tropical Medicine, UK; CBM Global
Dr Tim Evans
McGill University, Canada
Dr Githinji Gitahi
Amref Health Africa, Kenya; and UHC 2030, Switzerland and USA
Pradeep Gunarathne
CAN MH Lanka, Sri Lanka
Fahad Khan
Interactive Research and Development, Pakistan
Dr Lola Kola
University of Ibadan, Nigeria; University of Washington, USA
Kay Lankreijer
Bernard van Leer Foundation, The Netherlands
Prof Crick Lund
University of Cape Town, South Africa; Kings College London, UK
Raj Mariwala
Mariwala Health Initiative, India
Yves Miel Zuniga
#MentalHealthPH, The Philippines
Aneeta Pasha
Interactive Research and Development, Pakistan
Bharti Patel
SA Federation for Mental Health, South Africa
Prof Vikram Patel
Harvard University, USA
Taha Sabri
Taskeen, Pakistan
Charlene Sunkel
Global Mental Health Peer Network, South Africa
Prof Sir Graham Thornicroft
Kings College London, UK
Cecilia Vaca Jones
Bernard van Leer Foundation, The Netherlands
Robert Yates
Chatham House, UK
Peter Yaro
Basic Needs Ghana, Ghana
TABLE
OF
CON
TENTS
Executive summary 1
Introduction 6
The importance of UHC 7
Mental health as part of UHC 8
The need to integrate mental health in UHC 10
Part I: Why is it critical to integrate mental health in UHC? 12
Argument 1: There is no health without mental health 13
Integrating mental health in UHC: improving mental health outcomes 14
Integration of mental health in UHC: improving physical health outcomes 17
How COVID-19 sharpens the need to integrate mental health in UHC 20
Mothers, children and young people: at the heart of UHC 22
Conclusion 29
Argument 2: Mental health spending is an investment, not a cost 26
High cost-effectiveness of mental health interventions 28
Integrating mental health is a good economic investment 29
Integrating mental health increases the efficiency of healthcare systems 30
Good mental health as a core component of human capital 31
Conclusion 32
Argument 3: Mental health, UHC and human rights 33
UHC, mental health and the right to health 34
The rights of people with mental health conditions 35
Conclusion 37
Part II: How can the integration of mental health into UHC be achieved? 47
From intention to implementation: making scaled-up, integrated mental health care a reality 48
Key programmatic documents on scaling-up and integrating mental health in UHC 50
An example short-list of approaches for integrating mental health in UHC 54
The cost of scaling up mental health care 59
Conclusion 63
Conclusion 69
“No Health without Mental Health”: the Urgent Need for Mental Health Integration in Universal Health Coverage
EXECU
TIVE
SUMM
EXECUTIVE SUMMARY
ARY 1
If ever there was a time to invest in mental health, it’s

now … We must take this opportunity to build mental
health services that are fit for the future: inclusive,
community-based, and affordable. Because, ultimately,
there is no health without mental health”
Dr Tedros Adhanom Ghebreyesus, WHO Director-General, 14 May 2020
“Addressing mental health is central to achieving

universal health coverage. It deserves our commitment”
Antonio Guterres, UN Secretary General, 10 Oct 2020
2
EXECUTIVE SUMMARY
When world leaders met at the UN General Assembly in 2019 to discuss Universal Health
Coverage (UHC), they committed to “progressively cover one billion additional people by
2023 … with a view to cover all people by 2030.” As part of this ‘health for all’ declaration,
UN member states explicitly included mental health care in UHC. It was a recognition of the
fact that there is no health without mental health.
Yet, despite this political commitment, which was only the latest in a series of such
commitments, progress on mental health has been limited. In every country in the world
there is still a huge – and often growing – need for improved mental health care.
HOW WE’RE FAILING TO ADDRESS MENTAL HEALTH NEEDS – AND THE CONSEQUENCES
OF THAT FAILURE
In some countries, the gap in mental health care coverage for common conditions such
as depression and anxiety can be as high as 90%. While the services that are available are
often poor-quality, are not cost-effectively delivered and in some cases violate the human
rights of people living with mental health conditions.
This appalling situation is not surprising: governments around the world spend on average
under 2% of their health budgets on mental health, while less than 1% of global
development assistance for health has been directed towards mental health. All too often,
these resources are spent on costly and low-quality in-patient care when higher quality,
more cost-effective and rights-based community alternatives are available. For instance, in
low- and middle-income countries, 80% of mental health budgets are spent on in-patient
care (contrary to the wishes of many mental health activists for alternative care models, and
the advice of experts including the World Health Organisation (WHO)).
At the same time, the need for high-quality, rights-based mental health care is vast. Nearly
1 billion people around the world live with a mental health or a substance use condition.
Globally, there are 264 million people with anxiety and 322 million with depression.
Tragically, around 800,000 suicides take place every year – one death every 40 seconds;
suicide is the second leading cause of death among young people aged 15-29. As many as
10-20% of children and adolescents experience mental health disorders worldwide, while
an estimated 15-23% of children live with a parent with a mental health condition – with
potentially damaging consequences for their cognitive, emotional and physical
development. Mental health conditions also disproportionately affect socioeconomically
vulnerable populations, creating a vicious circle of mental health problems and
socioeconomic disadvantage.
The COVID-19 pandemic has exacerbated these problems. One study has suggested that
depressive symptoms tripled during the pandemic, and countries around the world are
seeing higher rates of suicide or suicidal ideation. At the same time, the crisis has disrupted
the provision of mental health services in over 90% of countries, according to the WHO.
There is also a clear link between mental and physical health: people with mental health
conditions are more vulnerable to both infectious and non-communicable physical
diseases. For example, people living with mental health conditions are four times more
likely to have HIV, while depression can reduce compliance with treatment for diseases
such as cancer. The relationship between mental and physical health holds true also for
COVID-19, and research has shown that a recent mental health diagnosis is strongly linked
to a higher risk of a COVID-19 infection.
3
EXECUTIVE SUMMARY
In addition, people living with mental health conditions can be among the most vulnerable
in society, enduring incarceration, chaining, coercion, overmedicalisation, institutionalisa-
tion, stigma and exclusion. They can experience these abuses both in their families and
local communities, and also in mental health systems. Moreover, in most communities
around the world the right to health of people living with mental health conditions is not
being met. That people with severe mental disorders tend to die up to 20 years earlier than
people without these conditions is a stark indication of that fact.
THE ARGUMENTS FOR INTEGRATING MENTAL HEALTH IN UHC
The most effective way to address all of the problems set out above is to integrate mental
health in UHC. This is a critical component of making UHC a success, and delivering holistic,
person-centred care. When we talk about integrating mental health in UHC, this is what we
mean:
• including mental health care in all relevant aspects of health systems, such as health
promotion, illness prevention, treatment and rehabilitation
• putting mental health care on a par with and – where relevant – accompanying
physical health care
• ensuring mental health conditions are covered by population-wide financial
protection measures.
Based on the data and policies of globally recognised authorities, there are three
arguments to support the integration of mental health in UHC:
• A health argument: There is a staggering – and growing – need to address

mental health outcomes. Moreover, mental health and physical health are
inextricably linked – improving mental health cannot fail to improve other areas of
health. To achieve truly universal health coverage, and save countless lives, mental
health care must be included in UHC.
• An economic argument: Investment in mental health should be seen as just
that – an investment for a future economic return and an opportunity to increase
national prosperity. Investment in common mental health conditions is estimated
to generate $5 in productivity gains and value-of-health benefits for every $1 spent.
Integrating mental health in UHC is also highly cost-effective, and can make health
spending more efficient: it could reduce expenditure in other parts of the health
sector by improving prevention and treatment compliance for physical conditions.
Given the positive impact of good mental health on early childhood development, it
can be further argued that mental health should be explicitly added as a component
of the World Bank’s Human Capital Index.
• A rights argument: The right to health, which UHC aims to uphold, includes the
right to mental health: without including mental health, UHC cannot be a
mechanism by which the right to health is put into action. Integrating high-
quality, rights-based, evidence-based mental health practices in health
systems – with a focus on primary and community-based care – would reduce the
opportunities for the kinds of human rights abuses already described. It would also
support the implementation of the Convention on the Rights of Persons with
Disabilities (CPRD) to achieve the full range of rights of people living with mental
health conditions (including the right to health).
4
EXECUTIVE SUMMARY
HOW THE INTEGRATION OF MENTAL HEALTH IN UHC CAN BE ACHIEVED
It is paramount for the health outcomes of entire populations, as well as for economic
prosperity, to ensure that mental health is rapidly integrated in health systems and
rights-based, high quality services are afforded sufficient and sustainable funding. In
addition, the full realisation of UHC necessitates that mental health should be a fully
integrated component within it. The good news is that key global blueprints on how to
achieve this already exist. Integrating mental health in UHC is a relatively low hanging fruit.
The key global framework for the scale-up of mental health within the context of UHC is the
WHO’s Mental Health Action Plan 2013-2020. (The Action Plan is due to be updated and
approved at the World Health Assembly in 2021 for a further 10 years: 2021-2030). The
Action Plan incorporates UHC as a cross-cutting principle, and focuses on a number of key
objectives, including setting up “comprehensive, integrated and responsive mental health
and social care services in community-based settings”, as well as the implementation of
“strategies for promotion and prevention in mental health”. It is supported by a number
of key technical publications by leading UN and international agencies, such as the WHO’s
Mental Health Gap Action Programme (mhGAP) Intervention Guide, as well as a number of
World Bank publications.
Separately, a key catalytic programme for integrating mental health in UHC was launched in
2019 by the WHO, called the Special Initiative for Mental Health (2019-2023). This initiative
aims to provide $60 million in funding and technical support across 12 countries over five
years, to scale up the integration of mental health in UHC and extend quality services to 100
million additional people.
It is critical to establish that, where the practicalities of integrating mental health in UHC are
concerned, there can be no ‘one-size-fits-all’ approach. However, given the current situation
of most mental health systems around the world, there are a number of changes that will
likely need to take place, such as:
• The creation and implementation of national mental health laws and mental
health policies that are aligned with international human rights conventions, to
ensure that the rights of people living with mental health conditions are always
protected and upheld
• An amplification of the voice of lived experience in policy design and
implementation to improve the services and support provided through UHC
• Integration of mental health in all UHC strategies and planning, and the inclusion
of mental health services within the basic package of essential services
• Increase in sustainable funding for mental health, to 5-10% of the health budget
(depending on resource setting)
• A focus on prevention, promotion and rehabilitation, including through
intersectoral collaboration (e.g. life skills programmes in schools; parent coaching;
peer support)
• Strengthening the national workforce for mental health, both supporting mental
health specialists and upskilling general health staff and other relevant professions
(e.g. teachers, police, social workers)
• Shifting service delivery towards non-specialised settings in the community
• Setting up a robust monitoring and evaluation system for mental health
(Note: Part II of the main report provides more detail on these action points.)
5
EXECUTIVE SUMMARY
Given the current low levels of funding for mental health in most countries, such a
significant change in mental health and UHC policies and practice will not happen without
further investment. Increasing expenditure on mental health to just 5-10% of total health
budgets (as suggested by The Lancet Commission on Global Mental Health and Sustainable
Development) would increase coverage by 40-80%, depending on the resource setting.
Ideally, the funding should come from domestic financing to ensure sustainability and
in-country ‘ownership’; although in some settings catalytic investment by international and
national donors may be necessary. This funding must be directed towards support that
upholds the human rights of all those with mental health needs.
We have never been better informed about how to successfully integrate mental health in
UHC, and the rewards this could bring. At the same time, the need for action has
never been greater. We therefore call on all key stakeholders to move together on this –
and move now:
• International agencies: Strengthen the case for integrating rights-based mental
health in UHC through policy development, supporting evidence generation and
dissemination, and galvanising political will
• National governments: Fully integrate mental health into national health
legislation, policies and programmes, in particular within UHC reforms, adopting a
rights-based approach and committing 5-10% of health budgets to mental health
accordingly
• International and national funders: Support integration of mental health in UHC
by providing catalytic funding, including through priority health programmes (e.g.
COVID-19 response, HIV/AIDS and TB, and maternal and child health programmes),
in support of the delivery of a rights-based approach
• Academic community: Further strengthen the evidence base for integration and
rights-based interventions
• Civil society: Advocate for the urgent need to integrate mental health in UHC in a
way that upholds human rights, holding national governments and global
institutions to account for the commitments made
As the world grapples with the impact of COVID-19 and designs the future of healthcare,
we need the global community to come together now and commit its political will
towards action and investment in mental health.
There is no health without mental health. The time to act is now.

THERE IS NO HEALTH WITHOUT MENTAL HEALTH.
THE TIME FOR ACTION IS NOW.
6
EXECUTIVE SUMMARY
“The States Parties to the present Covenant recognize the right of everyone to the
enjoyment of the highest attainable standard of physical and mental health”
Article 12.1 of the International Covenant on Economic, Social and Cultural Rights1
The right to the highest attainable standard of physical and mental health was first set
out in preamble of the 1946 Constitution of the World Health Organisation (WHO). It
defined health as “a state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity”.2 The 1948 Universal Declaration of Human
Rights includes health as part of the right to an adequate standard of living (art. 25).3
This was reaffirmed in the 1976 International Covenant on Economic, Social and
Cultural Rights (art. 12).4 Moreover, the right to health explicitly encompasses all
individuals, including people living with “long-term physical, mental, intellectual or
sensory impairments”. This was set out in article 25 of the 2006 Convention on the
Rights of Persons with Disabilities (CRPD): “States Parties recognize that persons
with disabilities have the right to the enjoyment of the highest attainable standard of
health without discrimination on the basis of disability.”5
Although it still covers only about half of the world’s population,6 Universal Health
Coverage (UHC) is, for many people, the most effective means of securing the right
to health. Yet, while the right to good physical health has been largely acknowledged
– and reflected in health systems and financing – the right to good mental health has
been largely absent from existing UHC systems. Moreover, while mental health policy
guidance and even global plans have included the need for mental health care to be
integrated into health systems,7 member states have not systematically done so.8
Drawing on an extensive body of evidence, this report makes the case for integrating
mental health in UHC provision – and urges policy makers to act now. It was written
in the midst of the COVID-19 pandemic – an emergency which has increased the need
for urgent action. However, integrating mental health in UHC is a need that goes
INTRO
beyond the pandemic – it is a need that existed before COVID-19, and, unless
addressed, will persist after it is gone.
THE IMPORTANCE OF UHC
The concept of UHC has been decades in the making. It has its roots in, for example,
DUC
New Zealand’s Social Security Act of 1938, the establishment of the UK’s National
Health Service in 1948, Japan’s universal health insurance system in 1961, and,
globally, the Declaration of Alma-Ata during the International Conference on Primary
Health Care in 1978. The Alma-Ata Declaration introduced the concept of ‘health for
all’ and focused on the cornerstone of UHC: primary healthcare.9 Since then, the
concept of UHC has been broadened to encompass the health system as a whole,
TION
including public health – “from health promotion to prevention, treatment,
rehabilitation, and palliative care”.10
INTRODUCTION 7
“The States Parties to the present

Covenant recognize the right of everyone
to the enjoyment of the highest
attainable standard of physical and
mental health”
Article 12.1 of the International Covenant on Economic, Social and Cultural Rights1
The right to the highest attainable standard of physical and mental health was first set out
in the preamble of the 1946 Constitution of the World Health Organisation (WHO). It
defined health as “a state of complete physical, mental and social well-being and not merely
the absence of disease or infirmity”.2 The 1948 Universal Declaration of Human Rights
includes health as part of the right to an adequate standard of living (art. 25).3 This was
reaffirmed in the 1976 International Covenant on Economic, Social and Cultural Rights
(art. 12).4 Moreover, the right to health explicitly encompasses all individuals, including
people living with “long-term physical, mental, intellectual or sensory impairments”. This
was set out in article 25 of the 2006 Convention on the Rights of Persons with Disabilities
(CRPD): “States Parties recognize that persons with disabilities have the right to the
enjoyment of the highest attainable standard of health without discrimination on the basis
of disability.”5
Although it still covers only about half of the world’s population,6 Universal Health
Coverage (UHC) is, for many people, the most effective means of securing the right to
health. Yet, while the right to good physical health has been largely acknowledged – and
reflected in health systems and financing – the right to good mental health has been largely
absent from existing UHC systems. Moreover, while mental health policy guidance and even
global plans have included the need for mental health care to be integrated into health
systems,7 member states have not systematically done so.8
Drawing on an extensive body of evidence, this report makes the case for integrating
mental health in UHC provision – and urges policy makers to act now. It was written in the
midst of the COVID-19 pandemic – an emergency which has increased the need for urgent
action. However, integrating mental health in UHC is a need that goes beyond the
pandemic – it is a need that existed before COVID-19, and, unless addressed, will persist
after it is gone.
THE IMPORTANCE OF UHC
The concept of UHC has been decades in the making. It has its roots in, for example, New
Zealand’s Social Security Act of 1938, the establishment of the UK’s National Health
Service in 1948, Japan’s universal health insurance system in 1961, and, globally, the
Declaration of Alma-Ata during the International Conference on Primary Health Care in
1978. The Alma-Ata Declaration introduced the concept of ‘health for all’ and focused on the
cornerstone of UHC: primary healthcare.9 Since then, the concept of UHC has been
broadened to encompass the health system as a whole, including public health – “from
health promotion to prevention, treatment, rehabilitation, and palliative care”.10
INTRODUCTION 7
The ‘UHC cube’
Source: WHO, “Universal coverage - three dimensions” webpage, accessed 17/09/2020.
UHC can be thought of working along three dimensions – sometimes referred to as the
‘UHC cube’:
• the range of effective and high-quality services covered
• the financial accessibility of these services (i.e. financial protection of service users)
• the proportion of the population that have access to these affordable services.11
UHC aims to fulfil all these dimensions so everyone can “obtain the services they need at a
cost that is affordable to themselves and to the nation as a whole”.12 As such, UHC is a
critical instrument to making the right to the best attainable health a reality for everyone – it
is “the right to health in action”.13
UHC is also a key aspect of sustainable development, and a target in its own right in the
Sustainable Development Goals. SDG target 3.8 reads: “Achieve universal health coverage,
including financial risk protection, access to quality essential health-care services and
access to safe, effective, quality and affordable essential medicines and vaccines for all”.14
Moreover, by improving health on a population and global level, UHC is a critical part of the
broader development agenda. For instance, the World Bank sees it as key to achieving its
“twin goals of ending extreme poverty and increasing equity and shared prosperity. … UHC
allows countries to make the most of their strongest asset: human capital”.15
MENTAL HEALTH AS PART OF UHC
Thanks to the tireless work of many states, activists and advocates, the importance of UHC
is now recognised globally. This was reaffirmed when, in 2019, world leaders assembled to
discuss UHC at the UN General Assembly. Mental health was part of that discussion.
The session saw world leaders commit to “progressively cover 1 billion additional people by
2023 with quality essential health services and quality, safe, effective, affordable and
essential medicines, vaccines, diagnostics and health technologies, with a view to cover all
people by 2030”. They also pledged to “stop the rise and reverse the trend of catastrophic
out-of-pocket health expenditure”.16 Thanks to the advocacy of UN member states and
INTRODUCTION 8
mental health activists and advocates, with the coordinated backing of the Global Mental
Health Action Network,17 world leaders also committed to “[i]mplement measures to
promote and improve mental health and well-being as an essential component of universal
health coverage”.18
This commitment built on a series of reports and initiatives that have also made the case
for the integration of mental health in UHC. These include the WHO Mental Health Action
Plan 2013-2020,19 the WHO-World Bank collaboration Out of the Shadows20 (as well as a
range of other World Bank publications),21 and The Lancet Commission on Global Mental
Health and Sustainable Development.22
The WHO Action Plan set out targets that all member states were expected to deliver, and
was based on six cross-cutting principles, the first of which was UHC. It stated that
“[r]esponses will be stronger and more effective when mental health interventions are
firmly integrated within the national health policy and plan”. It added that “the inclusion and
mainstreaming of mental health issues more explicitly within other priority health
programmes and partnerships … as well as within other relevant sectors’ policies and laws
… are important means of meeting the multidimensional requirements of mental health
systems and should remain central to leadership efforts of governments to improve
treatment services, prevent mental disorders and promote mental health.”
It recommended “mainstream[ing] mental health interventions into health, poverty

reduction, development policies, strategies and interventions” and “[e]xplicitly includ[ing]
mental health within general and priority health policies, plans and research agenda.”23
It is encouraging to see mental health care increasingly included in some areas of global
health policy discussions and formulation, but so far this has led to only limited
national policy change, and even less new investment and implementation. Moreover,
many of these discussions have not fully addressed how best to uphold the rights of
people with mental disorders in the context of UHC – such as the inclusion of person-
centred, rights-based mental health care through the move away from institutional care to
services delivered in the community where appropriate to do so. Most countries still lack a
real political commitment to upholding people’s right to good mental health, and lack the
sustainable domestic financing (and catalytic international and national donor financing,
where this is relevant) to create the change that is needed. Similarly, the UHC service
coverage index, which tracks how global UHC is implemented, does not meaningfully
include mental health.24
This failure to act has been regularly documented in the WHO Mental Health Atlas reports,25
which are based on self-reporting by governments, and by independent reports such as The
Lancet Commission on Global Mental Health and Sustainable Development.26 Indeed, the
gap in coverage for some mental health conditions is in the range of 90% in some countries
– and the gap is even larger if quality of care is taken into consideration.27 This is a serious
failure in a world where every 40 seconds someone somewhere dies by suicide.28 Even
where people with mental disorders are being treated, the nature of this treatment can
violate their human rights, for instance through coercive and abusive treatment, according
to regular reports from organisations such as Human Rights Watch.
INTRODUCTION 9
The harsh reality is that the large majority of people are still confronted with a lack of access
to rights-based, quality mental health care. Moreover, paying for mental health care can be
financially ruinous to many individuals and families, and the need for financial protection is
stark. Improvement is needed along all of the dimensions of the ‘UHC cube’.
The COVID-19 pandemic has made an already challenging situation worse – exacerbating
both mental health needs and the gaps in mental health services. Persons with disabilities
have been particularly affected. At the same time, funding for mental health globally has
become increasingly threatened, as economies shrink, the fiscal field narrows, and available
healthcare funds are diverted elsewhere.
THE NEED TO INTEGRATE MENTAL HEALTH IN UHC
If mental health is not integrated in UHC we put at risk both the quality of mental health
outcomes, and the overall attainment of UHC. Indeed, without a mental health component,
we cannot describe UHC as ‘universal health coverage’. There is no health without mental
health.
This report defines the full integration of mental health in UHC as:
• including mental health care in all relevant aspects of health systems, such as health
promotion, illness prevention, treatment and rehabilitation
• putting mental health care on a par with and – where relevant – accompanying
physical health care
• ensuring mental health conditions are covered by population-wide financial
protection measures.
Based on the data and policies of globally recognised authorities, Part I of this report makes
three arguments to support the integration of mental health in UHC:
• A health argument: In a world where nearly 1 billion people live with a mental
health or a substance use condition,29 there is a staggering – and growing – need to
address mental health directly. Moreover, mental health and physical health are
inextricably linked, and improving mental health cannot fail to improve other
areas of health. To achieve truly universal health coverage, and save countless lives,
mental health care must be included in UHC.
• An economic argument: Investment in mental health should be seen as just that –
an investment for a future economic return and an opportunity to increase national
prosperity. Integrating mental health into UHC is also highly cost-effective and can
make health spending more efficient.
• A rights argument: The right to health, which UHC aims to uphold, includes the
right to mental health. Integrating mental health care in health systems – if those
systems provide rights-based services – could also be a way to ensure that the
rights of people living with mental health conditions are recognised and protected.
Part II of this report discusses how the integration of mental health in UHC can be achieved.
This builds on the numerous relevant technical documents that have been produced and
on the many lessons learned by systems and organisations that have already undertaken
this integration.
Moving towards UHC and the integration of mental health within it are, above all else,
political choices. As such, we urge national and international decision-makers to spare no
effort to ensure the complete integration of mental health in national UHC programmes.
INTRODUCTION 10
REFERENCES
1 UN General Assembly (1966), International Covenant on Economic, Social and Cultural Rights
(New York: UN)
2 WHO (1948), Constitution of the World Health Organization (Geneva: WHO)
3 UN General Assembly (1948), Universal Declaration of Human Rights (New York: UN)
(New York: UN)
5 UN General Assembly (2007), Convention on the Rights of Persons with Disabilities : resolution
adopted by the General Assembly (New York: UN)
6 WHO, “Universal health coverage (UHC)” webpage (accessed 30/11/2020): “At least half of the
world’s population still do not have full coverage of essential health services”
7 WHO (2013), Mental Health Action Plan 2013-2020 (Geneva: WHO)
8 See, for instance, WHO (2018), Mental health Atlas 2017 (Geneva: WHO)
9 WHO (1978), Declaration of Alma Ata (Geneva: WHO); see also WHO and UNICEF (2018),
Declaration on primary health care (Geneva: WHO)
10 WHO, “Universal health coverage (UHC)” webpage (accessed 05/10/2020)
11 Kutzin, J. (2013), “Health financing for universal coverage and health system performance:
concepts and implications for policy”, Bull World Health Organ
12 WHO (2013), The world health report 2013: research for universal health coverage (Geneva:
WHO)
13 Save the Children (2017), Primary Health Care First: Strengthening the foundation for universal
health coverage (London: Save the Children)
14 WHO, “SDG 3: Ensure healthy lives and promote wellbeing for all at all ages” webpage (accessed
05/10/2020)
15 The World Bank, “Universal Health Coverage” webpage (accessed 05/10/2020)
16 UN General Assembly (2019), Political Declaration of the High-level Meeting on Universal Health
Coverage, “Universal health coverage: moving together to build a healthier world” (New York: UN)
17 United for Global Mental Health, “Global Mental Health Action Network” webpage (accessed
05/10/2020)
18 UN General Assembly (2019), Political Declaration of the High-level Meeting on Universal Health
Coverage, “Universal health coverage: moving together to build a healthier world” (New York: UN)
19 WHO (2013), Mental Health Action Plan 2013-2020 (Geneva: WHO). The original plan was scoped
for 2013-2020, but is being extended to 2030
20 The World Bank and WHO (2016), Out of the Shadows: making mental health a global
development priority (Washington DC: The World Bank Group)
21 See Part II below for more details
22 Patel, V., Saxena, S., et al. (2018), “The Lancet Commission on Global Mental Health and
Sustainable Development”, The Lancet
24 WHO (2019), Primary health care on the road to universal health coverage: 2019 monitoring
report (Geneva: WHO)
25 WHO, “Project Atlas” webpage (accessed 05/10/2020)
27 Patel, V., Saxena, S. (2019), “Achieving universal health coverage for mental disorders”, BMJ
28 WHO, “Suicide: one person dies every 40 seconds” webpage (accessed 24/11/2020)
29 United for Global Mental Health (2019), Parental and carer mental health: the impact on the
child. A narrative synthesis of existing evidence and opportunities (online publication). Data for 2017
INTRODUCTION 11
Argument 1: There is no health without mental health

“If ever there was a time to invest in mental health, it’s now … We must take this opportu-
nity to build mental health services that are fit for the future: inclusive, community-based,
and affordable. Because, ultimately, there is no health without mental health”
Dr Tedros Adhanom Ghebreyesus, WHO Director-General, 14 May
202030
PART I
Why is it critical to integrate
mental health in UHC?
PART I 12
Argument 1: There is no health without mental health

“If ever there was a time to invest in mental health, it’s now … We must take this opportu-
nity to build mental health services that are fit for the future: inclusive, community-based,
and affordable. Because, ultimately, there is no health without mental health”
Dr Tedros Adhanom Ghebreyesus, WHO Director-General, 14 May
2020177
ARGUMENT 1
There is no health without mental health
“If ever there was a time to invest in mental health, it’s

now … We must take this opportunity to build mental
health services that are fit for the future: inclusive,
community-based, and affordable. Because, ultimately,
there is no health without mental health”
Dr Tedros Adhanom Ghebreyesus, WHO Director-General, 14 May 202030
PART I 13
It is widely recognised that mental health is a key component of overall health, and world
and national leaders have increasingly adopted the slogan: “no health without mental
health”.31 Unfortunately, this increasing recognition has not, by and large, translated into
action and investment.
As a result, there is still a staggering, and growing, need to address mental health problems
directly – one exacerbated and made more urgent by the COVID-19 pandemic.
Making mental health a mainstream element of existing health systems in a rights-based

way, as part of the push towards UHC, is a golden opportunity to meet this need –
especially at the level of primary and community-based care. It is at these levels where most
of the contact between people and the healthcare system takes place, where most of the
UHC effort is already focused, and therefore where delivering mental health services would
have the most impact – both to directly address mental health conditions and, as a
knock-on effect, to improve physical health.
Services are just one aspect of mental health provision. Integrating mental health into UHC
must also include programmes to promote mental health and prevent mental health
problems.
INTEGRATING MENTAL HEALTH IN UHC: IMPROVING MENTAL HEALTH OUTCOMES
With nearly 1 billion people around the world living with a mental health or a substance
use condition, demand for mental health services is vast. At the same time, existing
mental health systems almost universally fail to address the needs of their populations.
To reverse this failure, rapid and decisive action and investment are needed to integrate
mental health in UHC. This includes ensuring that adequate promotion and prevention
schemes are put in place, and extending quality and affordable service coverage using a
rights-based approach to everyone who seeks treatment.
While seeking treatment (and selecting the type of treatment) is and must always remain a
choice, there are far too many barriers – such as availability and affordability – that people
who need and want treatment have to overcome. As things stand, the treatment gap for
mental health conditions is unacceptably large. Even in high-income settings, the gap in
coverage for common conditions (e.g. depression and anxiety) can be higher than 50%,
while in many low-income countries it can be as high as 90%.32
When the availability of different types of intervention (e.g. psychosocial and

pharmacological)33 or the quality of services are taken into account, the gap is even larger.
According to a study of the treatment of major depressive disorder (MDD) across 21
countries, “[o]nly a minority of participants with MDD received minimally adequate
treatment: 1 in 5 people in high-income and 1 in 27 in low-/lower-middle-income
countries”.34 Even for severe disorders like schizophrenia, the treatment gap can be very
large. A study has found, for example, that across 50 low- and middle-income countries, the
median treatment gap was ~70%.35 Unfortunately, and despite strong recommendations
from bodies such as the WHO and advocacy by lived experience advocates, mental health
systems are often focused on costly in-patient care rather than community- and
primary-level services, or promotion and prevention services.
The size of the mental health workforce also shows the extent of the gap in mental health
provision. According to the WHO, the median number of mental health workers per 100,000
PART I 14
people is only 9 globally, and fewer than 2 per 100,000 people in low-income countries.36
Overall, “only 1% of the global health workforce provides mental health care”.37 There is
an urgent need for greater task-shifting from doctors to nurses and to community - based
health workers in order to deliver optimal mental health services for all.
The stigma and discrimination that is frequently directed at mental health professionals
needs to change too, if more are to enter the field. Reports also suggest that mental health
patients are frequently stigmatised by health professionals themselves38 – something that
needs to be addressed through education.
While problems in mental health systems abound, the need for mental health care is
staggering. Nearly 1 billion people around the world live with a mental health or a
substance use condition.39 Globally, there are 264 million people with anxiety and 322
million with depression (often comorbidly).40 For many people, including young people,
mental health conditions are life-threatening. Tragically, around 800,000 suicides take place
every year – one death every 40 seconds;41 suicide is the second leading cause of death
among young people aged 15-29.42
Neurological conditions are another huge and growing source of demand for support. For
instance, while in 2017 approximately 50 million people were believed to be living with
dementia, projections suggest that by 2030 the number will reach 75 million.43
Vulnerable populations (across all resource settings) are particularly prone to mental health
conditions. This vulnerability is often defined by socioeconomic determinants like poverty
and income inequality, a low standard of education, food insecurity, inappropriate
housing, childhood adversity, violence, female gender, and minority ethnicity, amongst
others.44 What is more, research has suggested that there is a complex bi-directional
relationship between negative socioeconomic determinants and mental health conditions –
with each tending to exacerbate the other.45 The modern world is also creating new
triggers and vulnerabilities for mental health conditions, such as ‘climate anxiety’ and
excessive internet use.46
Conflict-affected populations have a particularly extreme prevalence of mental conditions

– at any given point in time, an average of 22% of conflict-affected populations are affected
by depression, anxiety, post-traumatic stress disorder, bipolar disorder or schizophrenia.47
Moreover, as refugee situations are becoming increasingly protracted, different countries
have taken different approaches on how much they can and are willing to integrate physical
and mental health services for refugees into often resource-constrained national health
systems.
The close relationship between mental health and people’s socioeconomic situation means
the gap in mental health care provision may be a barrier to achieving the global
development ambitions encapsulated in the Sustainable Development Goals. There is a
clear link between vulnerability to poverty (including intergenerational transmission of
poverty) and poor mental health. SDG target 5.2, the elimination of violence against women
and girls,48 will also be more difficult to achieve without addressing the mental health gap,
given the link between such violence and drug and alcohol use. There is also a link between
maternal mental health and stunting in children (see p. 23), that relates to SDG target 2.2.49
The fact that there is an overwhelming unmet need for mental health care, including in
most high-income settings, despite its terrible burden on individuals, families and even
PART I 15
whole populations, should not come as a surprise. Governments around the world spend
on average under 2% of their health budgets on mental health – a figure that tends to
be larger for higher-income countries, though not always.50 In low-income countries, this
translates to spending of only $0.20 on average per person per year.51 Much if this budget is
typically spent on high-cost, low-quality in-patient care rather than community- and
rights-based provision.
Similarly, less than 1% of global development assistance for health has been directed
towards mental health.52 Research from 2016 puts this into perspective: it found that more
is spent in coffee shops in the UK in just one week than is spent on mental health
development assistance in low- and middle-income countries (LMICs) in a whole year.53 This
spending has also tended to focus on emergency settings, with relatively little for longer
term improvements in mental health systems.
Mental health conditions can cause severe disability, and even death; while good mental
health can enable people to live a fulfilling life, as the case study below shows.
Kamala: a story of hope beyond hope (Nepal)
Kamala has not had an easy life. When she was very young, Kamala was sold to people traffickers by her
KAMALA:
stepfatherAand
STORY OF HOPEforBEYOND
was trafficked HOPE
three years. (NEPAL)
Eventually, when she was 9, Kamala was offered free food and
accommodation to work as a cook, as long as she agreed to study at a convent, which she did.
Kamala has not had an easy life. When she was very young, Kamala was sold to people
traffickers by her
She later went on stepfather
to work as a and was
tourist trafficked
guide. One day,forshethree years. Eventually,
was arrested when
and imprisoned she
after wasfound
police 9,
drugs in the bag she was carrying for a tourist. In prison, Kamala developed serious
Kamala was offered free food and accommodation to work as a cook, as long as she agreed mental health problems.
to
She became
study very violent,
at a convent, whichand sheended
did. up being chained. She received no treatment or medication. With
nowhere to go and nobody to turn to when she came out of prison, Kamala became homeless. Eventually,
however, a rescue centre run by an organisation called Koshish helped her find the right medication and
She later went
counselling. onnow
She to work
has a as a tourist
stable job. guide. One day, she was arrested and imprisoned
after police found drugs in the bag she was carrying for a tourist. In prison, Kamala developed
Kamalamental
serious said: “After I realised
health I had aShe
problems. mental illness,very
became I hadviolent,
no hopeandin my life. I became
ended up being suicidal.
chained.But as
Sheof
today, because
received I got timely
no treatment help and treatment,
or medication. With Inowhere
have reachedto goa position
and nobodywhere to I can beto
turn a hope
when forshe
others.”
came out of prison, Kamala became homeless. Eventually, however, a rescue centre run by an
Unfortunately,called
organisation millions of people
Koshish aroundher
helped thefind
worldthe
never getmedication
right the care theyandneed and want. While
counselling. SheNGOs
now has
and charities
a stable job. are able to help some people, to ensure that this sort of support is sustainably available to
everyone who wants it, governments urgently need to integrate mental health in UHC. This would ensure
that mental health services are available as an intrinsic part of health systems, and no one falls through the
Kamala
gaps. said: “After I realised I had a mental illness, I had no hope in my life. I became suicidal.
But as of today, because I got timely help and treatment, I have reached a position where I can
beSource:
a hope for from
adapted the Museum of Lost and Found Potential, developed by the Speak Your Mind campaign (2019)
others.”
Unfortunately, millions of people around the world never get the care they need and want.
While NGOs and charities are able to help some people, to ensure that this sort of support is
sustainably available to everyone who wants it, governments urgently need to integrate
mental health in UHC. This would ensure that mental health services are available as an
intrinsic part of health systems, and no one falls through the gaps.
Source: adapted from the Museum of Lost and Found Potential, developed by the Speak Your Mind campaign (2019)
Kamala’s story shows that good mental health care and support can transform the lives of
the most marginalised people, and have a positive impact on individuals and their
communities. Mental health conditions should be considered to be of equal importance to
physical conditions, and be treated as such. However, mental health systems have suffered
PART I 16
Kamala at the Museum of Lost and Found Potential, screenshot of a video exhibit , developed by the Speak Your
Mind campaign.
from decades of neglect and under-investment, resulting in poor services and coverage.
The inclusion of mental health in UHC using an approach that puts people’s human rights at
the centre , especially in primary and community care, is critical to reverse this trend. This
requires both integrating mental health in existing health systems, as well as expanding
UHC coverage to those populations not currently included.
It would enable hundreds of millions of people living with mental health conditions to
access quality and rights-based mental health services, perhaps for the first time, free of
financial risk. For these people, this could be life-changing: an opportunity to live long,
healthy, productive, and fulfilling lives. For the countries in which they live, it could help
them accelerate their progress towards sustainable development.
INTEGRATION OF MENTAL HEALTH IN UHC: IMPROVING PHYSICAL HEALTH OUTCOMES
Mental and physical health are intimately connected. Integrating mental health in UHC
will not only improve mental health outcomes but also support physical health care. It
is a critical component of making UHC a success, and delivering holistic, person-centred
care.
There is substantial evidence to suggest that when mental health services are integrated
with physical health programmes, the combined physical and mental health treatment
contributes to better overall health outcomes – translating directly to more lives saved, and
a reduction in the impact of physical illness.
PART I 17
In relation to infectious diseases, integration of mental health interventions has been

shown to reduce the incidence of HIV and TB (people living with mental health conditions
are 4 times more likely to have HIV;54 people with depression have a 2.6-fold higher risk of
contracting TB55); support adherence to treatment; and stop onwards transmission (and, in
the context of TB, the proliferation of drug resistance).56
Integrating mental health care into UHC could also support the prevention and treatment of
non-communicable diseases (NCDs), creating more effective health systems.57 The
overarching link between mental health conditions and chronic physical conditions was
confirmed in a study based on the World Mental Health surveys in 2016, which found that
“most associations between 16 mental disorders and subsequent onset or diagnosis of 10
[chronic] physical conditions were statistically significant.”58 Research has also shown that:
• “[c]linically diagnosed major depressive disorder was identified as the most

important risk factor for developing CVD [cardiovascular disease]”59
• depression reduces compliance with treatment, sometimes by as much as a
factor of three, in diseases such as cancer, end-stage renal failure and rheumatoid
arthritis60
• addressing the consumption of alcohol and other substances could also help
reduce unhealthy behaviours that contribute to the development of NCDs.61
Mehnaz: TB and mental health disorders (Pakistan)
After being married at 16, Mehnaz was subjected to physical abuse by her husband.
At 19, Mehnaz
MEHNAZ: was diagnosed
TB AND MENTAL with TB. ByDISORDERS
HEALTH then, she had(PAKISTAN)
moved back in with her father. After nine months
of treatment, she was declared cured. However, just 20 days later, she was re-diagnosed with drug-resistant
TB. This
After was married
being the result at
of 16,
her not taking was
Mehnaz care subjected
of herself properly due toabuse
to physical her stressful
by herand abusive relation-
husband.
ship with her husband. She was also facing challenges from her own family: her father used to side with her
abusive husband and would ask her to go back to living with him.
At 19, Mehnaz was diagnosed with TB. By then, she had moved back in with her father. After
nine months of made
Her relationships treatment,
her feelshe
thatwas declared
all men are bad.cured.
MehnazHowever,
started tojust
lose20 daysinlater,
interest peopleshe was
and the
re-diagnosed
things she usedwith
to do.drug-resistant TB. This
She sat in isolation, was the
and would result
even of herfornot
go hungry, taking
long periodscare of herself
of time, and did not
properly due to her
share her feelings with stressful
anyone else.and abusive relationship with her husband. She was also facing
challenges from her own family: her father used to side with her abusive husband and would
Mehnaz
ask her was then
to go enrolled
back in a with
to living mental health counselling programme.
him.
After only two sessions, Mehnaz’s father saw a notable improvement in her condition. He decided not to
Her relationships made her feel that all men are bad. Mehnaz started to lose interest in people
force her to go back to her husband unless and until her treatment was completed. This was a big step in
and the things
Mehnaz’s she
life. The used toalso
counsellor do.dispelled
She sat their
in isolation, and would
misconceptions about even gohelped
TB and hungry, for long
Mehnaz to getperiods
back
of
on time,
her TBand did not
treatment. share
The her feelings
programme helpedwith anyone
Mehnaz else.
become more sociable and begin to do simple tasks
around the house. She even picked up a hobby – stitching. Most importantly, her relationship with her family
improved.was then enrolled in a mental health counselling programme.
Mehnaz
Mehnaz
After nowtwo
only works in a garment
sessions, factoryfather
Mehnaz’s as a quality
saw achecker.
notable She is currently staying
improvement in herwith her parents
condition. Heand
her income helps support them. If not for the counselling, Mehnaz thinks she would never have returned to
decided not to force her to go back to her husband unless and until her treatment was
normal life.
completed. This was a big step in Mehnaz’s life. The counsellor also dispelled their
misconceptions
With the right help about TB and
and support, helped
Mehnaz wasMehnaz to get back
able to overcome on herodds,
incredible TB treatment.
and be moreThe
likely to avoid
a recurrence ofhelped
programme TB. Governments must act more
Mehnaz become to make sure theand
sociable same kind of
begin tosupport
do simplebecomes
taskssustainably
around the
availableShe
house. to everyone who needs
even picked and wants
up a hobby it. They must
– stitching. Mostintegrate mental health
importantly, in UHC to ensure
her relationship withthat
herit is
available
family as part of any aspect of the health system, including TB programmes.
improved.
Source: IRD, Pakistan
PART I 18
Mehnaz now works in a garment factory as a quality checker. She is currently staying with her
parents and her income helps support them. If not for the counselling, Mehnaz thinks she
would never have returned to normal life.
With the right help and support, Mehnaz was able to overcome incredible odds, and be more
likely to avoid a recurrence of TB. Governments must act to make sure the same kind of
support becomes sustainably available to everyone who needs and wants it. They must
integrate mental health in UHC to ensure that it is available as part of any aspect of the health
system, including TB programmes.
Source: IRD, Pakistan
It is especially urgent to integrate mental health in primary- and community-level care, as

well as within such priority programme areas as HIV, TB, maternal health and NCDs.
However, it should be noted that for some people, for example people living with severe
mental health conditions, it may be more appropriate to integrate physical health
treatments within specialised mental health care. 62
Mental health is not supplementary to health; it is integral to health. Using the image of the
‘UHC umbrella’, it is clear that the integration of health services, including mental health, is
key to ensuring optimal outcomes for health systems as a whole, as well as to protection
from the ‘clouds’ of negative social and environmental factors. At the same time, integration
of mental health in UHC would ensure that mental health services are delivered in a way
that does not cause financial hardship, and is ideally free at the point of delivery, requiring
no out-of-pocket payment from service users.
Source: WHO (2017), Together on the road to universal health coverage. A call to action (Geneva: WHO).
PART I 19
HOW COVID-19 SHARPENS THE NEED TO INTEGRATE MENTAL HEALTH IN UHC
As the UN Secretary General wrote in his report on mental health and COVID-19,63
endorsed by 95 member states,64 COVID-19 has greatly sharpened the need for
investment in mental health. The pandemic has increased mental health needs across
the world, and put massive extra strain on health systems. To respond effectively to
COVID-19, to create more effective health systems and to build back better after the
crisis, it is ever more crucial to integrate mental health care in UHC.
At the time of writing, global COVID-19 continues to cause death and disruption
worldwide.65 The pandemic has disproportionately affected the most vulnerable
communities. For instance, in the UK, “[t]he mortality rates from COVID-19 in the most
deprived areas were more than double the least deprived areas.”66 As a result, many people
live in fear of infection,67 especially if they find themselves in situations where they cannot
follow health and hygiene guidance as a result of their living conditions (e.g. due to
overcrowding, or lack of access to soap and water).68
COVID-19 has also caused a sharp economic downturn. The World Bank has predicted that
the number of people who will slide into extreme poverty (i.e. living on less than $1.90 per
day) will increase by up to 150 million due to COVID-19 by 2021.69 At the same time, when a
broader set of definitions is used (e.g. lack of basic shelter, child nutrition, clean water), the
UN predicts that the number of people in poverty will rise by an even more staggering
240-490 million.70
The mental health impacts of this are stark, and already beginning to bite. For example, a
study conducted in April 2020 suggested that the number of people in Ethiopia
experiencing depressive symptoms tripled versus pre-COVID-19 levels.71 Similar findings
have been reported in the US, where in late June 2020 40% of adults reported struggling
with mental health or substance use.72 A US study also found that COVID-19 survivors are at
increased risk of developing mental health conditions, even when compared with survivors
of other acute conditions, such as influenza and other respiratory tract infections.73
The increase in mental health conditions has coincided with a reduction in services. The
WHO found that mental health services were disrupted in 93% of the 130 countries that
responded to their survey. A third of them reported “complete or partial disruption across
at least 75% of specific MNS [mental, neurological and substance use]-related interventions/
services”.74 There have also been reports, for example from South Africa, that public-sector
pharmacies are running out of psychiatric medication.75
However, the most sobering evidence of the impact of COVID-19 has been the reports of
increased deaths as a result of mental health conditions and substance use during the
pandemic. For example, in India, by the summer of 2020, there was a 67% increase in the
number of media reports of suicide when compared against the same period in 2019.76 In
the US, deaths from drug overdoses are estimated to have risen by 13% in the first half of
2020 compared to the first half of 2019 (and in some states, the increase was over 30%).77
It is also important to recognise that COVID-19 has had a particularly severe mental health
impact on people with existing vulnerabilities. For instance, an online survey in the UK
found that people with pre-existing mental health conditions have been almost twice as
likely to feel panic, and three times as likely to have suicidal thoughts compared with the
general population.78 At the same time, people with substance-use conditions have seen a
PART I 20
significant reduction in their ability to access potentially life-saving services.79 The situation
of people living with mental health conditions in some LMICs is also particularly difficult.80
Women are another vulnerable group. In South Africa, a study of pregnant women in Cape
Town during the national lockdown showed that the “risk of CMDs [common mental
disorders] was almost three times more likely in women who were severely food insecure
or who experienced psychological or sexual abuse“, and that the “strength of the
association between key risk factors measured during the lockdown and psychological
distress increased during the COVID-19 lockdown”.81
Refugees and migrants are particularly at risk too. For example, a recent Scottish Refugee
Council online survey found that about a third of the respondents (30% of women and 33%
of men) categorised their recent mental health as poor or very poor.82 Similarly, children,
healthcare workers, and many other groups have found themselves in particularly
vulnerable situations.83
Using the evidence from the SARS and MERS epidemics as an analogue,84 stress disorders
associated with the pandemic in some COVID-19 survivors may persist for years.85 Economic
recovery is also likely take years in some regions,86 with knock-on effects for people’s
mental health. This all makes integrating mental health in UHC increasingly critical, so that
all those who need and want mental health care can get it.
At the same time, COVID-19 has put significant strain on health services and disrupted
some key health interventions (e.g. immunisation).87 This has created an urgent need for
health systems to optimise their efficiency to catch up. As already discussed, health systems
can only operate at optimal efficiency if they include mental health care. Addressing the
mental health needs of people experiencing physical health conditions can help
accelerate their recovery and reduce the chances of them developing such conditions in
the first place – infectious diseases and NCDs are more prevalent and more difficult to treat
among people with mental health conditions. Mental health care is also crucial for health
workers – both for their wellbeing and their ability to perform their roles and keep the
health system functioning.
When health funds are limited and the mental health of whole populations has been
compromised by COVID-19, the integration of mental health in UHC is an effective and
efficient response.
The comorbid relationship between mental and physical health also applies to COVID-19.
Improved mental health correlates both with higher vaccination rates,88 and with increased
compliance to epidemiological risk-avoidance protocols. For instance, a study conducted
at the peak of the Ebola outbreak in West Africa in 2015 concluded that “higher scores on
measures of PTSD symptoms and depression were associated with higher Ebola Virus
Disease (EVD) risk behaviours, and symptoms of PTSD were associated with lower levels of
EVD prevention behaviours”.89
The same relationship between mental health conditions and higher risk of infection has
been found in the context of COVID-19 as well. In the US, for example, analysis of about 60
million patient records found that a recent mental health diagnosis was strongly linked to
a higher risk of a COVID-19 infection, even when controlling for age, gender, ethnicity and
medical comorbidities.90 Moreover, when infected, a recent mental health diagnosis was
linked to a higher rate of hospitalisation and a greater risk of death.91 Notably, the same
PART I 21
holds true for people living with substance-use disorders – patients with a diagnosis of such
a disorder were more likely to contract COVID-19.92
The relationship between mental health and the risk of infection is another reason why
integrating mental health in UHC, as well as progress on UHC itself, could be a key
component of responding more effectively to COVID-19, and helping people become more
resilient to subsequent pandemics or global health emergencies.
As health systems recover from the impact of COVID-19, and are adapted and reformed
as a result of the crisis, it is critical that mental health is integrated in health systems at all
levels – from the promotion of mental wellbeing and the prevention of mental health
disorders, to treatment and rehabilitation.
MOTHERS, CHILDREN AND YOUNG PEOPLE: AT THE HEART OF UHC
Integrating mental health into the wider health system is critical for supporting
mothers’/caregivers’, children’s and young people’s mental health, as well as early
childhood development. What we do now can shape the well-being of (at least) three
generations: parents, their children, and their grandchildren.
Maternal, child and adolescent health93 has been a key area of focus for international
development in general (e.g. through such mechanisms as the Global Financing Facility).
This includes UHC and primary and community care.94 However, most international- and
national-level effort has focused on physical health, without including mental health,
despite its crucial importance to mothers/caregivers, children and young people.
Globally, 10-20% of children and adolescents experience mental health disorders,95 which
can often have a protracted impact, affecting them throughout their lives. For vulnerable
populations, this percentage can be much higher: 50-90% of children and adolescents living
in conflict zones suffer from PTSD.96 Moreover, just as childhood and adolescence are
crucial developmental stages, they are also the time when many mental health
conditions start to be exhibited. Half of all mental health conditions start by the age of 14,
and three-quarters by mid-20s.97
As a result, mental health and substance-use conditions are responsible for 27% of the
years lost due to disability in people aged 10-24 years around the world,98 and have been
estimated to cause a 20% reduction in annual income later in life.99 Tragically, suicide is the
second leading cause of death among 15-29 year olds worldwide.100
The mental health of parents/caregivers can have an impact on both the physical and
mental development of their children. Between 15-23% of children live with a parent with a
mental health condition.101 Indeed, “[m]ental health problems among women who are
pregnant or have recently given birth are among the most common causes of pregnancy-
related morbidity”.102 This is especially true in lower-income countries, where the prevalence
of both antepartum and postpartum depression can be approximately double what it is in
high-income countries.103 At the same time, the absence of maternal depression has been
associated with higher rates of responsive caregiving.104
Research has analysed the impact of parent’s/caregiver’s mental health on the cognitive and
emotional development of their children. For example, using the Avon Longitudinal Study of
Parents and Children in the UK, postnatal depression in both mothers and fathers has been
PART I 22
separately associated with a raised risk of “behaviour disturbance”105 and “adverse

emotional and behavioural outcomes” for children at 3.5 years of age.106 Moreover, in
severe cases, difficult family or external circumstances can lead to toxic stress that can have
“enduring effects on brain development and other organ systems”.107
Parent’s/caregiver’s mental health conditions can also be starkly reflected in their children’s
physical development. For instance, a Pakistani study found that children of mothers with
prenatal depression had a relative risk of 2.4 of having an above-average number of
diarrhoeal episodes per year.108 Maternal depression can also mean children have higher
rates of respiratory disease, increased hospital admissions, and a lower likelihood of
completing vaccination schedules.109 Finally, children of mothers with a common mental
disorder were found to be three times more likely to be stunted.110
The COVID-19 pandemic has exacerbated these challenges. Firstly, it has caused increased
anxiety and uncertainty about the future for children.111 Lockdown has exposed more
children to either experiencing or witnessing domestic abuse.112 At the same time,
two-thirds of the 136 countries that responded to a UNICEF survey reported a disruption to
services relating to violence against children (such as case management services, household
visits to children and women at risk of abuse, and violence prevention programmes).113
The pandemic has also exacerbated the rates of adult / parental anxiety and other mental
health conditions, including for pregnant women. For example, it has been noted that the
limitations placed on obstetric care by infection controls (e.g. quarantine and healthcare
professionals wearing personal protective equipment) “may increase risk for birth-related
posttraumatic stress disorder, especially for women with pre-existing trauma”.114
Moreover, just as parents/caregivers are affected by the economic consequences of

COVID-19, so are their children. According to the IMF and the UN, about half of all the
people who will fall into extreme poverty as a result of COVID-19 (living on under $1.90 per
day) are likely to be children.115 This is part of the acute stress caused by COVID-19, which
for some children can “impair their cognitive development and trigger longer-term mental
health challenges”. These negative impacts may stay with this generation of children for the
rest of their life.116
COVID-19 has also intensified already existing challenges in education. As the World Bank
has reported, at the peak of the lockdown, 1.6 billion children were out of school; and
conservative estimates suggest 7 million students may drop out of primary and secondary
education altogether.117 Girls are more at risk of dropping than boys, leading to a growing
risk of adolescent pregnancy,118 and with it a significantly higher risk of maternal mental
health conditions (for instance, “pregnant adolescents are 2-9 times more likely to develop
perinatal depression”).119 This not only impacts the health of the mother, but is a risk factor
for worse physical, social, behavioural and cognitive outcomes for the child.120
Finally, there is evidence that COVID-19 has increased suicidal ideation among young
people. For example, a US study has suggested that nearly 25% of young adults (aged
18-24 years) contemplated suicide due to the pandemic.121 In lower-income settings, a
similar picture emerges. For example, UNICEF reports that “[i]n Nepal, police reported a 40
per cent increase in suicides among girls, while a child helpline in Bangladesh intervened in
six cases of potential suicide in a single week”.122
PART I 23
Where maternal/caregiver, child and adolescent health and development is concerned,

therefore, it is critical to integrate mental health in UHC. This integration is particularly
urgent at primary and community healthcare level (including perinatal care, and in
programmes such as parent coaching). This is where most of the contact between these
groups and the health system already takes place,123 and where most of the UHC effort and
reforms are already focused. It would help address their mental health conditions directly,
and improve their physical health, for example, reducing stunting and increasing
vaccination uptake. Integrating mental health in health systems could, in fact, revolutionise
the delivery of care for mothers and children, and communities as a whole. This, in turn,
would improve the world’s chances of successfully reaching the relevant SDG targets.124
Ayisha: “This maternal sadness is terrible” (Ghana)
When she was pregnant with her first child, Ayisha experienced perinatal depression.
AYISHA: “THIS MATERNAL SADNESS IS TERRIBLE” (GHANA)
Her husband recalls: “I was scared. During her pregnancy, occasionally she could be so quiet and refuse to
When
speakshe was pregnant
to anyone, with
but I used her itfirst
to think waschild, Ayisha experienced
the pregnancy perinatal
weighing on her. It was sodepression.
serious after she deliv-
ered and that made me realise it was not a simple matter.”
Her husband recalls: “I was scared. During her pregnancy, occasionally she could be so quiet
Luckily,
and refuse duetotospeak
a timely
toscreening
anyone, during her last
but I used totrimester, Ayisha
think it was was
the monitoredweighing
pregnancy through to on
herher.
delivery
It was
soand for several
serious aftermonths afterwards.
she delivered andShe received
that madecounselling,
me realisewhich (among
it was not a other
simplethings) encouraged her
matter.”
to ensure that her child was immunised against childhood killer diseases. With the support of the community
health and psychiatric nurses, who visited her regularly, she was also able to provide her baby with exclu-
Luckily, due to a timely screening during her last trimester, Ayisha was monitored through to
sive breastfeeding.
her delivery and for several months afterwards. She received counselling, which (among other
things)
Ayishaencouraged herher
has talked about to ensure that“This
experience: hermaternal
child was immunised
sadness against
is terrible. It waschildhood killer
terrible for me. It looked
diseases. Withwas
like the world thenosupport of the
longer worth community
being health
in it. I thank andmy
God that psychiatric
baby was not nurses,
harmed.who visited
I didn’t have her
the
energy toshe
regularly, attend
wasto also
her as I needed
able to.” Ayisha
to provide her wishes all women
baby with couldbreastfeeding.
exclusive have the same support she had.
Ayishahas
Ayisha wastalked
one of about
the fortunate few. NGO BasicNeeds-Ghana
her experience: and its partners
“This maternal sadness were It
is terrible. there
wastoterrible
give herfor
the
support she needed. Through the Maternal Mental Health Project, funded by the UK’s Foreign,
me. It looked like the world was no longer worth being in it. I thank God that my baby was not Common-
wealth and Development Office (FCDO), BasicNeeds-Ghana and its partners have been able to train more
harmed. I didn’t have the energy to attend to her as I needed to.” Ayisha wishes all women
than 1,000 midwives and community health nurses, and 250 community mental health staff.
could have the same support she had.
While this is a step in the right direction, for a country the size of Ghana the job is far from done. Basic-
Needs-Ghana
Ayisha was onesaid: “Wefortunate
of the are proud of theNGO
few. progress we have been ableand
BasicNeeds-Ghana to make, with the support
its partners were thereof the
toFCDO. However,
give her for these
the support services
she needed.to become
Throughavailable to everyone
the Maternal who wants
Mental Healthto Project,
get them,funded
it is clearby
that
increased
the government
UK’s Foreign, action and investment
Commonwealth is required. Governments
and Development around
Office (FCDO), the world – including
BasicNeeds-Ghana and Gha-
its
na – should
partners haveintegrate mental
been able tohealth in UHC,
train more to ensure
than 1,000that everyoneand
midwives cancommunity
have someone to turnnurses,
health to for their
and
mental health needs.”
250 community mental health staff.
Source: BasicNeeds-Ghana
While this is a step in the right direction, for a country the size of Ghana the job is far from
done. BasicNeeds-Ghana said: “We are proud of the progress we have been able to make, with
the support of the FCDO. However, for these services to become available to everyone who
wants to get them, it is clear that increased government action and investment is required.
Governments around the world – including Ghana – should integrate mental health in UHC, to
ensure that everyone can have someone to turn to for their mental health needs.”
Source: BasicNeeds-Ghana
PART I 24
CONCLUSION
We have a long way to go on mental health: “When it comes to mental health, all countries
are developing countries.”125 To date, the huge and growing need for quality and
rights-based mental health care has gone largely unaddressed and unfunded – including
for such key groups as mothers/caregivers and children. This has huge implications: mental
health conditions are a critical source of death and disability in their own right, but they also
often have a negative impact on physical health. The COVID-19 pandemic has only made the
situation worse.
It is of paramount importance for the health – both mental and physical – of entire
populations to ensure that mental health is rapidly integrated into health systems, including
their promotion and prevention components. This involves providing sufficient and
sustainable funding for mental health, and including it as part of the ‘build back better’
CONCLUSION
response to COVID-19.
While theaintegration
We have long way toofgo
mental health
on mental is important
health: “When for the entire
it comes healthcare
to mental system,
health, it is
all countries
especially crucial at primary
125and community health levels. This is where most of the contact
are developing countries.” To date, the huge and growing need for quality and
between populations
rights-based and the
mental health health
care system
has gone takesunaddressed
largely place, and has always
and been –the
unfunded including
cornerstone of UHC. This move could revolutionise mental health care delivery
for such key groups as mothers/caregivers and children. This has huge implications: for entire
mental
populations, saving countless lives and significantly reducing ill health.
health conditions are a critical source of death and disability in their own right, but they also
often have a negative impact on physical health. The COVID-19 pandemic has only made
This is our message for all political leaders: the time to act is now.
the situation worse.
THIS IS OUR MESSAGE FOR ALL POLITICAL LEADERS: THE TIME TO ACT IS NOW.
It is of paramount importance for the health – both mental and physical – of entire
populations to ensure that mental health is rapidly integrated into health systems, including
their promotion and prevention components. This involves providing sufficient and
sustainable funding for mental health, and including it as part of the ‘build back better’
response to COVID-19.
While the integration of mental health is important for the entire healthcare system, it is
especially crucial at primary and community health levels. This is where most of the contact
between populations and the health system takes place, and has always been the
cornerstone of UHC. This move could revolutionise mental health care delivery for entire
populations, saving countless lives and significantly reducing ill health.
This is our message for all political leaders: the time to act is now.
One of IRD’s counselors is providing phone based counseling to her patients. Photo Credit: Shehzad Noorani
PART I 25
ARGUMENT 2
Mental health spending is an
investment, not a cost
PART I 26
A psychiatrist outreach clinic in the Upper West Region of Ghana, facilitated by BasicNeeds-Ghana in collaboration with the Ghana
Health Service. An outreach clinic provides mental health screening and diagnosis, treatment and referral in the community. It is a
way of taking mental health treatment closer to the community and the service users
PART I 27
It is widely recognised that health is a good investment.126 Indeed, this is the basis for the
World Bank’s Human Capital Project, which argues that investment in people – including in
their health – is a key component of building an increasingly prosperous and sustainable
society. Investment in people pays off, “ensuring that people accumulate the health,
knowledge and skills needed to realize their full potential and that they can put those skills
to use across the economy”.127 In other words, spending on health should be seen precisely
as an investment, an opportunity to increase national well-being and prosperity; and not as
a cost.128
Traditionally, this argument has been made about physical health. However, it is
incomplete if it does not include mental health. Without integrating mental health in UHC,
we will be failing to unlock the full productivity and economic potential of people living
with mental health conditions and their carers. Moreover, as already discussed, integrating
mental health in UHC is a simple and effective way of improving the efficiency of the health
system as a whole. Indeed, mental health is so fundamental to sustainable development,
that it can be argued that it should be added as a component of the Human Capital Index.
Given the difficult economic situation faced by most countries as a result of the COVID-19
pandemic, there is a risk that spending on mental health (and perhaps on health in
general, outside of direct COVID-19 expenditure) will be deprioritised or even cut. However,
this would be a false economy: investment in mental health (and health overall) must
remain a top priority for policymakers, if they wish to promote long-term economic
recovery and growth.
HIGH COST-EFFECTIVENESS OF MENTAL HEALTH INTERVENTIONS
Mental health interventions can be delivered in a highly cost-effective way; and, indeed,
increasingly so as a result of COVID-19-driven innovation. This is another strong
argument for integrating mental health in UHC at scale.
Mental health interventions can cost as little as 100 $Int 129 per year of healthy life to
deliver.130 This level of cost-effectiveness is in line with that of interventions in other areas
of health, e.g. HIV and NCDs.131 This means that mental health can be integrated into health
systems in a highly efficient way. This is especially true of primary and community care, as
compared with less efficient institutional care.132
Moreover, the COVID-19 pandemic has contributed to an acceleration in innovative and

efficient methods of delivering mental health care. It has intensified the challenges that
health systems and individual providers face (e.g. not being able to give patients direct
access to health professionals), and forced the mental health community come up with
ways to overcome these difficulties – at pace. When it comes to mental health, this has
created an “opportunity to build on what we know and advance progress in achieving the
mental health objectives of universal health coverage”,133 both from an access and a cost
perspective.
PART I 28
Innovation and
INNOVATION ANDadaptation:
ADAPTATION:continuing to serve
CONTINUING TOduring
SERVE the pandemic
DURING THE PANDEMIC
Cape
CapeMental Health, aa South
MentalHealth, South African
Africannon-profit organisation
non-profit organisationthat provides day-careday-care
that provides to adults and children
to adults
and children with severe and profound learning disabilities, was able to move its in-person to
with severe and profound learning disabilities, was able to move its in-person clubhouse-model services
a remote model within just 2-3 weeks. It adapted its programme to duplicate the “structured day that was
clubhouse-model services to a remote model within just 2-3 weeks. It adapted its programme
usually delivered in the facility so that the carer and the parent could do it at home” (for instance, doing a
to duplicate the “structured dayremote
song at the start). Staff providing that was usually
support and delivered
guidance, and in the facility
activities so adapted
were that thetocarer
suit aand
home
thesetting,
parente.g.
could
usingdo it at
fruit home”
and (for instance,
vegetables to practice doing a song at the start). Staff providing remote
counting. 134
support and guidance, and activities were adapted to suit a home setting, e.g. using fruit and
vegetables
ThriveGULU in Uganda
to practice used radio
counting. 134shows to disseminate accurate information on mental health issues.
Furthermore, to ensure that mental health and psychosocial support messaging reached even the most
disadvantaged
ThriveGULU service users,
in Uganda usedwho may
radio not have
shows owned radios,accurate
to disseminate ThriveGULU set up a van
information onthat was mounted
mental
with loudspeakers, and that played pre-recorded messages. This van was then driven around the villages.135
health issues. Furthermore, to ensure that mental health and psychosocial support messaging
reached even the
St. Patrick’s most
Mental disadvantaged
Health, a provider ofservice
inpatientusers, who may
and outpatient not have
mental healthowned
servicesradios,
to approximately
ThriveGULU
10% of the Irish population, was able to move 100% of its outpatient services online withinpre-recorded
set up a van that was mounted with loudspeakers, and that played just two and a
135
messages. This
half weeks. van was
Remote carethen driven
was also around
extended the villages.
to some inpatients, as about 80 out of their 300 inpatients were
set up with a home-care service. This new model of care has been so effective that St. Patrick’s plans to
St. continue
Patrick’s Mental
this schemeHealth,
in the future, beyondof
a provider COVID-19,
inpatientoffering a model of mental
and outpatient rapid de-institutionalisation
health services to that
could inform approaches
approximately 10% of theelsewhere.
136
Irish population, was able to move 100% of its outpatient services
online within just two and a half weeks. Remote care was also extended to some inpatients, as
about 80 out of their 300 inpatients were set up with a home-care service. This new model of
care has been so effective that St. Patrick’s plans to continue this scheme in the future, beyond
COVID-19, offering a model of rapid de-institutionalisation that could inform approaches
elsewhere.136
INTEGRATING MENTAL HEALTH IS A GOOD ECONOMIC INVESTMENT
The economic impact of poor mental health is too large to be ignored. Mental health
care urgently needs to be scaled up and integrated into health systems to offset this
impact and accelerate sustainable growth, especially in the context of COVID-19. Mental
health can help improve productivity and ‘de-risk’ investments in other areas of health
care (e.g. HIV, TB, maternal and child health).
Across 36 countries (representing 80% of the world’s population), a staggering 12 billion

productive days are lost each year due to depression and anxiety alone.137 Up to 20% of
the world’s working population is estimated to have a mental health condition at any given
time.138 One study estimated that poor mental health cost the global economy $2.5 trillion
in 2010 in reduced economic productivity and direct cost of care. This cost is projected to
rise to $6 trillion by 2030.139 While this is disastrous on global and national levels, it also
translates directly to impoverishment for individuals and families, sometimes across
generations,140 as mental health conditions limit people’s opportunity to work and earn an
income.
The scale-up and integration of mental health into health systems is urgently needed to
offset this economic loss. Extensive research has found that investing in mental health
interventions for common mental health conditions, such as anxiety and depression, could
deliver a return on investment of 3:1 in direct economic benefits, and 5:1 if the ‘value of
health’ is included as well. These findings are compatible with, indeed rely on, the
integration of mental health in UHC. For instance, the modelling assumed that all cases
would be seen as part of outpatient and primary care, largely in “non-specialist health care
settings by doctors, nurses and psychosocial care providers trained in the identification,
PART I 29
assessment, and management of depression and anxiety disorders”, in line with the WHO’s
Mental Health Gap Action Programme (mhGAP) (see p. 51).141
The same positive economic relationship holds true for more severe mental illness as well.
For example, in the UK, a study on the integration of suicide prevention in primary care
(based on awareness training of GPs, and subsequent referral for more specialist
treatment) found that economic gains through directly avoided productivity losses (to say
nothing of the saved lives themselves) were 20 times higher than the cost of the
intervention.142
Given the frequent comorbidities between mental and physical health, it is also likely that
investment in mental health could ‘de-risk’ (and perhaps even magnify) the delivery of
economic gains from other health programmes, e.g. in infectious diseases (such as TB and
HIV), or in maternal and child health. When combined with mental health, the spending on
other areas of health (and on UHC as a whole) will be in a position to deliver its full
economic potential.
For instance, in a submission to the Global Fund to Fight AIDS, TB and Malaria’s 2022-2027
strategy consultation, it has recently been argued that: “Integrating mental and substance
use disorder treatment into HIV and TB platforms may synergistically increase [the
economic] gains [from investment into HIV and TB health care] by reducing community
transmission and drug resistance, as well as social and economic costs to individuals and
households affected by these multimorbidities.”143 Fully integrating mental health into the
Global Fund’s 2022-2027 strategy could, therefore, substantially contribute to economic
growth, as well as reduce HIV and TB transmission rates.
Moreover, integrating and mainstreaming mental health in UHC can also support the
integration of mental health into the broader national development agenda, creating
opportunities for intersectoral collaboration (e.g. with the education sector, or social
services / violence prevention). For instance, a longitudinal study of stunted children in
Jamaica showed that children who received even simple psychosocial stimulation (home
visits promoting caregiver-infant play and verbal interaction) were three times more likely to
have some college-level education, and earned 25% more than the control group of stunted
children who did not have the home visits (and had earnings in line with the non-stunted
comparison group).144
Given the higher prevalence of mental health conditions during COVID-19, the return on
investment of scaling-up mental health care is likely to be even larger than prior to the
pandemic – both directly and through its effect on comorbidities. At the same time, in a
situation where the global Human Development Index (a measure of progress in key
dimensions of human activity, such as health and education)145 is projected to fall for the
first time since its introduction in 1990, investment in mental health is a lever that countries
around the world can scarcely afford to ignore.146
INTEGRATING MENTAL HEALTH INCREASES THE EFFICIENCY OF HEALTHCARE SYSTEMS
Increasing investment in mental health, and integrating mental health in health

systems, can be relatively low-hanging fruit in creating the conditions for the more
efficient use of precious healthcare resources, both in terms of effective prevention, and
cost-efficient delivery of care. Crucially, the more effective use of health resources in the
context of UHC will translate into improved rates of coverage and financial protection.
PART I 30
As well as supporting economic growth in general, mental health integration can also
promote more effective spending within health systems in particular. This is especially the
case if spending on mental health is focused on de-institutionalisation in favour of mental
health prevention and promotion activities in community settings.
Mental health conditions have been linked to a higher risk of developing physical health
conditions, and therefore with potentially higher direct healthcare spending to treat those
conditions. This is true across a large range of disease types (see Argument 1, p. 17 - 19). It
follows that addressing mental health conditions can reduce the prevalence of physical
conditions, and therefore the number of people who need to be treated for them, at a cost
to the healthcare system. For example, screening and intervention for alcohol misuse as part
of primary care in the UK has been shown to save more than twice as much money for the
healthcare system as the intervention itself cost.147
Moreover, addressing mental health conditions alongside physical health conditions can
lead to a disproportionate reduction in the overall cost of care. A Canadian population-based
study of nearly 1 million adults compared the healthcare costs of people living with and
without mental health conditions. It found that: “3-year adjusted mean costs were $38,250 for
those with a mental health disorder and $22,280 for those without a mental health disorder”;
and that mental health conditions were “associated with higher rates of hospitalization and
emergency department visits.”148 A number of studies have make a direct link between a
mental health intervention and healthcare resource utilisation, finding that, in the case of
diabetes, “effective depression treatment is associated with decreases in many types of
health care costs”.149
As well as saving money for the healthcare system, mental health interventions are highly
cost-effective where other areas of public spending are concerned, such as for social services,
education and the criminal justice system. For instance, school-based Social and Emotional
Learning Programmes, evaluated in the UK, were found to successfully address the needs of
particularly vulnerable children and deliver significant savings, mostly through reduction in
crime.150
The efficient use of resources, “doing more with the same”, is crucial in the context of UHC,151
as more effective use of health (and other public) resources may translate into improved
rates of coverage and financial protection. Integrating mental health is relatively low-hanging
fruit in achieving this goal. Given the added pressure on health systems and public finances
due to COVID-19, integrating mental health in health systems must be a priority, to help
ensure that available health resources are spent in a maximally effective way.
GOOD MENTAL HEALTH AS A CORE COMPONENT OF HUMAN CAPITAL
Human capital is “the knowledge, skills, and health that people accumulate over their lives,
enabling them to realize their potential as productive members of society.”152 Progress in
increasing human capital is tracked through the Human Capital Index, “an international met-
ric that benchmarks key components of human capital across countries”. The Human Capital
Index, which is at the core of the World Bank’s Human Capital Programme, has a number of
components: 153
• Survival from birth to school age, measured using under-five mortality rates
• Expected years of quality-adjusted schooling
• Adult survival rates, defined as the fraction of 15-year-olds who survive until age 60
• The rate of stunting for children under five
PART I 31
Given the pivotal role that mental health plays in enabling people to live healthy lives and
engage in work and education, it should be seen as a fundamental pillar of human
capital. Indeed, it can be argued that it should be explicitly added as a fifth component of
the Human Capital Index, or at least be explicitly addressed as a key enabler to the
successful attainment of its four existing components (see the table below).
Human Capital Index component Example mental health impact on component154

Under-five mortality rate Maternal (and caregiver) mental health can have an impact on
HUMAN CAPITAL INDEX COMPONENT theEXAMPLE
physical health
MENTAL of children,
HEALTH e.g. IMPACT
children ofON prenatally
COMPONENTde- 154
pressed mothers in Pakistan were found to have a relative risk
of having a higher than average number of diarrhoeal episodes
per year of 2.4; (and
Maternal and children of depressed
caregiver) mental health mothers
can are
havealso
an at
risk ofimpact
higher onrates of respiratory disease, hospital admission
the physical health of children, e.g. children of
and reduced vaccination completion
prenatally depressed mothers in Pakistan were found to
Expected years ofmortality
Under-five quality-adjusted
rate school- Poor maternal (and caregiver)
have a relative mental
risk of having health can
a higher thanhave an
average
ing impactnumber
on the cognitive
of diarrhoeal development
episodesofper theiryear
children,
of 2.4;asand
well
as lead to a higher
children risk of emotional
of depressed mothers difficulties
are alsolike ADHD
at risk of and
conduct disorder
higher rates of respiratory disease, hospital admission
% of 15-year-olds who survive until age 60 Mentaland health conditions
reduced are linked
vaccination to worse physical health
completion
outcomes, across both infectious and non-communicable dis-
eases.Poor
In addition,
maternal consumption of drugs
(and caregiver) and alcohol
mental increases
health can have
Expected years of the risk of physical ill health
an impact on the cognitive development of their
quality-adjusted
The rate schooling
of stunting for children under five The mental health
children, of mothers
as well as leadand
to acaregivers
higher risk can
ofhave an
emotional
impactdifficulties
on whether their
like ADHDchildren
and are stunted.
conduct For example,
disorder
children of mothers with a common mental disorder were found
to be three times more likely to be stunted
Mental health conditions are linked to worse physical
% of 15-year-olds who health outcomes, across both infectious and non-
survive until age 60 communicable diseases. In addition, consumption of
drugs and alcohol increases the risk of physical ill health
The mental health of mothers and caregivers can have

an impact on whether their children are stunted. For
The rate of stunting for example, children of mothers with a common mental
children under five disorder were found to be three times more likely to be
stunted
CONCLUSION
Resources spent on mental health should not be seen as a cost. They are truly ‘human
capital’ investments that can generate a direct return for the economy and for human
development. They can improve the effectiveness of other health system spending, and
help uphold the rights of everyone to good mental health. Moreover, many mental health
interventions are already highly cost-efficient.
There is a strong economic case for investment in mental health. The time to invest is
THERE IS A STRONG ECONOMIC CASE FOR INVESTMENT IN MENTAL HEALTH.
now.
THE TIME TO INVEST IS NOW.
PART I 32
ARGUMENT 3
Mental health, UHC and human rights
PART I 33
There are two mechanisms through which the integrating mental health in UHC is
inextricably linked to human rights.
Firstly, in the context of UHC, the provision of quality, rights-based mental health care (to
people who choose to access it) is a critical part of ensuring that their right to health care as
a whole is met.
Secondly, integration of mental health in UHC creates a potential means for the protection
of the rights of people with mental health conditions through reducing the opportunity for
abuses of their human rights.155
UHC, MENTAL HEALTH AND THE RIGHT TO HEALTH
Access to quality, affordable healthcare – including mental health care – is a right, not a
privilege. Mental health must be integrated in UHC, if UHC is to achieve its goal of giving
everyone the right to health.
The concept of UHC, based as it is in the WHO Constitutions of 1948, is fundamentally

rooted in human rights and equity: access to affordable health is a fundamental human
right, not a privilege.156 At the same time, mental health is an inalienable part of the right
to health. For instance, the International Covenant on Economic, Social and Cultural Rights
(article 12.1) affirmed “the right of everyone to the enjoyment of the highest attainable
standard of physical and mental health”.157
UHC cannot fully meet its goal of promoting the right to health without the inclusion of
mental health. In other words, if mental health is not integrated into UHC, national health
systems will invariably discriminate against people living with mental health conditions. This
was clearly recognised in the 2019 Political Declaration of the High-level Meeting on
Universal Health Coverage, which explicitly confirmed the link between mental health and
the right to health in the context of UHC. In that document, UN member states reaffirmed
“the right of every human being, without distinction of any kind, to the enjoyment of the
highest attainable standard of physical and mental health.”158
At present, the right to mental health care is not being upheld. The clearest indications of
this come from comparing the average mortality rates of people living with severe mental
conditions and those without. For instance, people living with major depression and
schizophrenia “have a 40% to 60% greater chance of dying prematurely than the general
population, owing to physical health problems that are often left unattended … and
suicide”.159 Overall, people living with severe mental health conditions may die up to 20
years earlier than people without these conditions.160
To meet this right and ensure the required level of coverage, therefore, it will be critical to
include quality, rights-based mental health care within UHC service packages to ensure that
services are available to those who need them and who want to access them. However, this
is not just an issue of high-quality service coverage. It is also about creating an environment
in which the risks of developing a mental health condition are minimised. Integrating men-
tal health in UHC can be the first step towards establishing a cross-sectoral collaboration to
address the socioeconomic determinants of mental health (see Argument 1, p. 15).
Furthermore, it is an issue of financial access, a key consideration for UHC. According to

Human Rights Watch: “More than two-thirds of countries do not cover reimbursement for
PART I 34
mental health services in national health insurance schemes.”161 This forces people in need
to spend large sums of money out-of-pocket. In Goa, for example, 15% of women with
depression were found to spend more than 10% of their monthly household income on
health – defined as ‘catastrophic health expenditure’.162 In Ethiopia, a study from 2017
identified poverty as the number one barrier to engagement with mental health care.163 To
ensure that the right to health is met, UHC needs to provide quality, rights-based services
while protecting service users from financial hardship, ideally through services that are free
at the point of delivery, requiring no out-of-pocket payments from patients.
Once again, COVID-19 adds further urgency to these considerations. As well as interrupting
the provision of mental health services, while increasing the need for them, the pandemic
has triggered an economic downturn that will make it harder for people to pay for mental
health care, and more likely to need it.
THE RIGHTS OF PEOPLE WITH MENTAL HEALTH CONDITIONS
As well as being critical to delivery of the holistic ‘right to health’, integrating mental
health in UHC may also contribute to reducing the human rights abuses of people living
with mental health conditions.
As The Lancet Commission on Global Mental Health and Sustainable Development

emphasised, people living with mental health conditions can be among the most
vulnerable in society. They can often endure extreme forms of human rights violations,164
such as chaining, which is commonly practiced.165 Even in their families and local
communities, many people living with mental health conditions experience the complex
and multifaceted burden of social rejection and abuse.166
In addition, within many mental health systems, people can suffer abuses, such as
incarceration, coercion and over-medicalisation.167 According to the WHO, adults with
psychosocial and intellectual disabilities who live in institutions are “a highly marginalized,
vulnerable group whose quality of life, human rights and reinclusion in society are
compromised by outdated, often inhumane institutional practices”.168 Unfortunately, it is
typical for the lion’s share of the already meagre national mental health budgets to be spent
on this ineffective and inhumane form of care. For instance, in low- and middle-income
countries, 80% of mental health budgets are spent on mental hospitals.169
Both within institutions and communities, COVID-19 has further exacerbated the
vulnerabilities of people living with mental health conditions. Mental health institutions
are often not designed for infection control and can be overcrowded, putting the people in
them at particular risk of infection.170 Validity International has collected evidence of rights
abuses of people with disabilities during COVID-19 in multiple countries. These include poor
care in institutions, lack of access to food, and discrimination in accessing basic, specialist
and emergency health care.171
In a similar vein, Human Rights Watch has recently reported that chaining has continued
during the COVID-19 pandemic, significantly reducing the ability of those chained to protect
themselves from infection.172 Finally, on an even more basic level, there have been reports
that people living with mental health conditions, often deeply marginalised within their
communities, have struggled to obtain food and other basic items during lockdowns.173
PART I 35
A transition to high-quality, sufficiently funded, evidence-based, rights-based,

community-based and universally accessible mental health care integrated into UHC would
confer a number of benefits. For instance, as primary and community care are the focus of
UHC, integrating mental health into UHC could catalyse the ‘de-institutionalisation’ of
mental health. It would move mental health care away from the often ineffective, inhumane
and costly tertiary institutions to services centred on the more effective and less costly
primary and community mental health provision.174 Leveraging UHC to transition to this
blueprint of service delivery will also be important to ensure that any further funding that is
allocated to mental health is appropriately distributed, based on the de-centralised model
of care.
Moreover, in conjunction with initiatives such as aligning national mental health legislation
to international human rights covenants and running community outreach and education
programmes, integration of mental health in UHC could reduce the opportunity for rights
abuses. For example, it could replace chaining with high-quality evidence-based care, and
help abolish so-called conversion therapy – a discredited and abusive practice of trying to
change someone’s sexual orientation.175 It could also improve people’s perception of mental
health conditions, for example by promoting the understanding that they are preventable,
manageable and treatable.
The integration of mental health in UHC, if implemented according to a rights-based

approach, would be a key stepping-stone towards realising the rights of people living with
mental health conditions, in accordance with the Convention on the Rights of Persons with
Disabilities (CRPD), including the right to health, the right to freedom from torture, the right
to liberty and security of the person, and others rights.
To ensure that the integration of mental health in UHC can achieve these outcomes, it will
be important to leverage such initiatives as the WHO’s Quality Rights Programme,176 the
formal monitoring and accountability mechanisms of the CRPD,177 the efforts of NGOs like
Human Rights Watch, the WHO Mental Health Atlas initiative,178 as well as any future
outputs from the Countdown Global Mental Health 2030 project, “an independent,
multistakeholder monitoring and accountability collaboration for mental health”.179
PART I 36
ENOCK MALOYA PHIRI: “I CAN FEEL FREE” (MALAWI)

Enock Maloya Phiri: “I can feel free” (Malawi)
“From time to time I would have an attack. Fear would just strike me, and I would take off
running
“From timevery fast.
to time At that
I would time,
have everyone
an attack. Fearwas
wouldafraid of me.
just strike me,People would
and I would mock
take me shouting,
off running very fast.
‘Crazy
At man!everyone
that time, Crazy man!’ People
was afraid would
of me. beat
People me.mock
would Someme threw rocks
shouting, at me.
‘Crazy Others
man! Crazy tied
man!’me up,
People
would
sayingbeat me. Some
I should threw rocks at me. Others tied me up, saying I should be killed.”
be killed.”
Enock
EnockMaloya
Maloya was
was1919years old old
years and and
thriving in 2013.
thriving in Trained as a tailorasbyaatailor
2013. Trained development programme, he
by a development
was
programme, he was married and had a good job in the city, working for a former things
married and had a good job in the city, working for a former cabinet minister. Then “some started
cabinet
happening”. He lost his job, separated from his wife, and fled back to his home village.
minister. Then “some things started happening”. He lost his job, separated from his wife, and
fled
“I back
never to that
knew his home village.
a mentally ill person could get well. Because I have seen my friends who didn’t go to the
hospital and sought help from traditional healers instead. Even now, they are still disturbed. Their illness
hasn’t leftknew
“I never them. that
But after I ran to the
a mentally hospital, could
ill person I got well.
getIwell.
feel fine and healthy
Because I haveand energetic
seen in a good
my friends whoway.
Ididn’t
take mygomedicine at the proper
to the hospital and time,
soughtandhelp
yeah,from
that’straditional
the way.” healers instead. Even now, they are
still disturbed. Their illness hasn’t left them. But after I ran to the hospital, I got well. I feel fine
Since his uncleand
and healthy convinced
energetichim to
in go to the way.
a good hospital, Enock
I take myhas been taking
medicine hisproper
at the medications
time,and
and has ben-
yeah,
efited from regular
that’s the way.” visits from clinicians and community health workers. He has reunited with his wife and
children and resumed his career as a tailor.
Since his
“People areuncle convinced
nice to himbring
me now. They to gotheir
to the hospital,
clothes for me toEnock has been taking
sew sometimes. hisget
Kids can medications
close to me and
has benefited from regular visits from clinicians and community health workers.
now. In the past, they would shout, ‘Enock is coming!’ and all the kids would hide indoors. Now, Hemyhas
relation-
ship with the
reunited community
with his wifeisand
great. Now, they
children and call, ‘Mr. Phiri,his
resumed Mr.career
Phiri.’ Yeah, I am a happy person. I can feel
as a tailor.
free, yeah.”
“People are nice to me now. They bring their clothes for me to sew sometimes. Kids can get
Source: Bukhman, G., et al. (2020), “The Lancet NCDI Poverty Commission: bridging a gap in universal health coverage for the poorest
close The
billion”, to me now. In the past, they would shout, ‘Enock is coming!’ and all the kids would hide
Lancet
indoors. Now, my relationship with the community is great. Now, they call, ‘Mr. Phiri, Mr. Phiri.’
Yeah, I am a happy person. I can feel free, yeah.”
Source: Bukhman, G., et al. (2020), “The Lancet NCDI Poverty Commission: bridging a gap in universal health
coverage for the poorest billion”, The Lancet
CONCLUSION
In the words of recent commentators, it is a “moral outrage” and an “insult to our basic
humanity” that most people living with mental health conditions are denied access to
quality care and support.180 It is no less an outrage that the rights of people living with
mental health conditions are ubiquitously abused.181 The mortality gap between people
living with severe mental health conditions and people without mental health conditions is
a “scandal … that contravenes international conventions for the ‘right to health’”.182 This has
never been in sharper relief than during the COVID-19 pandemic, where people living with
disabilities have frequently been denied access to treatment and endured further erosion in
their rights.
Urgent investment in mental health and the integration of mental health in health systems
are sorely needed to reverse this injustice; and to ensure that UHC can live up to its
promise of the right to health for all.
THE TIME TO ACT IS NOW, OR RISK FAILING THE VERY CONCEPT OF UHC AND LEAVING
MANY MILLIONS EVEN FURTHER BEHIND.
PART I 37
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31 For example, in the UK: HM Government and the Department of Health (2011), No Health
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32 Patel, V. and Saxena, S. (2019), “Achieving universal health coverage for mental disorders”, BMJ
33 Typically, in low-resource settings, the availability of psychosocial interventions is lower than
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prescriptions for medications can be done by non-specialist health workers as long as they have
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34 Thornicroft, G., Chatterji, S., Evans-Lacko, S., et al. (2017), “Undertreatment of people with major
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35 Lora, A. et al. (2012), “Service availability and utilization and treatment gap for schizophrenic
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43 Alzheimer’s Disease International, “Dementia statistics” webpage (accessed 05/10/2020)
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health programmes (Geneva: WHO)
Sustainable Development”, The Lancet; Lund, C. et al. (2018), “Social determinants of mental
disorders and the Sustainable Development Goals: a systematic review of reviews”, The Lancet
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PART I 38
46 Wu, J. (2020), “Climate anxiety in young people: a call to action”, The Lancet Planetary Health. OECD
(2018), Children & Young People’s Mental Health in the Digital Age. Shaping the Future (Paris: OECD)
47 Charlson, F. et al. (2019), “New WHO prevalence estimates of mental disorders in conflict
settings: a systematic review and meta-analysis”, The Lancet
48 Choo, E. et al. (2014), “The intersecting roles of violence, gender, and substance use in the
49 For a further discussion of the links between the SDGs and mental health, see Global Mental
Health Action Network (2020), “Mental Health for All. Greater investment – greater access” (online
briefing, accessed 20/11/2020)
50 WHO, “Health and Well-Being” indicators webpage (accessed 05/10/2020); WHO (2018), Mental
health Atlas 2017 (Geneva: WHO)
51 ODI (2016), Investing in mental health in low-income countries (London: ODI)
53 ODI (2016), Mental health funding and the SDG. What now and who pays? (London: ODI)
55 Oh, K. et al. (2017), “Depression and risk of tuberculosis: a nationwide population-based cohort
study”, Int J Tuberc Lung Dis
57 See, for instance, WHO, “Synergies for beating NCDs and promoting mental health and
well-being” webpage, 20/03/2018 (accessed 20/10/2020); and Stein, D. et al. (2019), “Integrating
mental health with other non-communicable diseases”, BMJ
58 Scott, K. et al. (2016), “Association of Mental Disorders With Subsequent Chronic Physical
Conditions: World Mental Health Surveys From 17 Countries”, JAMA Psychiatry. For a synthesis of
additional evidence on the link between mental health and NCDs, see Stein, D. et al. (2019),
“Integrating mental health with other non-communicable diseases”, BMJ
59 Van der Kooy, K. et al. (2007), “Depression and the risk for cardiovascular diseases: systematic
review and meta analysis”, Int J Geriatr Psychiatry
60 DiMatteo, M., Lepper, H., Croghan, T. (2000), “Depression Is a Risk Factor for Noncompliance With
Medical Treatment: Meta-analysis of the Effects of Anxiety and Depression on Patient
Adherence”, Arch Intern Med
61 WHO Regional Office for Europe (2019), Harmful use of alcohol, alcohol dependence and mental
health conditions: a review of the evidence for their association and integrated treatment approaches
(Copenhagen: WHO Regional Office for Europe)
62 For example, in a psychiatric hospital in Rwanda, “HIV services have been integrated into
psychiatric care at the tertiary (hospital) level, enabling patients to receive testing and treatment in the
hospital and also to return for psychiatric care and HIV care during outpatient visits at the
hospital’s clinic”. For more detail, as well as further discussion of integrated care in the context of mental
health conditions, see Thornicroft, G. et al. (2019), “Integrated care for people with long-term mental and
physical health conditions in low-income and middle-income countries”, The Lancet Psychiatry
63 UN (2020), Policy Brief: COVID-19 and the Need for Action on Mental Health (New York: UN)
64 UN General Assembly (2020), “Identical letters dated 29 June 2020 from the Permanent
Representatives of Bahrain, Belgium, Canada and Ecuador to the United Nations addressed to the
Secretary-General and the President of the General Assembly” (New York, UN), accessed 05/10/2020
65 WHO, “WHO Coronavirus Disease (COVID-19) Dashboard” webpage (accessed 22/11/2020)
66 Public Health England (2020), Disparities in the risk and outcomes of COVID-19 (London: Public
Health England)
PART I 39
67 Vigo, D. et al. (2020), “Mental health of communities during the COVID-19 pandemic”, Canadian
Journal of Psychiatry
68 United for Global Mental Health, “COVID-19 and mental health webinar 5: Public Health
Information Campaigns” webpage (accessed 05/10/2020)
69 The World Bank (2020), Poverty and Shared Prosperity 2020: Reversals of Fortune
(Washington, DC: The World Bank Group)
70 Referenced in The Economist, “Failing the poor: Covid-19 has reversed years of gains in the war
on poverty”, 26/09/2020 (accessed 05/10/2020)
72 Czeisler, M., Lane, R., Petrosky, E., et al. (2020), “Mental Health, Substance Use, and Suicidal
Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020”, MMWR Morb Mortal Wkly
Rep
73 Taquet, M. et al. (2020), “Bidirectional associations between COVID-19 and psychiatric
disorder: retrospective cohort studies of 62 354 COVID-19 cases in the USA”, The Lancet Psychiatry
74 WHO (2020), The Impact of COVID-19 on Mental, Neurological and Substance Use Services:
Results of a Rapid Assessment (Geneva: WHO)
75 From correspondence with national campaigners in mental health in South Africa
76 Burgess, R. (2020) “First Justice, then Pills: Re-imagining Global Mental Health in a Time of
COVID”, UCL YouTube Lunch Hour Lecture (accessed 16/09/2020)
77 Wen, L. et al. (2020), “The opioid crisis and the 2020 US election: crossroads for a national
pandemic”, The Lancet
78 Mental Health Foundation (2020), “Coronavirus. The divergence of mental health
experiences during the pandemic” (online publication, accessed 05/10/2020)
79 United for Global Mental Health, “COVID-19 and mental health webinar 20: Substance Use”
webpage (accessed 05/10/2020)
80 Vigo, D. (2020), “The differential outcomes of Coronavirus Disease 2019 in low- and middle-
income countries vs high-income countries”, JAMA Psychiatry
81 Abrahams, Z. et al. (2020), “Domestic violence, food insecurity and mental health of pregnant
women in the COVID-19 lockdown in Cape Town, South Africa”, Research Square pre-print (accessed
22/11/2020)
82 Scottish Refugee Council (2020), The impact of COVID-19 on refugees and refugee-assisting
organisations in Scotland (Glasgow: Scottish Refugee Council)
83 For further reference, see: UN (2020), Policy Brief: COVID-19 and the Need for Action on Mental
Health (New York: UN); United for Global Mental Health (2020), The impact of COVID-19 on Global
Mental Health. A Brief (online publication, accessed 05/10/2020); Bond Mental Health and
Psychosocial Disability Group (2020), “Covid-19 and mental health: immediate and long-term
impacts” (online briefing paper, accessed 10/05/2020)
84 SARS - Severe Acute Respiratory Syndrome, a coronavirus disease that caused an outbreak in
2003, with nearly 1,000 deaths. MERS - Middle East Respiratory Syndrome, another coronavirus that
emerged in 2012
85 Rogers, J. et al. (2020), “Psychiatric and neuropsychiatric presentations associated with
severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19
pandemic”, The Lancet Psychiatry
86 See, e.g. Gurara, D. et al., “COVID-19: Without Help, Low-Income Developing Countries Risk a
Lost Decade”, IMF Blogs, 27/08/2020 (accessed 05/10/2020)
87 See e.g. WHO (2020), Pulse survey on continuity of essential health services during the
COVID-19 pandemic: interim report, 27 August 2020 (Geneva: WHO); Bill and Melinda Gates Foundation
(2020), 2020 Goalkeepers Report: COVID-19, a global perspective (Seattle: Bill and Melinda Gates
Foundation)
PART I 40
88 Bond Mental Health and Psychosocial Disability Group (2020), “Covid-19 and mental health:
immediate and long-term impacts” (online briefing paper, accessed 10/05/2020)
89 Betancourt, T., Brennan, R., Vinck, P., VanderWeele, T., Spencer-Walters, D., Jeong, J., et al.
(2016), “Associations between Mental Health and Ebola-Related Health Behaviors: A Regionally
Representative Cross-sectional Survey in Post-conflict Sierra Leone”, PLoS Med
90 Adjusted odds ratio of between 5.7 and 7.6, depending on the mental health diagnosis
91 Wang, Q. et al. (2020), “Increased risk of COVID-19 infection and mortality in people with
mental disorders: analysis from electronic health records in the United States”, World Psychiatry.
92 Wang, Q. et al. (2020), “COVID-19 risk and outcomes in patients with substance use
disorders: analyses from electronic health records in the United States”, Mol Psychiatry. Adjusted
odds ratio of 8.7.
93 This section discusses the populations of mothers, fathers, caregivers and their children as
an important illustration of the trends described in the preceding sections; while recognising that
there are multiple other populations (such as men, women and young people beyond their roles as
caregivers or receivers of care, older adults experiencing the challenges of conditions such as
dementia, and many others) to whom a similar analysis could equally apply
94 E.g. Save the Children (2017), Primary Health Care First: Strengthening the foundation for
universal health coverage (London: Save the Children)
95 WHO, “Child and adolescent mental health” webpage (accessed 05/10/2020)
96 The World Bank (2016), Mental health among displaced people and refugees: Making the
case for action at the World Bank Group (Washington DC: The World Bank Group)
Individual report (online publication, accessed 25/09/2020)
99 Smith, J. et al. (2010), “Long-Term Economic Costs of Psychological Problems During
Childhood”, Soc Sci Med
child. A narrative synthesis of existing evidence and opportunities (online publication)
102 WHO, UNICEF, The World Bank (2018), Nurturing care for early childhood development: a
framework for helping children survive and thrive to transform health and human potential (Geneva:
WHO)
103 Gelaye, B. et al. (2016), “Epidemiology of maternal depression, risk factors, and child
outcomes in low-income and middle-income countries”, Lancet Psychiatry (also referring to previous
research in the field). Antepartum prevalence: 7-15% in high-income countries versus 19-25% in
low- and middle-income countries; postpartum prevalence: 10% in high-income countries versus
20% in low- and middle-income countries
104 Scherer, E. et al. (2019), “The relationship between responsive caregiving and child outcomes:
evidence from direct observations of mother-child dyads in Pakistan”, BCM Public Health
105 Netsi, E. et al. (2018), “Association of persistent and severe postnatal depression with child
outcomes”, JAMA Psychiatry. The risk of behavioural problems was approximately double for children
whose mothers had non-persistent depression, and approximately 3 to 5 times higher for mothers
with persistent depression (range depending on severity of depression symptoms)
106 Ramchandani, P. et al. (2005), “Paternal depression in the postnatal period and child
development: a prospective population study”, The Lancet. Paternal depression in the postnatal
period increased the risk of adverse emotional and behavioural outcomes by approximately a factor
PART I 41
of two for children at 3.5 years of age, and the risk of conduct problems in boys by approximately
a factor of 2.5, even when controlling for factors such as maternal postnatal depression and later
paternal depression
107 Harvard University Centre on the Developing Child (2013), InBrief: Early Childhood Mental
Health (online publication, accessed 05/10/2020)
108 Rahman, A., et al. (2004), “Impact of Maternal Depression on Infant Nutritional Status and
Illness. A cohort study”, Arch Gen Psychiatry
110 Girma, S., Fikadu, T., Abdisa, E. (2019), “Maternal Common Mental Disorder as Predictors of
Stunting among Children Aged 6-59 Months in Western Ethiopia: A Case-Control Study”, Int J Pediatr
111 UN (2020), Policy Brief: The Impact of COVID-19 on children (New York: UN)
112 Cf. e.g. Bradbury-Jones, C., Isham, L. (2020), “The pandemic paradox: The consequences of
COVID฀19 on domestic violence”, J Clin Nurs, which includes information and early statistics on the
rise in domestic violence (and homicide) during COVID-19; IFRC, “Sexual and Gender-Based Violence
in COVID-19” briefing (accessed 05/10/2020); and WHO Health Cluster, “Responding to uptick in GBV
in the context of the COVID-19 pandemic” webpage (accessed 05/10/2020)
113 UNICEF (2020), Protecting Children from Violence in the Time of COVID-19: Disruptions in
prevention and response services (New York: UNICEF)
114 Hermann, A. et al. (2020), “Meeting Maternal Mental Health Needs During the COVID-19
Pandemic”, JAMA Psychiatry
117 The World Bank, “COVID-19 Could Lead to Permanent Loss in Learning and Trillions of
Dollars in Lost Earnings” press release, 18/06/2020 (accessed 05/10/2020); referring to The World
Bank (2020), Simulating The Potential Impacts Of Covid-19 School Closures On Schooling And
Learning Outcomes: A Set Of Global Estimates (Washington DC: The World Bank Group)
118 UN (2020), Policy Brief: The Impact of COVID-19 on children (New York: UN), referring to
Kassa, G. et al. (2018), “Prevalence and determinants of adolescent pregnancy in Africa: a systematic
review and Meta-analysis”, Reprod Health. According to Save the Children, “an additional 2.5 million
girls [are] at risk of child marriage over five years and adolescent pregnancies expected to rise by up
to 1 million in 2020, as a result of the economic impacts of the COVID-19 crisis” (Save the Children
(2020), The Global Girlhood Report 2020 (London: Save the Children))
120 See also Bond Mental Health and Psychosocial Disability Group (2020), “Covid-19 and mental
health: immediate and long-term impacts” (online briefing paper, accessed 10/05/2020)
121 Czeisler, M., Lane, R., Petrosky, E., et al. (2020), “Mental Health, Substance Use, and Suicidal
Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020”, MMWR Morb Mortal
Wkly Rep
122 UNICEF Regional Office for South Asia (2020), Lives upended: How COVID-19 threatens the
futures of 600 million South Asian children (Kathmandu: UNICEF Regional Office for South Asia)
123 See Save the Children (2017), Primary Health Care First: Strengthening the foundation for
universal health coverage (London: Save the Children), quoting World Bank research that suggests
that 90% of all care needs can be covered through primary healthcare
124 E.g., target 3.2, mandating a reduction in under-5 mortality to 25 per 1,000 live births or
lower; and target 2.2, addressing the wasting and stunting of children
125 Collins, P., Saxena, S. (2016), “Action on mental health needs global cooperation”, Nature
PART I 42
126 See e.g. Okonjo-Iweala, N., “Towards Universal Health coverage: Why financing is key”, World
Bank Blogs, 18/06/2019; Jamison, D., Summers, L. (2013), “Global health 2035: a world converging
within a generation”, The Lancet; Save the Children (2015), Within our Means: why countries can
afford universal health coverage (London: Save the Children)
127 Marquez, P., Hewlett, E. (2018), “Lessons from OECD countries: mental health is critical for
human capital development”, in The World Bank (2018), Global Mental Health: some perspectives on
challenges and options for scaling up response (Washington DC: The World Bank Group)
128 Indeed, it has been argued that “[a]round one quarter of the economic growth in low- and
middle-income countries between 2000-2011 resulted from improved health” (UHC2030, “World
leaders for universal health coverage: achieving the SDGs through health for all” webpage, quoting
Angel Gurria, Secretary General at OECD (accessed 05/10/2020))
129 Comparisons in international dollars allow adjustment for the “differences in the
relative price and purchasing power of countries and thereby facilitate comparison across regions”
(Chisholm, D., Saxena, S. (2011), “Cost effectiveness of strategies to combat neuropsychiatric
conditions in sub-Saharan Africa and South East Asia: mathematical modelling study”, BMJ)
130 WHO (2019), “Draft menu of cost-effective interventions for mental health” (WHO discussion
paper, accessed 05/10/2020). This analysis is due to be incorporated into the revised Appendix 2 of
the extended WHO Mental Health Action Plan 2013-2020
131 Cf. WHO (2017), ‘Best buys’ and other recommended interventions for the prevention and
control of noncommunicable diseases (Geneva: WHO), where a number of interventions are costed
as being “>I$100 per DALY averted in LMICs”; and Patel, V. et al. (2007), “Treatment and prevention of
mental disorders in low-income and middle-income countries”, The Lancet
132 Saxena, S., Thornicroft, G., Knapp, M., Whiteford, H. (2007), “Resources for mental health:
scarcity, inequity, and inefficiency”, The Lancet
133 Kola, L. (2020), “Global mental health and COVID-19”, The Lancet Psychiatry
134 The Lancet Psychiatry, Mental Health Innovation Network, MHPSS.net and United for Global
Mental Health webinar, 14 July 2020, “How to support patients and caregivers” (accessed 22/11/2020)
Mental Health webinar, 16 June 2020, “Stories from the Field – ensuring continuity of mental health
care during COVID-19” (accessed 22/11/2020)
Mental Health webinar, 16 June 2020, “Stories from the Field – ensuring continuity of mental health
care during COVID-19” (accessed 22/11/2020). For more information and additional examples, refer
to the Health Innovation Network (MHIN) website (https://www.mhinnovation.net/), and in the
materials (recordings and notes) from the webinars on mental health, co-hosted by United for Global
Mental Health, the Lancet Psychiatry, MHIN, and MHPSS.net (https://unitedgmh.org/mh-for-all-webi-
nars, especially webinars from May 12, 2020, June 16, 2020, July 7, 2020, and July 14, 2020)
137 Chisholm, D., Sweeny, K., Sheehan, P., Rasmussen, B., Smit, F., Cuijpers, P., et al. (2016),
“Scaling-up treatment of depression and anxiety: a global return on investment analysis”, The Lancet
Psychiatry
139 Bloom, D., Cafiero, E., et al. (2011). The Global Economic Burden of Noncommunicable
Diseases (Geneva: World Economic Forum)
141 Chisholm, D., Sweeny, K., Sheehan, P., Rasmussen, B., Smit, F., Cuijpers, P., et al. (2016),
“Scaling-up treatment of depression and anxiety: a global return on investment analysis”, The Lancet
PART I 43
Psychiatry. It is worth noting that this study was conservative in the benefits that were included in
the analysis, e.g. explicitly stating that it excluded any benefits from reduced use of other health and
welfare-related services, or the positive effect of interventions on the health of close family
members. These results have also been replicated by smaller studies. For instance, studies
conducted in the UK have shown a 4:1 and even a 9:1 return on investment from improved
productivity (lower absenteeism and presenteeism): Knapp, M., McDaid, D., Parsonage, M. (2011),
Mental health promotion and prevention: the economic case (London: Department of Health). See
Part II of this report for mhGAP
142 Knapp, M., McDaid, D., Parsonage, M. (2011), Mental health promotion and prevention: the
economic case (London: Department of Health)
143 Collins, P., Sweetland, A., Wagenaar, B. (2020), “Ending HIV and Tuberculosis—What Has
Mental Health Got to Do with It?”, JAMA Health Forum; see also Sweetland, A. et al. (2018),
“Tuberculosis: an opportunity to integrate mental health services in primary care in low-resource
settings”, The Lancet Psychiatry
144 Gertler, P., et al. (2014), “Labor Market Returns to an Early Childhood Stimulation
Intervention in Jamaica”, Science (summary available from the Latif Jameel Poverty Action Lab,
accessed 17/10/2020)
145 UNDP, “Human Development Index (HDI)” webpage (accessed 05/10/2020)
146 UNDP (2020), 2020 Human Development Perspectives. Covid-19 And Human Development:
Assessing The Crisis, Envisioning The Recovery (New York: UNDP)
147 Knapp, M., McDaid, D., Parsonage, M. (2011), Mental health promotion and prevention: the
economic case (London: Department of Health)
148 Sporinova, B. et al. (2019), “Association of Mental Health Disorders With Health Care
Utilization and Costs Among Adults With Chronic Disease”, JAMA Network Open
149 Katon, W. (2011), “Epidemiology and treatment of depression in patients with chronic
medical illness”, Dialogues Clin Neurosci, summarising the findings of Katon, W., Unutzer, J., Fan, M.,
et al. (2006), “Cost-effectiveness and net benefit of enhanced treatment of depression for
older adults with diabetes and depression”, Diabetes Care; Simon, G., Katon, W., Lin, E., et al. (2007),
“Cost-effectiveness of systematic depression treatment among people with diabetes mellitus”, Arch
Gen Psychiatry; Katon, W., Russo, J., Von Korff, M. et al. (2008), “Long-term effects on medical costs of
improving depression outcomes in patients with depression and diabetes”, Diabetes Care
150 WHO Regional Office for Europe (2014), The Case For Investing In Public Health
(Copenhagen: WHO Regional Office for Europe); Knapp, M., McDaid, D., Parsonage, M. (2011), Mental
health promotion and prevention: the economic case (London: Department of Health)
151 WHO (2010), The world health report: health systems financing: the path to universal
coverage (Geneva: WHO)
152 The World Bank (2018), The Human Capital Project (Washington DC: The World Bank Group)
153 The World Bank (2020), The Human Capital Index 2020 Update: human capital in the time of
COVID-19 (Washington DC: The World Bank Group)
154 See above, Argument 1, for more detail and references
155 See Patel, V., Saxena, S., et al. (2018), “The Lancet Commission on Global Mental Health
and Sustainable Development”, The Lancet for the structuring of relationship of mental health and
human rights in this way: “Human rights need to be considered with respect to mental health in two
main ways: first, mental health as a human right itself, as an inalienable component of health; and
second, people living in vulnerable situations (including those with mental disorders) are at increased
risk of having their rights ignored or abused”
156 WHO, “Questions and Answers on Universal Health Coverage” web publication (accessed
05/10/2020)
PART I 44
(New York: UN)
158 UN General Assembly (2019), Political Declaration of the High-level Meeting on Universal
Health Coverage, “Universal health coverage: moving together to build a healthier world”
(New York: UN)
160 Liu, N. et. al. (2017), “Excess mortality in persons with severe mental disorders: a
multilevel intervention framework and priorities for clinical practice, policy and research agendas”,
World Psychiatry. Severe mental disorders were defined as “schizophrenia and other psychotic
disorders, bipolar disorder, and moderate to severe depression”. For a recent detailed study of
reduction in life expectancy from mental and substance use conditions in Denmark, see Plana-Ripoll,
O. et al. (2020), “Nature and prevalence of combinations of mental disorders and their association
with excess mortality in a population-based cohort study”, World Psychiatry. This study found that,
for individuals with diagnosed mental conditions registered in secondary care, “[a]ny combination
of mental disorders was associated with a shorter life expectancy compared to the general Danish
population”
161 HRW, “Living in chains. Shackling of people with psychosocial disabilities worldwide”
webpage, 06/10/2020 (accessed 21/10/2020)
162 Patel, V., Chisholm, D., Kirkwood, B., Mabey, D. (2007), “Prioritizing health problems in
women in developing countries: comparing the financial burden of reproductive tract infections,
anaemia and depressive disorders in a community survey in India”, Tropical Medicine and
International Health
163 Hailemariam, M. et al. (2017), “Engaging and staying engaged: a phenomenological study of
barriers to equitable access to mental healthcare for people with severe mental disorders in a rural
African setting”, Int J Equity Health
165 HRW, “Ending the Unthinkable Injustice of Human Chaining” webpage, 07/04/2020
(accessed 05/10/2020); HRW, “#BreakTheChains” webpage (accessed 21/10/2020); HRW, “Living in
chains. Shackling of people with psychosocial disabilities worldwide” webpage, 06/10/2020 (accessed
21/10/2020)
166 Kleinman, A. (2009), “Global mental health: a failure of humanity”, The Lancet
167 UN General Assembly (2020), Right of everyone to the enjoyment of the highest attainable
standard of physical and mental health: Report of the Special Rapporteur on the right of everyone
to the enjoyment of the highest attainable standard of physical and mental health (New York: UN);
Saxena, S., Thornicroft, G., Knapp, M., Whiteford, H. (2007), “Resources for mental health: scarcity,
inequity, and inefficiency”, The Lancet
168 WHO Regional Office for Europe (2018), Mental health, human rights and standards of care:
Assessment of the quality of institutional care for adults with psychosocial and intellectual disabilities
in the WHO European Region (Copenhagen: WHO Regional Office for Europe)
169 WHO (2018), Mental health atlas 2017 (Geneva: WHO)
170 See e.g. Yao, H., Chen, J., Xu, Y. (2020) “Patients with mental health disorders in the COVID-19
epidemic”, The Lancet Psychiatry; Moreno, C., et al. (2020) “How mental health care should change as
a consequence of the COVID-19 pandemic”, The Lancet Psychiatry; WHO Regional Office for Europe
(2020), Long-stay mental health care institutions and the COVID-19 crisis: identifying and addressing
the challenges for better response and preparedness (Copenhagen: WHO Regional Office for
Europe); Vigo, D. et al. (2020), “Mental health of communities during the COVID-19 pandemic”,
Canadian Journal of Psychiatry
PART I 45
171 E.g. Validity International, “Statement on behalf of the Coordinating Group of the COVID-19
Disability Rights Monitor at the Opening of the Twenty-Third Session of the Committee on the Rights
of Persons with Disabilities” webpage, 28/08/2020 (accessed 21/10/2020)
172 HRW, “COVID-19 Poses Extreme Threat to People Shackled in Nigeria” webpage, 30/03/2020
(accessed 14/08/2020)
173 United for Global Mental Health, “COVID-19 and mental health webinar 14: mental health
and poverty alleviation” webpage (accessed 05/10/2020); note also Validity International, “COVID-19
Disability Rights Monitor calls on governments to ensure access to food, medication and essential
supplies for persons with disabilities” webpage 17/09/2020 (accessed 21/10/2020)
174 See, for example, Saxena, S., Thornicroft, G., Knapp, M., Whiteford, H. (2007), “Resources
for mental health: scarcity, inequity, and inefficiency”, The Lancet. However, de-institutionalisation
should happen only once alternative, functional community-based provision is in place. Note the Life
Esidimeni tragedy, where the transfer of ~1,700 psychiatric patients out of an institution, but without
proper community-based provision in its place, caused the deaths of at least 144 patients in South
Africa
175 For more information, see Outright Action International (2020), Harmful Treatment: the
global reach of so-called conversion therapy (New York: Outright Action International)
176 WHO, “WHO QualityRights initiative – improving quality, promoting human rights” webpage
(accessed 05/10/2020); see also Part II below
177 See, for instance, OHCRH (2010), Monitoring the Convention on the Rights of Persons with
Disabilities: guidance for human rights monitors, professional training series No. 17 (New York: UN)
178 Saxena, S. et al. (2019), “Countdown Global Mental Health 2030”, The Lancet
179 Patel, V., Farmer, P. (2020), “The moral case for global mental health delivery”, The Lancet
180 Kleinman, A. (2009), “Global mental health: a failure of humanity”, The Lancet
182 Thornicroft, G. (2011), “Physical health disparities and mental illness: the scandal of
premature mortality”, Br J Psychiatry
PART I 46
PART II
How can the integration of mental
health into UHC be achieved?
PART II 47
From intention to implementation:

making scaled-up, integrated mental
health care a reality
“Addressing mental health is central to achieving
universal health coverage. It deserves our commitment”
Antonio Guterres, UN Secretary General, 10 Oct 2020183
PART II 48
Given the many advantages of integrating mental health in UHC, as already outlined, it is
clear that countries need to move from intention to implementation as quickly as possible.
Returning to the analogy of the ‘UHC cube’, governments across all resource settings need
to take steps to ensure that:
• mental health conditions are sufficiently and appropriately included within national
UHC service packages
• high-quality rights-based services are accessible to everybody who needs and wants
care
• they are provided in such a way that does not cause service users financial
hardship.
This task will require a concerted effort and investment from service users, policymakers,
funders, the expert and medical communities, civil society, lived experience advocates, and
others. A number of challenges will need to be overcome, for example:184
• a lack of mental health laws and policies aligned with human rights instruments
• stigma and exclusion, including stigma within the health system towards people
living with mental health conditions185
• an over-reliance on institutions and tertiary care centres, often providing
poor- quality and not rights-based services
• a lack of trained staff to deliver the services, and a sub-optimally deployed
workforce with poor retention rates
• a frequent lack of mental health data to support policy and funding decisions,
especially in lower- and lower-middle-income countries
• an often challenging fiscal environment.
However, the good news is that we can benefit from many years of relevant programmatic,
technical and operational work by the WHO, the World Bank, the voluntary and academic
sectors, and many other organisations and individuals across different resource settings.
We can also learn from countries and communities that have already sought to scale-up
mental health services as a part of UHC, and how they were able to overcome the
challenges described.
Moreover, the global movement for mental health has generated significant momentum
in recent years, and the trend has continued during COVID-19. There is growing interest
among the general public in mental health – Google searches on the issue of ‘mental health’
have been increasing by about 10% per year over the past three years.186 Similarly, there
was unprecedented public engagement with World Mental Health Day in October 2020: the
official World Mental Health Day campaign hashtag (#MoveForMentalHealth) generated
~19,000 social media posts and had a reach of over 94 million, within the space of just 36
hours.187 In addition, ‘Mental Health for All’ has been an official Gates Foundation
Accelerator since 2019.188 This momentum should be used as a springboard to advance the
integration of mental health in UHC and the strengthening of health systems.
To support this aim, this section will:

• bring together key programmatic documents on the scale-up and integration of
mental health in UHC
• suggest what an approach to integrating mental health in UHC could look like across
different resource settings
• estimate how much such a scale-up and integration could cost
• give examples of health systems that have taken successful steps on this journey.
PART II 49
It is, unfortunately, outside of the scope of this section to discuss approaches to the
implementation of UHC itself. To find out more about this, please refer to resources such
as the WHO World Health Report 2010 on health systems financing,189 the WHO handbook
Strategizing national health in the 21st century,190 the World Bank High-Performing Health
Financing Universal Health Coverage report from 2019,191 the 2018 World Bank report
Delivering Quality Health Services: A Global Imperative for Universal Health Coverage,192
and the 2016 World Bank publication UHC in Africa: A Framework for Action,193 and the UN
policy briefing on COVID-19 and UHC,194 among many others.195 A number of key
publications also track UHC’s overall progress, including by the WHO and the World Bank,196
and recent publication by UHC2030.197
KEY PROGRAMMATIC DOCUMENTS ON SCALING-UP AND INTEGRATING MENTAL HEALTH

IN UHC
Significant work has been done in recent years by the WHO, the World Bank, and other
organisations and individuals on how to integrate mental health in health systems. We
are in a position now to leverage this knowledge to take rapid action.
The key global framework for the scale-up of mental health within the context of UHC is
the WHO’s Mental Health Action Plan 2013-2020.198 This document, created in consultation
with and ratified by member states, sets high-level global goals and suggests concrete activ-
ities to achieve them. Originally ratified for the period of 2013-2020, the Action Plan is being
extended until 2030 (with updates being made to Appendices 1 and 2)199 – a reflection of
the critical importance and continuing relevance of this document.200
The Action Plan incorporates UHC as a cross-cutting principle, and focuses on four key
objectives, which include setting up “comprehensive, integrated and responsive mental
health and social care services in community-based settings”, as well as the implementation
of “strategies for promotion and prevention in mental health”.201
Achieving these objectives relies on building genuine political commitment for mental
health integration in UHC, and mobilising domestic and international catalytic donor
financing.
A powerful visual representation of the Action Plan’s objectives is the WHO’s service mix
pyramid. In the pyramid – which illustrates the optimal mix of services for mental health
care delivery – self-care, informal community care and primary care services predominate,
with fewer services delivered in hospitals and specialist facilities. This approach is closely
aligned with the focus of UHC on community-based health services and primary care, as
exemplified by the ‘UHC umbrella’ (see Argument 1, p. 19).
PART II 50
Source: Shidhaye, R., Lund, C., Chisholm, D. (2015), “Health Care Platform Interventions”, p. 202, in: Patel, V. et al. eds. Disease
Control Priorities, Third Edition (Volume 4), Mental, Neurological, and Substance Use Disorders (Washington DC: The World
Bank Group). Adapted from WHO (2003), “Organization of Services for Mental Health,” p. 34, in WHO, Mental Health Policy and
Service Guidance Package (Geneva, WHO)
In addition to the Action Plan, the WHO provides a number of other key documents to
support specific aspects of scaling-up mental health provision (see the table below).
Document NAME
DOCUMENT name Document
DOCUMENT description
DESCRIPTION
The Mental Health Gap A technical set of documents (including operations and training manuals,
Action Programme • implementation
A technical setguides, and other
of documents resources)
(including to supportand
operations the training
scale-up of
(mhGAP) mental health provision, especially in low- and middle-resource
manuals, implementation guides, and other resources) to support settings202
The Mental Health Gap the scale-up
mhGAP can beofused
mental
as ahealth provision,
“capacity buildingespecially in low-ofand
tool for a range middle-
health
Action Programme resource settings
professionals 202
and para professionals” in mental health,203 given the critical
(mhGAP) mhGAP can
• shortages of abe used as
qualified a “capacity
mental health building
workforcetool for athe
around range
worldof health
professionals and para professionals” in mental health203, given the
Draft menu of cost-ef- Acritical
working shortages
document, ofbased
a qualified
on themental health workforce
WHO-CHOICE around
methodology, the
assessing
fective interventions for world
the indicative value for money of a range of key interventions 204
mental health
Currently in draft form, for inclusion in the updated WHO Mental Health
A working
• Action document, based
Plan 2013-2020-2030 in on the WHO-CHOICE methodology,
2021
Draft menu of cost- assessing the indicative value for money of a range of key
effective interventions
QualityRights Ainterventions
204
toolkit based on the CRPD to help improve adherence to human rights in
for mental health Currently
• mental in draft
health form,care
and social for inclusion
facilities205in the updated WHO Mental
Health Action Plan 2013-2020-2030
The toolkit provides guidance on the rightsin 2021
and quality standards that need
to be in place in mental health and social care institutions, how to assess
• these, andbased
A toolkit how toon
actthe
on CRPD
the basis of the
to help assessment
improve (including
adherence to help
to human
improve
rights inaccountability
mental health to service users)
and social care facilities205
• The toolkit provides guidance on the rights and quality standards
QualityRights that need to be in place in mental health and social care institutions,
how to assess these, and how to act on the basis of the assessment
(including to help improve accountability to service users)
PART II 51
Mental health policy and A toolkit to help “develop policies and comprehensive strategies for improv-
Mentalguidance
service health policy
package A the
• ing toolkit to help
mental “develop
health policies and
of populations”, and comprehensive
deliver the most strategies for
effective ser-
and service guidance improving
vices thescope
within the mental
of health of populations”,
the available and deliver the most
resources206
package effective services within the scope of the available resources206
Building Back Better: A 2013 report that outlines the rationale for “understanding emergencies as
Sustainable Mental Health opportunities to build better mental health care”, provides 10 case studies
Building • A 2013 report that outlines the rationale for “understanding
Care afterBack Better:
Emergencies of where this was achieved, and draws overarching lessons from them207
Sustainable Mental emergencies as opportunities to build better mental health care”,
Health Care after provides 10 case studies of where this was achieved, and draws
Inter-Agency Standing A 2007 document, developed with 207 support from the WHO, “to enable
Emergencies overarching lessons from them
Committee Guidelines humanitarian actors to plan, establish and coordinate a set of minimum
on Mental Health and multi-sectoral responses to protect and improve people’s mental health and
A 2007 document, developed withofsupport from the WHO, “to
208
Psychosocial Support in • psychosocial well-being in the midst an emergency”
Building Back
Emergency Better:
Settings enable humanitarian actors to plan, establish and coordinate a set of
Sustainable Mental
minimum multi-sectoral responses to protect and improve people’s
Health Care after
mental health and psychosocial well-being in the midst of an
Emergencies
emergency”208
A key programme that will generate substantial relevant learning, and one that deserves
special mention, is the WHO’s catalytic Special Initiative for Mental Health (2019-2023),
launched in 2019. This initiative aims to provide $60 million of catalytic funding and
technical support across 12 selected countries over five years, to scale up the integration of
mental health in UHC and extend quality interventions and services to 100 million
additional people. This initiative is designed to “enable WHO to support governments to
lead substantial scale up of care for mental health conditions”,209 catalysing local resources
and support for mental health.
The World Bank has also produced a number of programmatic documents on the need for
and the approaches to scaling up and integrating mental health within health systems (see
the table below).
Document name Document description

DOCUMENT NAME DOCUMENT DESCRIPTION
Out of the Shadows: Making Mental A 2016 report that made the case for making mental health
Health a Global Development Priority a global development priority, and suggested a number of
Out of the Shadows: • A 2016 reportways
thattomade
integrate mental
the case forhealth
making care in existing
mental platforms,
health a global as
210
Making Mental Health development well as potential
priority, and mechanisms
suggested a to
numberfund this
of ways to integrate
a Global Development mental health care in existing platforms, as well as potential
Moving the Needle: Mental Health mechanisms
Priority Sto- Ato2018
fundreport
this210that collated a list of technical assessments
ries from Around the World and operational guidelines for integrating mental health in
community-based healthcare, and provided a deep-dive on
• A 2018 reporthow mental
that health
collated scale-up
a list could assessments
of technical be financed211and
Moving the Needle: operational guidelines for integrating mental health in
Mental Health Stories community-based
Harnessing
from Around Technology
the World to Address the A 2019healthcare, and provided
study that outlined a deep-dive
how technology canon how new
“garner
mental
Global Mental Health Crisis: An Introduc- health scale-up could be financed
insights, build efficiencies, and scale support in responding
211
tory Brief to the mental health challenges unfolding in a wide array of

communities and contexts”212
Harnessing Technology • A 2019 study that outlined how technology can “garner new insights,
toHealing
Address Minds, Changing Lives: A build efficiencies,
the Global A 2018 and scalethat
report support in responding
described to the mental
the implementation in 2013-
Mental Health Crisis:
Movement for Community-based Mentalhealth challenges unfolding in a wide array of communities
2016 of a programme to integrate mental health into andthe
An Introductory Brief
Health Care in Peru contexts” 212
Peruvian health system, including specific successes and
challenges213
Healing Minds,
Changing Lives: A • A 2018 report that described the implementation in 2013-2016 of
Movement for a programme to integrate mental health into the Peruvian health
Community-based
system, including specific successes and challenges213
Mental Health Care in
Peru
PART II 52
Mental Health
Mental in Transition:
Health in Assessment A 2017 report that, with Ukraine as its focus, provided “rec-
and Guidance for
Transition: Strengthening Integra- ommendations to inform policy and operational guidance for
tion of Mental Health into Primary Health strengthening integration of mental health into primary health
Assessment and A 2017 report that, with Ukraine as its focus, provided
•Service
CareGuidance
and Community-Based care and community-based service platforms”214
for
Platforms in Ukraine “recommendations to inform policy and operational guidance for
Strengthening strengtheningThe review focused
integration on common
of mental mental
health into disorders
primary (anxiety,
health care
Integration of Mental depression,
and community-based PTSD),
service and alcohol-use
platforms” 214 disorder
Health into Primary • The review focused on common mental disorders (anxiety,
Health
Mental CareAmong
Health and Displaced People
depression, PTSD),
A 2018and alcohol-use
report disorder
that describes the mental health needs of the
Community-Based
and Refugees: Making the Case for Ac- highly vulnerable refugee population, and suggests strate-
Service
tion Platforms
under in Response and
Humanitarian gies for how these needs could be met215
Ukraine
Development Programs
Mental Health Among

Displaced People and
Refugees: Making the • A 2018 report that describes the mental health needs of the highly
Case for Action under vulnerable refugee population, and suggests strategies for how these
Humanitarian needs could be met215
Response and
Development Programs
Within the context of COVID-19, a key document that sets out what should be done on
mental health is the UN Policy Brief on COVID-19 and the Need for Action on Mental
Health.216 The brief makes three recommendations:
• Apply a whole-of-society approach to promote, protect and care for mental health.
• Ensure widespread availability of emergency mental health and psychosocial
support.
• Support recovery from COVID-19 by building mental health services for the future.
The last recommendation in particular is key for integrating mental health in UHC. It
encompasses actions such as setting up “affordable community-based services that are
effective and protective of people’s human rights as part of any national COVID-19 recovery
plan”, including mental health in “health care benefit packages and insurance schemes to
ensure essential mental health needs are covered”, and involving people with lived
experience in the “strengthening of mental health services”.217 The importance of
integrating mental health in COVID-19 UHC response plans is echoed in the UN Policy Brief
on COVID-19 and Universal Health Coverage.218
Lastly, a significant amount of translational research on scaling up mental health provision

and integrating mental health in health systems has been conducted – and experience
codified – within the academic and mental health community at the global,219 regional,220
and country levels,221 and in response to the COVID-19 pandemic.222 The ‘PRogramme for
Improving Mental health carE’ (PRIME), which ran between 2011 and 2019, and worked on
integrating mental health into primary care in Ethiopia, India, Nepal, South Africa and
Uganda, is one example of such efforts. Emerald, a mental health systems research project
in Ethiopia, India, Nepal, Nigeria, South Africa and Uganda, is another.223 This body of
knowledge has been further bolstered by the direct experience of multiple organisations
in the field, which can be explored on platforms such as the Mental Health Innovation
Network and includes learning and experience gained from dealing with the challenges of
COVID-19.224 A more holistic approach to mental health is, furthermore, being called for by
mental health funders, such as the Wellcome Trust.225
PART II 53
In addition to all these sources, the global community is able to learn from the successes
and challenges of countries that have already gone some way towards integrating mental
health in UHC. (See p. 60 - 63) for the detailed case studies of Peru and Pakistan, for exam-
ple.)
Of course, there is still room for additional insight and research.226 However, like never
before, we are in a position to build from and leverage this substantial body of work,
information, learning and experience to move towards swift action on integrating mental
health in health systems.
AN EXAMPLE SHORT-LIST OF APPROACHES FOR INTEGRATING MENTAL HEALTH IN UHC
Based on the key documents and frameworks already listed, this section provides an
example shortlist of priority activities that would be required – across all resource
settings – to integrate mental health in UHC.
It is critical that the local context drives the selection and adaptation of strategies,
approaches and interventions discussed in the documents and frameworks listed on pp. 50
- 53.
However, as an illustrative example of what integrating mental health care in UHC might
look like, this section describes a set of potential priority activities across low-, medium-
and high-resource settings, structured around the four objectives of the WHO Action Plan.
Depending on the local context, some of these activities will be more urgent in light of the
COVID-19 pandemic.
It is important to note that, just as mental health is a complex, cross-sectoral issue, so the
successful implementation of a programme of activity like the one presented below will also
require strong cross-sectoral collaboration. It will need to go beyond health – and public
health – systems, and towards a whole-of-society and whole-of-government approach. It
will also need to strictly uphold the human rights of people living with mental health
conditions and their families.
A mother and child leaving Pursukoon Zindagi’s Wellness Centre, a safe space for counselling established in
resource constrained settings. Photo Credit: Shehzad Noorani
PART II 54
WHO Action All resource settings

Plan objec-
tives
Strength- Include people with lived experience, their families and other stakeholder groups
en effective (e.g. young people) in the development of all approaches and plans, and their implemen-
leadership and tation and monitoring
WHO ACTION PLAN
governance for ALL RESOURCE SETTINGS
OBJECTIVES Ensure there is an appropriate legal and policy basis for mental health, e.g. laws
mental health
/ policies are in line with human rights instruments and protect (or even increase)
mental health financing, especially given other pressures on health budgets; policy is
Include
cross-sectoral people
where with(e.g.
needed livedlinks
experience,
with socialtheir families
services, and other
employment stakeholder
and education
sectors),groups (e.g. young
and explicitly people)
addresses the in the development
needs of all approaches
of vulnerable populations; and plans,
even within a
country, and their
policies implementation
may and monitoring
need to be adapted to regions based on local context
Build a whole-of-government consensus
Ensure there is an appropriate on the
legal andimportance of mental
policy basis health,
for mental includ-
health,
ing, where possible, at the highest level of government (e.g. President or Prime Minister)
e.g. laws / policies are in line with human rights instruments and protect
(or evenmental
Fully integrate increase) mental
health health
services infinancing, especially
UHC reforms given other
and planning, pressures
ensuring that
on health
mental health budgets; policy
is a fundamental part is
ofcross-sectoral
the process. Inwhere needed
the shorter (e.g.
term, links that
ensure withmen-
tal healthsocial services,
is integrated employment
into and
priority health education
and sectors),
other social and explicitly
programmes address-
nationally (e.g.
MNCH, NCDs, HIV)
es the needs of vulnerable populations; even within a country, policies may
Include need to be adapted
an adequate range oftomental
regionshealth
basedservices
on local context
and approaches (pharmaco-
logical and non-pharmacological) in national basic packages of essential services;
Build
ensure that a whole-of-government
mental health medicines are consensus
included in the on basic
the importance of mental
medicines lists
health, including, where possible, at the highest level of government (e.g.
Include President
mental health services
or Prime / medicines within the financial protection mech-
Minister)
anisms of the health system (e.g. national insurance schemes) for all, inclusive of
delivery in
Strengthen effective bothintegrate
Fully specialised and non-specialised
mental health servicessettings;
in UHCno user fees
reforms andshould be charged
planning,
leadership and for essential mental health services, wherever they are delivered. To
ensuring that mental health is a fundamental part of the process. In the ensure sustainability
governance for and in-country ownership, resources should be raised and investment made domestically,
shorter term, ensure that mental health is integrated into priority health and
where possible
mental health other social programmes nationally (e.g. MNCH, NCDs, HIV)
Develop a national specialist mental health workforce, e.g. make mental health more
prominent on university
Include curricula,
an adequate create
range of amental
career health
progression for mental
services health profes-
and approaches
sionals within the health service, improve staff retention, and
(pharmacological and non-pharmacological) in national basictraining
scale up the packages of of
general essential
health staff and other relevant professions (e.g. teachers, police,
services; ensure that mental health medicines are included in the social work-
ers) in mental health clinical
basic medicines lists and non-clinical skills (e.g. communication), and emotional
coping skills for the workforce itself
Includesettings
Low-resource mentalwith health
fewservices / medicines within
Medium-resource set- the financial protection
High-resource set-
mechanisms
mental health resourcesof the
andhealthtings
systemwith(e.g.
some national
mentalinsurance schemes)
tings with for all,
good mental
inclusive of delivery in bothhealth
infrastructure specialised
resourcesand non-specialised
and settings; noand
health resources user
fees should be charged forinfrastructure
essential mental health services,
(actions wherever
infrastructure they
(actions
are delivered. To ensure sustainability
in addition to and in-countryinownership,
low-re- addition toresources
low- and
should be raised and investment sourcemade domestically,medium-resource
settings) where possible set-
tings)
Develop a national specialist mental health workforce, e.g. make mental
health more prominent on university curricula, create a career progression
for mental health professionals within the health service, improve staff
retention, and scale up the training of general health staff and other
relevant professions (e.g. teachers, police, social workers) in mental health
clinical and non-clinical skills (e.g. communication), and emotional coping
skills for the workforce itself
PART II 55
Provide com- Enable primary care to identify Create equitable geo- Create full geograph-
prehensive, common mental disorders and MEDIUM-RESOURCE graphical coverage of HIGH-RESOURCE
ic coverage of mental
integrated and deploy basic evidence-based mental health care SETTINGS
health care WITH GOOD
integrated in
LOW-RESOURCE SETTINGS WITH SOME
responsive pharmacological and psy- MENTAL
primary care HEALTH
SETTINGS WITH FEW Ensure
MENTAL HEALTH
effective coor- RESOURCES AND
WHO ACTION
mental PLAN
health chosocial interventions in an
RESOURCES
dination of AND
care across Provide full range of
and social
OBJECTIVES integratedMENTAL HEALTH
way with other treat- INFRASTRUCTURE
service delivery plat- targeted specialist ser-
care services ment (e.g. using task-shifting
RESOURCES AND and INFRASTRUCTURE (ACTIONS IN
forms, within
(ACTIONS mental
IN vices (e.g. also for early
in community- the mhGAPINFRASTRUCTURE
approach, with face- ADDITION TO LOW-
based settings to-face or digital supervision); ADDITION TO LOW-men- intervention for psycho-
health and between
tal health and
RESOURCE physical
SETTINGS) ses, AND MEDIUM-
addictions)
and to identify / refer severe RESOURCE SETTINGS)
health (including integra-
cases to secondary care (general Complete move of
tion of mental health care
hospitals). This can be further mental health inpatient
with other secondary
enabled by use of peer
Enable primary care to support Create services from psychiat-
care,equitable
such as maternal Create full geographic
workers, as well as peer super- ric hospitals to general
identify common mental and child health,
geographical coverage HIV)
of coverage of mental health
vision to ensure
disorders and the highbasic
deploy quality mental health care hospitals
care integrated in primary
of interventions
evidence-based is maintained
pharmaco- Provide basic range
Expand service deliv-
care
care to train,Ensure effective
logical and of targeted specialist
Enable secondary ery via more advanced
psychosocial services in
coordination of tertiary
care across Provide full range of
support and supervise primary digital technology, e.g.
interventions in an integrat- service (e.g. forplatforms,
caredelivery children targeted specialist
care delivery of mental health virtual reality
ed way with other treat- within
andmental
young health
people, and
older services (e.g. also for early
services;
ment (e.g.treat people
using with
task-shifting between
adults, forensic settings) intervention for
moreandsevere mental health
the mhGAP approach, mental health and psychoses, addictions)
problems in an integrated
with face-to-face Consolidate
or digital way physical health move of
with and to in outpa- (including
other treatment
supervision); mentalintegration of
health inpatient Complete move of mental
tientidentify
and inpatient facilities; and mental
/ refer severe healthfrom
services care psychiat-
with health inpatient services
refer to tertiary
cases care (specialist
to secondary care ricsecondary
other hospitalscare,to general
such from psychiatric
(general
services) hospitals).
where This can
appropriate hospitalsand child health, hospitals to general
as maternal
be further enabled by use HIV) hospitals
Initiate scale-down
of peer of special-
support workers, as Provide comprehensive
ist care, e.g. through closure
well as peer supervision to mental
Provide health
basic rangetraining
of tar- Expand service delivery via
of some
ensure long-stay
the high institutions
quality of in geted for specialist
general health-care more advanced
Provide favour of community
interventions is settings, andservices
staff in tertiary care digital technology, e.g. virtu-
comprehensive, movement maintainedof mental health inpa- (e.g. for children and young al reality.
integrated and tient services to general hospi- people, older adults, forensic
responsive mental tals.Enable
Before scale-down,
secondary ensuresettings)
care to
health and social caresafe train,
and support
viable and
alternatives
services in fullysupervise
in place.primary
227
Improvecare quality Consolidate move of mental
community- based of delivery
remaining of mental
psychiatric health
hospitalshealth inpatient services
services; treat people with from
settings Establish meansmental
of licensing
more severe health psychiatric hospitals to gen-
problems in antreating
all practitioners people eral hospitals
integrated
withwaymental
withdisorders,
other treatmentincluding
in
non-formal
outpatient care
andfacilities
inpatient Provide comprehensive
facilities; and refer to tertiary mental health training for
Leverage digital technologies,
care (specialist services) general health-care staff
where appropriate,
where appropriate to improve
service reach and efficiency
(being mindful
Initiate of limitations,
scale-down of e.g.
dataspecialist
privacy, care,
potential lack of
e.g. through
access to internet
closure of someand data for
long-stay
poorest populations)
institutions in favour of
community settings, and
movement of mental health
inpatient services to general
hospitals.
Before scale-down,
ensure safe and viable
alternatives fully in
place.227 Improve quality
of remaining psychiatric
hospitals
PART II 56
Implement Implement evidence-based and Implement coordinated Implement intensive and

strategies for culturally relevant programmes programmes in com- tailored programmes in
promotion and inEstablish means
communities of workplaces
and munities and workplac- communities and work-
licensing all practitioners
prevention in to promote understanding of es on mental health places on mental health
treating people with
mental health mental health, reduce stig- promotion, stigma promotion, stigma
mental disorders,
ma, increase help-seeking
including non-formal care
reduction, encourage- reduction, encourage-
behaviours
facilities and encourage ment of help-seeking ment of help-seeking
demand for mental health care behaviours and de- behaviours and de-
and services,
Leverage and enable self-
digital mand for mental health mand for mental health
care (though taking
technologies, wherecare not to
appro- services, and self-help, services, and self-help
increase demand before
priate, to improve serviceincreas- including focus on spe- (though taking care not
ing supply)
reach and cific vulnerable groups to increase demand be-
efficiency (being mindful of (though taking care not fore increasing supply)
Set up peer-support
limitations, networks
e.g. data privacy, to increase demand be-
topotential
provide encouragement
lack of access to and a Put in place intensive
fore increasing supply)
sense of belonging,
internet and data forbuild empow-
poorest suicide prevention
erment and
populations) resilience, and share Improve quality and ac- programmes (e.g. reduce
expertise cessibility of suicide pre- access to means of self-
vention and drug and harm, hotlines, media
Put in place suicide prevention
alcohol use prevention training) and alcohol
Implement and policies (e.g.Implement
programmes
programmes (e.g. opioid Implement
coordinated and drugintensive and
use preven-
reduce access toand
evidence-based pesticides), and
programmes in communities tailored
substitution therapy) tion programmes in
programmes
alcohol and
culturally drug use preven- and workplaces on mental
relevant communities and
tion programmes
programmes in and policieshealth Create a range
promotion, stigma Create a full
of inde- workplaces on mental
range of
(e.g. reduction and
communities of access to pendent
reduction, and supported health
encouragement independent
promotion,and sup-
stigma
workplaces to promote
alcohol) accommodation
of help-seeking for
behaviours ported accommodation
reduction, encouragement
understanding of mental and people
demandwith for long-term
mental offor people withbehaviours
help-seeking long-term
Run antenatal, early childhood,
health, reduce stigma, health services, and and demand for mental
mental disorders mental disorders
school (e.g.
increase life-skills training),
help-seeking self-help, including focus on health services, and
and parenting
behaviours and Put vulnerable
/ parent coach- specific in place communi-
groups Put in place
self-help a range of
(though
ing interventions,
encourage demand and
forbolster (though
ty-based
taking rehabilitation
care not to evidence-based
taking ser-
care not to increase
other relevant
mental health intersectoral
care and / inter- tailored
increase for people
demand beforewith vices in
demand community
before increasing
governmental
services, andareas increasing
enablefor collabora- supply) disabilities supply)
psychosocial platforms, e.g. schools,
tion (though
(e.g. with
self-care the justice system) colleges and workplaces
Implement strategies taking care not to increase Improve quality and Put in place intensive suicide
Integrate
demandmental health into accessibility of suicide
before increasing prevention programmes
for promotion and community-based rehabilita- prevention and drug and
prevention in mental supply) (e.g. reduce access to means
tion and inclusive development alcohol use prevention of self-harm, hotlines, media
health programmes
Set up peer-support programmes (e.g. opioid training) and alcohol and
networks
Put in placetoprogrammes
provide to substitution therapy) drug use prevention
encouragement and a sense programmes
support the mental health of
of belonging, build Create a range of
caregivers of people with mental
empowerment and independent and Create a full range of
health conditions
resilience, (e.g. dementia)supported accommodation
and share independent and
Wherever
expertisepossible, address for people with long-term supported accommodation
socioeconomic determinants mental disorders for people with long-term
ofPut in place
poor suicide
mental health, e.g. mental disorders
prevention programmes
implementing poverty alleviation
and policies (e.g. reduce
measures, improving housing
access to pesticides), and
conditions, ensuring that children
alcohol and drug use
and
prevention have
parents safe (green)
programmes
spaces to play and exercise
and policies (e.g. reduce
access to alcohol)
PART II 57
Strengthen Identify key mental

Run antenatal, health
early Identify
Put in place additional indi- Establish
Put in place linked
a rangehealth
of
information sys- childhood,that
indicators can (e.g.
school be tracked community-based
cators on access and services to
evidence-basedsystems
information in
tems, evidence tolife-skills
support decision-making
training), and use of mental
rehabilitation health
tailored for allow data platforms,
community triangulation
e.g.
and research parenting
and funding /allocations, ensure people
parent coaching with psychosocial
services and stigma schools, collegessources
from different and work-
for mental interventions,
increased and bolster
accountability, and disabilities
perceptions places
Put in place machine
health enable comparison over time/ and
other relevant intersectoral
intergovernmental Conduct more re- learning and AI ana-
between countries areas for
collaboration (e.g. with the source-intensive lytics across datasets
Pilot andsystem)
justice scale interventions to research (larger studies, to develop real-time risk
manage mental health using cross-linking databas- profiles
community-based approaches
Integrate mental health into es, use of social media
community-based
(psychosocial and pharmacolog- analytics)
rehabilitation and inclusive
ical)
development programmes
Implement systems to moni-
tor,
Puttrack and programmes
in place maintain service
to
quality
support the mental health
of caregivers of people with
mental health conditions
(e.g. dementia)
Wherever possible, address

socioeconomic
determinants of poor
mental health, e.g.
implementing poverty
alleviation measures,
improving housing
conditions, ensuring that
children and parents have
safe (green) spaces to play
and exercise
Identify key mental health Identify additional Establish linked health

indicators that can be indicators on access and information systems to
tracked to support use of mental health allow data triangulation from
decision-making and funding services and stigma different sources
allocations, ensure increased perceptions
accountability, and enable Put in place machine
comparison over time and Conduct more resource- learning and AI analytics
between countries. intensive research (larger across datasets to develop
Strengthen studies, cross-linking real-time risk profiles
information Pilot and scale databases, use of social
systems, evidence interventions to manage media
and research for mental health using analytics)
mental health community-based
approaches (psychosocial
and pharmacological)
Implement systems to
monitor, track and
maintain service quality
Source: adapted from WHO (2013) Mental Health Action Plan 2013-2020 (including draft Appendix 2, currently under consultation256); Patel, V.,
Saxena, S., et al. (2018), “The Lancet Commission on Global Mental Health and Sustainable Development”, The Lancet; Maulik, P., Thornicroft,
G., Saxena, S. (2020), “Roadmap to strengthen global mental health systems to tackle the impact of the COVID-19 pandemic”, IJMHS; ODI
(2020), Non-digital interventions for adolescent mental health and psychosocial well-being (London: ODI); Thornicroft, G. et al. (2019), “Integrated
care for people with long-term mental and physical health conditions in low-income and middle-income countries”, The Lancet Psychiatry; Patel,
V. et al. (2016), “Addressing the burden of mental, neurological, and substance use disorders: key messages from Disease control Priorities, 3rd
edition”, The Lancet
PART II 58
THE COST OF SCALING UP MENTAL HEALTH CARE
Increasing expenditure on mental health to just 5-10% of total government health

spending would increase coverage by 40-80% in low- and middle-income countries. To
ensure sustainability, it is best for this funding to come from domestic sources; though,
in some cases, catalytic national and international donor financing may be needed.
Although the exact cost of the integration of mental health in health systems would depend
on the specific country, setting and approach taken,228 The Lancet Commission for Global
Mental Health and Sustainable Development has suggested that countries should be
aiming to commit at least 5-10% of their health spending to mental health, depending on
the resource level of each country (5% for lower-income countries, and 10% for higher-
income countries).229 Although still relatively modest, this would represent a substantial
growth in resources committed to mental health (~2x growth for HICs, and ~10x growth for
LICs).230 This underlines the fact that, across all resource settings (including high-income),
mental health is still significantly underfunded.231 Moreover, as the Peru example on p. 60
shows, to be maximally effective these funds would need to be directed towards high
quality, rights-based services, mainly provided at community level.
If investment is gradually scaled up to these levels by 2030, recent work commissioned by

United for Global Mental Health from Deakin University (using the WHO OneHealth Tool)
has suggested that this would substantially increase treatment coverage. For five major
conditions, coverage would be expanded to 55-100% depending on resource setting and
condition (based on an investment of 5% of the health budget in low-income settings, 7.5%
in middle-income settings, and 10% in high-income settings).232 This would amount to
between 40% and 80% more coverage see the table below. Further investment would be
needed to achieve greater levels of coverage.
Lower-middle Upper-middle
Low income income income
High income
Change in coverage by 2030, by resource

Change as
setting, in coverage
a result ofby 2030, byinresource
increase Current Target Current Target Current Target Current Target
Current Target Current Target Current Target Current Target
setting, as a result of increase in investment
investment
Anxiety disorders 10% 89% 14% 55% 22% 78% 37% 85%
Depression 10% 89% 14% 55% 22% 78% 37% 85%
Psychosis 11% 90% 31% 72% 37% 93% 51% 99%
Bipolar disorder 10% 89% 14% 55% 22% 78% 37% 85%
Epilepsy 25% 100% 35% 76% 45% 100% 90% 100%
%increase
% increasein
intreatment
treatmentcoverage
coverageby
by2030
2030 79% 79% 41% 41% 56% 56% 48% 48%
It is important that the financing comes primarily from domestic funds to ensure that health
systems are set up to be sustainable, are fully ‘owned’ by the countries and citizens
themselves,233 and to enable a more efficient pooling of resources. Some countries have
already had marked successes in financing the integration of mental health in health
systems, through domestic budgetary allocations combined with reforms in the approach
to service delivery. These countries include Brazil, Sri Lanka, Ethiopia and, as the case study
below describes, Peru.
PART II 59
In 2012, about 20% of Peruvians were living with a mental health condition,234 including 10%
of children.235 As is often the case, the most vulnerable Peruvians were also the most se-
verely
CASE affected: in one regionTHE
STUDY: REFORMING (heavily
MENTALaffected
HEALTHby political
SYSTEMviolence
IN PERU in235the late 20th
century), the lifetime prevalence of mental conditions was estimated to be as high as 50% of
allIninhabitants.
2012, about 23620% of Peruvians were living with a mental health condition,236 including 10% of
children. As is often the case, the most vulnerable Peruvians were also the
237
most severely
CASE STUDY: REFORMING THE MENTAL HEALTH SYSTEM IN PERU235
affected: in one region (heavily affected by political violence in the late
At the same time, investment levels in mental health were disproportionately small 20th century), the com-
lifetime prevalence of mental conditions was estimated to be as high as 50% of all inhabit-
pared238 with the need for care. In 2011, just 0.27% of the health budget was committed to
ants.
mental health, 98% of which was spent on tertiary institutions.237 There was also a severe
lack of human
At the same time, resources
investmentto provide
levels in care,
mentalwith onlywere
health 700disproportionately
psychiatrists working small in the whole of
compared
Peru
with(0.57 per for
the need 100,000 inhabitants);
care. In of these,
2011, just 0.27% of the 85%
healthwere concentrated
budget was committed in Lima. 238
to mentalMoreover,
there was little financial protection for mental health239 conditions, as patients had to pay for
health, 98% of which was spent on tertiary institutions. There was also a severe lack of
mental
humanhealth
resourcesservices out-of-pocket
to provide or through
care, with only their ownworking
700 psychiatrists insurance.
in the whole of Peru (0.57
239
per 100,000 inhabitants); of these, 85% were concentrated in Lima.240 Moreover, there was little
Itfinancial
was a situation that
protection formeant
mental more
healththan 85% ofaspeople
conditions, who
patients hadneeded mental
to pay for mentalhealth
healthservices
services no
received out-of-pocket or through
care in 2012. 240
As a their own
result, insurance.241
neuropsychiatric conditions accounted for approx-
imately one sixth of all disability-adjusted life years lost in Peru,241 and accounted for the
It was a situation
greatest economic that meant
cost to more
the than 85%
country ofchronic
of all people who needed
diseases.242 mental health services
242
received no care in 2012. As a result, neuropsychiatric conditions accounted for
approximately one sixth of all disability-adjusted life years lost in Peru,243 and accounted for the
An important step towards reform was the passing of Law 29889: the “General Health Law
greatest economic cost to the country of all chronic diseases.244
guaranteeing the rights of people with mental health problems”. This “explicitly guarantees
the
An availability of programs
important step and services
towards reform for mental
was the passing healthcare
of Law 29889: the country-wide, including
“General Health Law
interventions
guaranteeing related toofthe
the rights promotion,
people prevention,
with mental recoveryThis
health problems”. and“explicitly
rehabilitation of every
guarantees the
citizen at every
availability level of and
of programs the healthcare system”.
services for mental
243
Following
healthcare this, a number
country-wide, of key develop-
including
ments to enable
interventions the scale-up
related of mental
to the promotion, health inrecovery
prevention, Peru, and itsrehabilitation
and integration of
in every
UHC. citizen
at every level of the healthcare system”.245 Following this, a number of key developments to
Firstly,
enablemental health
the scale-up of services were in
mental health integrated
Peru, and into the Seguro
its integration Integral de Salud (SIS), the
in UHC.
publicly-funded health insurance designed to cover the most vulnerable Peruvians.244 Im-
Firstly, mental
portantly, health services
integration included were
an integrated
adjustment into
ofthe
theSeguro Integral de Salud
reimbursement (SIS),
rate for the health
mental
services to a level that insurance
was seendesigned
as viabletoby providers – avulnerable
critical step in ensuring that Peru-
246
publicly-funded health cover the most Peruvians.
Importantly,
vians coveredintegration included
by SIS could anmental
access adjustment of the
health reimbursement
services rate
in practice. 245 for mental health
services to a level that was seen as viable by providers – a critical step in ensuring that
Peruvians covered by SIS could access mental health services in practice.247
Secondly, in 2014, a stable, long-term source of domestic financing for mental health was
put in place
Secondly, in through a 10-year
2014, a stable, budget
long-term specifically
source committed
of domestic financingtofor
the scale-up
mental of was
health communi-
put
ty-based mental ahealth,
in place through 10-yearand linked
budget to achieving
specifically specific
committed results
to the (prior
scale-up of to that, mental health
community-based
was financed
mental health,from the NCD
and linked budget).246
to achieving Moreover,
specific results this funding
(prior to that, has grown
mental over
health wastime, from
financed
from the NCD budget). Moreover, this funding has grown over time, from $25 million to over
$25 million to over 248 million.247
$100
$100 million.249
Thirdly, mental health service provision started on a journey of transformation from a hos-
Thirdly, mental
pital-based to ahealth service provision
decentralised model, started onin
resulting a journey of transformation
closer integration frommental
between a health
hospital-based
provision to ahealth
and the decentralised
systemmodel, resulting in closer integration between mental health
through:
● training
provision and the health
primary system
care through:
clinicians to detect and offer basic treatment for common mental health
• training primary
conditions careWHO’s
(using clinicians to detect
mhGAP) 248 and offer basic treatment for common mental
health
● the conditions
opening of (using
over 150 WHO’s mhGAP)
community mental
250
health centres (CMHCs), with approximately 50 more
• the planned,
opening of over 150
to provide community
more specialised mental
mental health centres
health (CMHCs),
services, and aswith approximately
referral and supervision
249
pointsplanned,
50 more for primary healthcare
to provide more specialised mental health services, and as referral and
● the opening
supervision of 24
points forshort hospitalisation
primary healthcareservices
251 for mental health in general hospitals250
●
• the opening of 24 short hospitalisation services for planned)
the creation of 11 sheltered homes (with 30 more to support
mental health patienthospitals
in general 251
recovery.252
• the creation of 11 sheltered homes (with 30 more planned) to support patient recovery253
These reforms have led to a marked improvement in how mental health care is delivered in Peru. Care
These reforms
coverage have
for people ledmental
with to a marked improvement
health conditions in how
increased to mental
over 25%health care(still
by 2018 is delivered in from
a long way
target, but a significant improvement from the starting point). 252
Peru. Care coverage for people with mental health conditions increased to over 25% by 2018
(still a long way from target, but a significant improvement from the starting point).254
The new model of care is also highly cost-effective. According to the World Bank, the average cost of an
outpatient consultation in a specialised hospital setting was $58.96, five times more than the cost for the
same intervention in a CMHC ($11.58). The same is true for in-patient care. The average bed-day cost
in a specialised facility was $90.86, while the daily cost of residential treatment at a halfway house was
PART II 60
$28.48, more than three times less.253
Of course, a lot remains to be done: further scaling the model and the investment in mental health (to
reachThe10%newofmodel of care
the overall is also
health highlyintegrating
budget); cost-effective. mentalAccording to theallWorld
health across publicBank, the promoting
policies; average
costparticipation
citizen of an outpatient in the consultation
development in of athe
specialised hospital
sector;254 and setting
ensuring was $58.96,
effective five times implemen-
and rights-based more
than
tation of the cost for into
the policies the day-today
same intervention
practice. in a CMHC ($11.58). The same is true for in-patient care.
The average bed-day cost in a specialised facility was $90.86, while the daily cost of residential
Fortreatment at a halfway
instance, interviews withhouse was $28.48,from
key stakeholders more than three
service times less.255show that while mental
user organisations
health services are now integrated in the SIS, a significant amount of paperwork and procedure is required
notOf only to obtain
course, a lotinsurance
remainsfor to mental
be done: health
further conditions,
scaling but
the also
modelto make
and thean investment
appointmentinformentalservices.
With no guidance
health (to reach on10%
howof to the
navigate thehealth
overall process, this isintegrating
budget); a substantial barrierhealth
mental to those who all
across need access to
public
care. Moreover,
policies; the quality
promoting of services
citizen is ofteninpoor.
participation Users highlightofathe
the development significant
sector;256focus
and onensuring
the biomedical
ef-
approach
fective to
andmental health asimplementation
rights-based opposed to a more holistic,
of the psychosocial
policies model.practice.
into day-today Users also note instances
of maltreatment of patients by health workers. Across the board, action is needed to tackle stigma towards
mental disorders.interviews
For instance, Finally, citizen
withparticipation
key stakeholders in mentalfrom health sector
service userdevelopment
organisations “is still
show incipient”, and
that while
canmental
be more health services are now integrated in the SIS, a significant amount of paperwork and for
of a formality, rather than true involvement or consultation. There is thus still a great need
user voices
procedure to be heard in Peru,
is required which
not only could be
to obtain attained through
insurance establish
for mental healthaconditions,
central coordinating
but also to mecha-
255
nism to support mental health associations.
make an appointment for services. With no guidance on how to navigate the process, this is
a substantial barrier to those who need access to care. Moreover, the quality of services is
It is important to acknowledge that Peru has made important initial steps in mainstreaming mental health,
often poor. Users highlight a significant focus on the biomedical approach to mental health as
with already impressive results. It is essential that it continues its journey towards an inclusive, rights-
opposed to a more holistic, psychosocial model. Users also note instances of maltreatment of
based approach to mental health, improving the quality of services and making a true effort to promote
andpatients by health
protect the rights of workers. Across
people with the board,disabilities.
psychosocial action is needed to tackle stigma towards mental
disorders. Finally, citizen participation in mental health sector development “is still incipient”,
and can be more of a formality, rather than true involvement or consultation. There is thus still
a great need for user voices to be heard in Peru, which could be attained through establish a
central coordinating mechanism to support mental health associations.257
It is important to acknowledge that Peru has made important initial steps in mainstreaming
mental health, with already impressive results. It is essential that it continues its journey
towards an inclusive, rights-based approach to mental health, improving the quality of services
and making a true effort to promote and protect the rights of people with psychosocial
disabilities.
At the same time, some countries will need to rely on catalytic national and international
donor funding, at least in the early stages of integrating mental health in UHC. To this end,
the Global Financing Facility, the Global Fund, and other international and national donors
should aim to integrate mental health into their coordinated health system financing
efforts. These should emphasise improving the quality of services using a rights-based
community level approach.
The case study from Pakistan, below, is an example of integration through catalytic donor
funding.
PART II 61
Case study: Integrating mental health care in primary care in Pakistan
Pakistan has a treatment

CASE STUDY: INTEGRATING gap of about
MENTAL 90%,HEALTH
even for common
CARE INmental disorders.
PRIMARY CARE Only
IN aPAKISTAN
handful of institu-
tions and professionals provide appropriate treatment: recent estimates suggest that there are only about
500 psychiatrists
Pakistan in Pakistan,
has a treatment orof
gap about
about one psychiatrist
90%, even forper 400,000mental
common people.disorders.
257
In 2017,Only
the government
a handful
of institutions
spent only 0.4%and professionals
of its health budgetprovide appropriate
on mental health. treatment: recent estimates suggest that
258
there are only about 500 psychiatrists in Pakistan, or about one psychiatrist per 400,000
By contrast,
people. 258 the need is high. Studies estimate the prevalence of depression among pregnant Pakistani
In 2017, the government spent only 0.4% of its health budget on mental health.259
women ranges from between 36% to 40%,259 while anxiety among pregnant women has been found to be
Byhigh
as contrast,
as 49%. At the
the260need is same time, stigma
high. Studies and lack
estimate the of awarenessofmake
prevalence it harder
depression for people
among to seek mental
pregnant
Pakistani women ranges from between 36% to 40%,
health services. 260
while anxiety among pregnant women
has been found to be as high as 49%.261 At the same time, stigma and lack of awareness make
To improvefor
it harder thepeople
situation, Interactive
to seek mentalResearch and Development (IRD) Pakistan, with the funding and sup-
health services.
port of Grand Challenges Canada and the Government of Canada, established and successfully scaled the
Pursukoon
To improveZindagi , or ‘Peaceful
the situation, Life’, programme.
Interactive Research and The programme is(IRD)
Development designed
Pakistan,to provide brief psychologi-
with the
cal treatment or referral using a task-shifting approach (training ‘lay counsellors’),
funding and support of Grand Challenges Canada and the Government of Canada, established while being fully integrated
in the delivery of routine health services and existing patient-care cycles.
and successfully scaled the Pursukoon Zindagi, or ‘Peaceful Life’, programme. The programme
is designed to provide brief psychological treatment or referral using a task-shifting approach
The programme began as a community-based mental health pilot in 2014 in three resource-constrained
(training ‘lay counsellors’), while being fully integrated in the delivery of routine health services
settings in Karachi. Since 2018 it has been integrated within the primary care networks of major provid-
andthere,
ers existing patient-care
as well as within cycles.
specific disease programmes (diabetes, TB, HIV, COPD/lung health, etc.). At
the time of writing, the programme is operating in 20 primary care centres, and 80 lay counsellors have
The programme
been began as261
trained and deployed. a community-based mental health
These counsellors conduct pilot
screening forindepression
2014 in three
and anxiety, offer basic
resource-constrained
counselling treatment andsettings in Karachi.
customised Since 2018 it has
treatment-adherence been integrated
counselling, within
and refer morethe primary
severe cases to a
care networks of major providers there, as well as within specific disease programmes
psychologist.
(diabetes, TB, HIV, COPD/lung health, etc.). At the time of writing, the programme is operating in
As
20 well as focussing on ‘supply’,
and 80thelayprogramme is have
takingbeen
stepstrained
to buildand
thedeployed.
‘demand’ for mental
These health
262
primary care centres, counsellors
counsellors
services in theconduct screening
communities they for depression
serve. and anxiety,
For example, it engagesoffer
keybasic counselling
community treatment
members to ensure buy-in,
andconducts
and customised treatment-adherence
focused dialogues to reduce counselling,
stigma andand refer awareness
increase more severe cases to
of mental a
health conditions and
psychologist.
services.
The results
As well of the programme
as focussing are the
on ‘supply’, impressive.
programme Sinceis2018,
takingover
steps100,000
to buildpeople have beenfor
the ‘demand’ screened
mental (of
whom two thirds were female). Of these, over 5,000 presented with
health services in the communities they serve. For example, it engages key community symptoms of depression and anxiety,
262
and nearly 4,000 have been enrolled for further treatment.
members to ensure buy-in, and conducts focused dialogues to reduce stigma and increase
awareness of mental health conditions and services.
The programme is also highly appreciated by the patients. In the words of one patient: “I had been ex-
periencing
The resultsmental
of thedistress
programme for theare
past three months.
impressive. Since I was
2018,losing
overinterest
100,000 in people
day-to-day
haveactivities
been and not
enjoying my life at all. Then I met the mental health team from IRD
screened (of whom two thirds were female). Of these, over 5,000 presented with symptomsand attended a mental health awareness
of
session, which helped me learn that I am under a lot of mental
depression and anxiety, and nearly 4,000 have been enrolled for further treatment.stress, for which I eventually
263 sought out
counselling. Now I feel fresh and actively participate in my day-to-day routine. I also advocate about mental
health in my community.”
The programme is also highly appreciated by the patients. In the words of one patient: “I had
been experiencing mental distress for the past three months. I was losing interest in day-to-
During the COVID-19 outbreak in Pakistan, moreover, the programme was able to pivot in an agile way to
day activities and not enjoying my life at all. Then I met the mental health team from IRD and
respond to the pandemic by setting up:263
attended a mentalmental
a proactive health health
awarenesssupportsession, which helped me learn
and treatment-adherence that I am
counselling undertoapatients
helpline lot of tested
mental for
stress, for which I eventually sought out counselling.
COVID-19 and quarantined, supporting 22,000 people to date Now I feel fresh and actively
participate in my helpline
a reactive day-to-day routine.
for the generalI also advocate
population to about
accessmental health in services,
free counselling my community.”
supporting over
800 people
During partnerships
the COVID-19 outbreak
with in Pakistan,
eight healthcare moreover, the
organisations, programme
providing was800
more than able to pivot
frontline in anworkers
health
agile way tomental
with respond to the
health pandemic by setting up:264
support.
• a proactive mental health support and treatment-adherence counselling helpline to
patients tested for COVID-19 and quarantined, supporting 22,000 people to date
• a reactive helpline for the general population to access free counselling services, supporting
over 800 people
• partnerships with eight healthcare organisations, providing more than 800 frontline health
workers with mental health support.
PART II 62
***
Thanks to the hard work and success of organisations such as Interactive Research and
Development (IRD) and funders like Grand Challenges Canada, as well as other activists and
advocates, the importance of mental health and its integration in health systems is beginning
to get traction in Pakistan.
As Dr Zafar Mirza, the Former State Minister of Health of Pakistan, recently put it: “Investments
in mental health should be commensurate with the direct and indirect burden of mental health
conditions.”265 This is reflected in the launch in 2019 of the President’s Programme to Promote
Mental Health of Pakistanis (focused on women’s and young people’s mental health),266 and in
the recent decision to pilot mental health as a core part of UHC within the public health
systems. Moreover, according to Dr Safi Malik, the Director General, National Health Services
Regulation and Coordination: “We have … now finalised the first-level care facility packages for
achieving Universal Health Coverage across the country. One of the most important
components of that is mental health.” This will be rolled out in 12 districts initially, but
subsequently expanded.267
It is critical that the scaling and continued integration of mental health in health systems
continues, with sustainable funding provided by the government, so that these critical services
are available universally across the country.
CONCLUSION
A lot of work has been done to create comprehensive frameworks and guidelines for the
scale-up and integration of mental health in health systems: the good news is, we are now
in a position where we know what to do. We can move quickly because we do not need to
re-invent the wheel.
We therefore have a real opportunity to make substantial progress on integrating mental

health in UHC. With concerted commitment and action on existing frameworks and initia-
tives (e.g. the WHO Mental Health Action Plan,268 or the WHO Special Initiative for Mental
Health),269 it is no longer a dream, but an attainable reality.
The time for action is now. THE TIME FOR ACTION IS NOW.
PART II 63
REFERENCES
183 WHO, “The Big Event for Mental Health” webpage, 10/10/2020 (accessed 21/10/2020)
184 See Patel, V. and Saxena, S. (2019), “Achieving universal health coverage for mental
disorders”, BMJ
185 See Patel, V. and Saxena, S. (2019), “Achieving universal health coverage for mental
disorders”, BMJ
186 Worldwide weekly data for search interest of “mental health” (topic), all categories, web
search, accessed 20/10/2020 via Google Trends. Percentage growth calculated between years 2016-
17, 2017-18, 2018-19, and 2019-20 (October to October)
187 #MoveForMentalHealth social media engagement tracking by United for Global Mental
Health, for the period 8-10 October. Tracking includes primarily data from Twitter, and limited data
from other online sources including Instagram and Facebook (in line with privacy policies and
regulations)
188 The Bill and Melinda Gates Foundation, “Mental Health for All” webpage (accessed
21/11/2020)
189 WHO (2010), The world health report: health systems financing: the path to universal
coverage (Geneva: WHO)
190 WHO, “Strategizing national health in the 21st century: a handbook” webpage (accessed
05/10/2020)
191 The World Bank (2019), High-Performance Health Financing Universal Health Coverage:
Driving Sustainable, Inclusive Growth in the 21st Century (Washington DC: The World Bank Group)
192 The World Bank, WHO, OECD (2018), Delivering quality health services: a global imperative
for universal health coverage (Washington DC: The World Bank Group)
193 The World Bank (2016), UHC in Africa: A Framework for Action (Washington DC: The World
Bank Group)
194 UN (2020), Policy brief: COVID-19 and Universal Health Coverage (New York: UN)
195 E.g. Jamison, D., Summers, L. et al. (2013), “Global health 2035: a world converging within a
generation”, The Lancet; a set of UHC case studies from the World Bank (The World Bank, “Universal
Health Coverage Study Series (UNICO)” webpage, accessed 05/10/2020); a WHO report on research
and UHC (WHO (2013), The world health report 2013: research for universal health coverage
(Geneva: WHO)); resources from UHC2030 (see the UHC2030 resources webpage, https://www.
uhc2030.org/resources/), including the 2020 Joint vision for Healthy Lives report (Geneva: WHO and
IBRD / The World Bank) and the 2020 Time to Get our Act Together on Health Emergencies and UHC
discussion paper (online publication, accessed 05/10/2020); the UNICEF approach to health systems
strengthening (UNICEF (2016), The UNICEF Health Systems Strengthening Approach (New York:
UNICEF); and WEF publications, such as Wipfli, H. (2019), “4 radical shifts required to achieve
universal health coverage worldwide” (WEF online article, accessed 05/10/2020)
196 WHO (2019), Primary health care on the road to universal health coverage: 2019 monitoring
report (Geneva: WHO); WHO and the World Bank (2020), Global monitoring report on financial
protection in health 2019 (Geneva: WHO and IBRD / The World Bank);
WHO (2020), World health statistics 2020: monitoring health for the SDGs, sustainable development
goals (Geneva: WHO)
197 UHC2030 (2020), State of commitment to universal health coverage: synthesis, 2020 (Geneva
and Washington DC: UHC2030)
PART II 64
199 Appendix 1: “Indicators for measuring progress towards defined targets of the
comprehensive mental health action plan”; Appendix 2: “Options for the implementation of the
comprehensive mental health action plan”
200 WHO (2020), “Update of Appendices 1 and 2 of WHO Comprehensive Mental Health Action
Plan: document for consultation process” (online document, accessed 05/10/2020)
202 WHO, “WHO Mental Health Gap Action Programme (mhGAP)” webpage (accessed
05/10/2020)
203 WHO (2016), mhGAP intervention guide for mental, neurological and substance use
disorders in non-specialized health settings. Version 2.0 (Geneva: WHO)
204 WHO (2019), “Draft menu of cost-effective interventions for mental health” (WHO discussion
paper, accessed 05/10/2020). This analysis is due to be incorporated into the revised Appendix 2 of
the extended WHO Mental Health Action Plan 2013-2020
205 WHO, “WHO QualityRights Tool Kit” webpage (accessed 05/10/2020). In addition to this, to
ensure quality, accountability to service users, and compliance with human rights covenants, this
toolkit could be supplemented with the formal monitoring and accountability mechanisms of the
CRPD, the efforts of NGOs and CSOs like the Human Rights Watch, the WHO Mental Health Atlas
initiative, as well as any future outputs from the Countdown Global Mental Health 2030 project (see
Argument 3, above, for more details and references)
206 WHO, “The WHO mental health policy and service guidance package” webpage (accessed
05/10/2020)
207 WHO (2013), Building back better: sustainable mental health care after emergencies
(Geneva: WHO). Mobilisation following a crisis can also be a trigger towards more sustained reform
and integration of mental health in UHC, as in the case of the Philippines after typhoon Haiyan (see
WHO, “Mental health care accessible at the primary level is Eastern Visayas” webpage, 22/01/2019
(accessed 23/10/2020))
208 Inter-Agency Standing Committee (IASC) (2007), IASC Guidelines on Mental Health and
Psychosocial Support in Emergency Settings (Geneva: IASC)
209 WHO (2019), The WHO special initiative for mental health (2019-2023): universal health
coverage for mental health (Geneva: WHO)
211 The World Bank (2018), Moving the needle: mental health stories from around the world
(Global Mental Health Initiative Washington DC: The World Bank Group)
212 Batada, A., Leon Solano, R. (2019), Harnessing Technology to Address the Global Mental
Health Crisis: An Introductory Brief (Washington DC: The World Bank Group)
213 The World Bank (2018), Healing Minds, Changing Lives: a movement for community-based
mental health in Peru (Washington DC: The World Bank Group)
214 The World Bank (2017), Mental Health in Transition: Assessment and Guidance for
Strengthening Integration of Mental Health into Primary Health Care and Community-Based Service
Platforms in Ukraine (Washington DC: The World Bank Group)
215 The World Bank (2018), Mental Health Among Displaced People and Refugees: Making the
Case For Action Under Humanitarian Response and Development Programs (Washington DC: The
World Bank Group)
218 UN (2020), Policy brief: COVID-19 and Universal Health Coverage (New York: UN)
219 E.g. Patel, V., Saxena, S. (2019), “Achieving universal health coverage for mental
PART II 65
disorders”, BMJ; ODI (2020), Non-digital interventions for adolescent mental health and
psychosocial well-being (London: ODI); Thornicroft, G. et al. (2019), “Integrated care for people with
long-term mental and physical health conditions in low-income and middle-income countries”, The
Lancet Psychiatry
220 Collins, P., Saxena, S. (2016), “Action on mental health needs global cooperation”, Nature,
flagging such programmes as PRIME, the Arctic Council, and BasicNeeds
221 See, for instance, Toyama, M. et al. (2017), “Peruvian Mental Health Reform: a framework
for scaling-up mental health services”, IJHPM; Araya, R. et al. (2012), “Lessons from scaling up a
depression treatment program in primary care in Chile”, Rev Panam Salud Publica; or the lessons
from Canada, e.g. in Marquez, P., Saxena, S., and Walker, M. (2017), “Advancing global mental health
action: lessons from Canada”, in The World Bank (2018), Global Mental Health: some perspectives on
challenges and options for scaling up response (WBG Global Mental Health Initiative Washington DC:
The World Bank Group); and India, e.g. Khan, A., et al. (2020), “Design and Development of a
Digital Program for Training Non-specialist Health Workers to Deliver an Evidence-Based
Psychological Treatment for Depression in Primary Care in India”, Journal of Technology in Behavioral
Science, and Shinde, S. et al. (pre-print from Research Square), “What makes multicomponent
school-based health promotion interventions work? A qualitative study nested in the SEHER trial in
Bihar, India” (accessed 05/10/2020)
222 Maulik, P., Thornicroft, G., Saxena, S. (2020), “Roadmap to strengthen global mental health
systems to tackle the impact of the COVID-19 pandemic”, IJMHS; Mental Health Commission of
Canada (2020), COVID-19 and mental health: Policy responses and emerging issues (environmental
scan) (Ottawa: Mental Health Commission of Canada)
223 For the PRIME project, see the PRIME website for more details (http://www.prime.uct.ac.za/),
as well as Lund, c. et al. (2012), “PRIME: A programme to reduce the treatment gap for mental
disorders in five low and middle-income countries”, PLoS Med for the programme’s approach. For
the Emerald project, see e.g. the Centre for Global Mental Health “EMERALD: Emerging mental health
systems in low- and middle-income countries” webpage (accessed 22/11/2020), as well as Chisholm,
D. et al. (2019), “Mental health financing challenges, opportunities and strategies in low- and
middle-income countries: findings from the Emerald project”, BJPsych Open
224 The Mental Health Innovation Network: https://www.mhinnovation.net/
225 The Wellcome Trust (2020), Expanding our vision for mental health: listening to young people
and learning from COVID-19 (London: Wellcome Trust)
226 See, for example, Collins, P., Saxena, S. (2016), “Action on mental health needs global
cooperation”, Nature
227 Note the Life Esidimeni tragedy, where the transfer of ~1,700 psychiatric patients out of an
institution, but without proper community-based provision in its place, caused the deaths of at least
144 patients in South Africa
228 Note a recent study that emphasised the dual importance of investment and operating at
optimal efficiency: GBD 2019 Universal Health Coverage Collaborators (2020), “Measuring universal
health coverage based on an index of effective coverage of health services in 204 countries and
territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019”, The
Lancet
230 Vigo, D., Kestel, D., et al. (2019), “Disease burden and government spending on mental,
neurological, and substance use disorders, and self-harm: cross-sectional, ecological study of health
system response in the Americas”, Lancet Public Health
231 Worth noting also is the relatively low overall level of spend for healthcare (in the region
PART II 66
of 4-6% for low- and middle-income countries). This is in contrast to such agreements as the Abuja
Declaration (2001), whereby the African Union countries committed to spend at least 15% of their
budgets on the health sector
232 Based on research conducted by Deakin University, commissioned by United for Global
Mental Health; see United for Global Mental Health and Speak Your Mind Campaign (2020), The
Return on the Individual report (online publication)
233 Vledder, M. (2019), “Three Reasons Domestic Resource Mobilization Is Key to Sustainable
Investments in Women, Children and Adolescents”, Global Financing Facility Blogs, 19/06/2019
(accessed 05/10/2020)
234 Toyama, M. et al. (2017), “Peruvian Mental Health Reform: a framework for scaling-up mental
health services”, IJHPM
235 Marquez, P. and Bayona Garcia, J., “Paradigm shift: Peru leading the way in reforming mental
health services”, World Bank Blogs 25/03/2019 (accessed 23/10/2020)
237 WHO (2012), Mental Health Atlas 2011 – Peru country profile (online publication)
238 WHO (2012), Mental Health Atlas 2011 – Peru country profile (online publication), Toyama,
M. et al. (2017), “Peruvian Mental Health Reform: a framework for scaling-up mental health services”,
IJHPM
239 The World Bank (2018), Healing minds, changing lives. A movement for community-based
mental health care in Peru (Washington DC: The World Bank Group)
247 The World Bank webinar, “Investing in Mental Health”, 15/09/2020
249 Toyama, M. et al. (2017), “Peruvian Mental Health Reform: a framework for scaling-up
mental health services”, IJHPM; United for Global Mental Health (2020), “March for Mental Health:
Peru” (online video project for World Mental Health Day) (accessed 23/10/2020)
250 United for Global Mental Health (2020), “March for Mental Health: Peru” (online video project
for World Mental Health Day) (accessed 23/10/2020)
251 Toyama, M. et al. (2017), “Peruvian Mental Health Reform: a framework for scaling-up
mental health services”, IJHPM; United for Global Mental Health (2020), “March for Mental Health:
Peru” (online video project for World Mental Health Day) (accessed 23/10/2020)
252 The World Bank webinar, “Investing in Mental Health”, 15/09/2020
PART II 67
254 United for Global Mental Health (2020), “March for Mental Health: Peru” (online video project
for World Mental Health Day) (accessed 23/10/2020)
255 Huapaya, V., Hidalgo, L., Rivera, D. (2020), Country profile: Peru. Analysis for mental health
campaigning and advocacy (online publication)
256 WHO (2020), Zero draft of updated Appendix 2 of the Comprehensive mental health action
plan 2013-2030: updating options for implementation (accessed 05/10/2020)
257 Sikander, S. (2020), “Pakistan”, The Lancet Psychiatry
258 WHO (2018), Mental Health Atlas 2017 – Pakistan Country Profile (online publication)
259 Sabir, M., Nagi, M., & Kazmi, T. (2019), “Prevalence of antenatal depression among women
receiving antenatal care during last trimester of pregnancy in a tertiary care private institute of
Lahore”, Pakistan Journal of Medical Sciences
260 Waqas, A., Raza, N., Lodhi, H., Muhammad, Z., Jamal, M., Rehman, A. (2015), “Psychosocial
Factors of Antenatal Anxiety and Depression in Pakistan: Is Social Support a Mediator?”, PLoS ONE
261 Information from IRD, as of 21/10/2020
264 Dr Zafar Mirza’s presentation at the virtual Mental Health Forum, organised by the WHO, 8
October 2020
265 Mirza, Z. et al. (2019), “Mental health care in Pakistan boosted by the highest office”, The
Lancet
266 United for Global Mental Health (2020), “March for Mental Health: Pakistan” (online video
project for World Mental Health Day) (accessed 09/10/2020)
267 United for Global Mental Health (2020), “March for Mental Health: Pakistan” (online video
project for World Mental Health Day) (accessed 09/10/2020)
269 WHO (2019), The WHO special initiative for mental health (2019-2023): universal health
coverage for mental health (Geneva: WHO)
PART II 68
Ten years ahead of the SDG deadline, the goal of attaining UHC for all is still a long way off.
About half of the world’s population is still not covered by essential health services.270 At the
same time, 100 million people are pushed into extreme poverty every year through
healthcare expenses, and over 930 million spend at least 10% of their household budgets
on healthcare.271 Looking forward, estimates from 2019 suggested that, at the historic
pace of change, about a third of the world’s people “will remain underserved by 2030”.272
COVID-19 has further increased the level of uncertainty. According to the 2020
Goalkeepers report, the level of UHC coverage in 2030 could, in the most pessimistic
scenario, even decrease in comparison to 2019.273
Mental health is an inalienable part of health. Despite the complexity of mental health,
its integration in UHC is a relatively low-hanging fruit for increasing the effectiveness and
comprehensiveness of health systems, and a desperately needed boost to meet the goal of
UHC by 2030. It is deeply worrying that in the past some countries have excluded aspects of
mental health from UHC.274
There is, moreover, an urgent need to make progress on mental health, in and of itself.
Every 40 seconds (or about as long as it takes someone to read to this point in this
Conclusion) someone somewhere dies by suicide. By the time the reader finishes reading
this Conclusion, another 40 seconds will have elapsed.
We therefore call for the following actions to be taken as a matter of urgency:
Stakeholder group Action

International agencies Continue to strengthen the case for integration of mental health in UHC through
policy development, facilitating information exchange, publishing evidence (including
from the WHO Special Initiative for Mental Health), and galvanising political will in
support of a rights-based approach
Provide technical advice and guidance, where relevant
Include mental health in global monitoring mechanisms (e.g. UHC coverage

index, the Human Capital Index)
National governments Fully integrate mental health into national health legislation and national health
CON
and UHC policies in compliance with human rights conventions
Commit 5-10% of health budget to mental health (depending on resource setting),

prioritising mental health integration in UHC in medium-term budget frameworks
Pilot implementation programmes and scale-up quickly, e.g. by following rec-

ommendations set out in Part II of this report, and key policy documents (such as
CLU
WHO’s Mental Health Action Plan 2013-2020)
International and Support the integration of mental health in UHC by providing catalytic funding in
national funders those contexts where national governments are unable to fund this fully in support
of a right-based approach
Integrate mental health in priority-funded health programmes, e.g. HIV, mater-
SION
nal and child health, NCDs
CONCLUSION 69
Ten years ahead of the SDG deadline, the goal of attaining UHC for all is still a long way off.
About half of the world’s population is still not covered by essential health services.270 At the
same time, 100 million people are pushed into extreme poverty every year through
healthcare expenses, and over 930 million spend at least 10% of their household
budgets on healthcare.271 Looking forward, estimates from 2019 suggested that, at the
historic pace of change, about a third of the world’s people “will remain underserved by
2030”.272 COVID-19 has further increased the level of uncertainty. According to the 2020
Goalkeepers report, the level of UHC coverage in 2030 could, in the most pessimistic
scenario, even decrease in comparison to 2019.273
Mental health is an inalienable part of health. Despite the complexity of mental health,
its integration in UHC is a relatively low-hanging fruit for increasing the effectiveness and
comprehensiveness of health systems, and a desperately needed boost to meet the goal of
UHC by 2030. It is deeply worrying that in the past some countries have excluded aspects of
mental health from UHC.274
There is, moreover, an urgent need to make progress on mental health, in and of itself.
Every 40 seconds (or about as long as it takes someone to read to this point in this
Conclusion) someone somewhere dies by suicide. By the time the reader finishes reading
this Conclusion, another 40 seconds will have elapsed.
We therefore call for the following actions to be taken as a matter of urgency:
Stakeholder group Action

International agencies Continue to strengthen the case for integration of mental health in UHC through
ACTION facilitating information exchange, publishing evidence (including
STAKEHOLDER GROUPpolicy development,
from the WHO Special Initiative for Mental Health), and galvanising political will in
support ofContinue
a rights-based approachthe case for integration of mental health in
to strengthen
UHC through policy development, facilitating information exchange,
Provide technical advice
publishing and (including
evidence where
guidance,from relevant
the WHO Special Initiative for
Mental Health), and galvanising political will in support of a rights-based
International Include mental health in global monitoring mechanisms (e.g. UHC coverage
approach
agencies index, the Human Capital Index)
National governments Fully integrate mental health into national health legislation and national health
and UHCInclude
policiesmental
in compliance
health with human
in global rights conventions
monitoring mechanisms
(e.g. UHC service coverage index, the Human Capital Index)
Commit 5-10% of health budget to mental health (depending on resource setting),
prioritising mental health integration in UHC in medium-term budget frameworks
Fully integrate mental health into national health legislation and
Pilot implementation programmes and scale-up quickly, e.g. by following rec-
national health and UHC policies in compliance with human rights
ommendations set out in Part II of this report, and key policy documents (such as
conventions
WHO’s Mental Health Action Plan 2013-2020)
Commit 5-10% of health budget to mental health (depending on
National
International and Support the integration
resource of mental
setting), health mental
prioritising in UHC health
by providing catalytic
integration in UHCfunding
in in
national funders
governments those contexts where national governments
medium-term budget frameworks are unable to fund this fully in support
of a right-based approach
IntegratePilot implementation
mental programmes
health in priority-funded and programmes,
health scale-up quickly,e.g.e.g.
HIV,by
mater-
following recommendations
nal and child health, NCDs set out in Part II of this report, and key
policy documents (such as WHO’s Mental Health Action Plan 2013-2020)
CONCLUSION 70
The academic com- SupportSupport

further strengthening
the integrationofofthe evidence
mental healthbase for the
in UHC by integration of mental
providing catalytic
munity health infunding
UHC, asinwell as how best to achieve this (especially in lower-
those contexts where national governments are unable and mid-
to
International and dle-income settings and using a right-based approach)
fund this fully in support of a right-based approach
national funders
Integrate mental health in priority-funded health programmes, e.g.
HIV, maternal and child health, NCDs
Accelerate progress towards Countdown 2030, an independent global mental
health monitoring mechanism
Support further strengthening of the evidence base for the integration
of mental health in UHC, as well as how best to achieve this (especially
Civil society Advocate for the rights of people with mental health conditions and their inclu-
in lower-
sion in the and middle-income
development settings
of any strategies, plansand
andusing a right-based approach)
implementation
The academic
community Provide
Advocate technical
for rapid action advice
to fullyand guidance,
integrate where
mental relevant
health in UHC with all relevant
stakeholders (especially national governments), keeping them accountable for any
Accelerate
commitments, and progress
supportingtowards Countdown
monitoring 2030, an independent global
and evaluation
mental health monitoring mechanism
Promote integration of mental health in UHC in any implementation work
Advocate for the rights of people with mental health conditions and
their inclusion in the development of any strategies, plans and
implementation
Advocate for rapid action to fully integrate mental health in UHC with
Civil society all relevant stakeholders (especially national governments), keeping
them accountable for any commitments, and supporting monitoring
and evaluation
Promote integration of mental health in UHC in any implementation

work
As the world grapples with the impact of COVID-19 and designs the future of healthcare,
we need the global community to come together now and commit its political will
towards action and investment in mental health.
There is no health without mental health. The time to act is now.

THERE IS NO HEALTH WITHOUT MENTAL HEALTH.
THE TIME TO ACT IS NOW.
CONCLUSION 71
REFERENCES
270 WHO, “Universal health coverage (UHC)” webpage (accessed 30/11/2020)
271 WHO website, “Universal Health Coverage (UHC)” webpage (accessed 05/10/2020)
272 UN General Assembly (2019), Political Declaration of the High-level Meeting on Universal
Health Coverage, “Universal health coverage: moving together to build a healthier world”
(New York: UN)
273 Bill and Melinda Gates Foundation (2020), 2020 Goalkeepers Report: COVID-19, a global
perspective (Seattle: Bill and Melinda Gates Foundation); based on UHC effective coverage index,
there was 62% coverage in 2019, versus 60% in 2030 in the worst-case scenario
CONCLUSION 72
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“NO

Prof Pamela Collins

If ever there was a time to invest in mental health, it’s

“Addressing mental health is central to achieving

THE ARGUMENTS FOR INTEGRATING MENTAL HEALTH IN UHC

• A health argument: There is a staggering – and growing – need to address

HOW THE INTEGRATION OF MENTAL HEALTH IN UHC CAN BE ACHIEVED

There is no health without mental health. The time to act is now.

THE IMPORTANCE OF UHC

“The States Parties to the present

THE IMPORTANCE OF UHC

The ‘UHC cube’

Source: WHO, “Universal coverage - three dimensions” webpage, accessed 17/09/2020.

MENTAL HEALTH AS PART OF UHC

It recommended “mainstream[ing] mental health interventions into health, poverty

THE NEED TO INTEGRATE MENTAL HEALTH IN UHC

Argument 1: There is no health without mental health

Argument 1: There is no health without mental health

“If ever there was a time to invest in mental health, it’s

Making mental health a mainstream element of existing health systems in a rights-based

INTEGRATING MENTAL HEALTH IN UHC: IMPROVING MENTAL HEALTH OUTCOMES

When the availability of different types of intervention (e.g. psychosocial and

Conflict-affected populations have a particularly extreme prevalence of mental conditions

Kamala: a story of hope beyond hope (Nepal)

INTEGRATION OF MENTAL HEALTH IN UHC: IMPROVING PHYSICAL HEALTH OUTCOMES

In relation to infectious diseases, integration of mental health interventions has been

• “[c]linically diagnosed major depressive disorder was identified as the most

It is especially urgent to integrate mental health in primary- and community-level care, as

HOW COVID-19 SHARPENS THE NEED TO INTEGRATE MENTAL HEALTH IN UHC

MOTHERS, CHILDREN AND YOUNG PEOPLE: AT THE HEART OF UHC

separately associated with a raised risk of “behaviour disturbance”105 and “adverse

Moreover, just as parents/caregivers are affected by the economic consequences of

Where maternal/caregiver, child and adolescent health and development is concerned,

Ayisha: “This maternal sadness is terrible” (Ghana)

HIGH COST-EFFECTIVENESS OF MENTAL HEALTH INTERVENTIONS

Moreover, the COVID-19 pandemic has contributed to an acceleration in innovative and

INTEGRATING MENTAL HEALTH IS A GOOD ECONOMIC INVESTMENT

Across 36 countries (representing 80% of the world’s population), a staggering 12 billion

INTEGRATING MENTAL HEALTH INCREASES THE EFFICIENCY OF HEALTHCARE SYSTEMS

Increasing investment in mental health, and integrating mental health in health

GOOD MENTAL HEALTH AS A CORE COMPONENT OF HUMAN CAPITAL

Human Capital Index component Example mental health impact on component154

The mental health of mothers and caregivers can have

UHC, MENTAL HEALTH AND THE RIGHT TO HEALTH

The concept of UHC, based as it is in the WHO Constitutions of 1948, is fundamentally

Furthermore, it is an issue of financial access, a key consideration for UHC. According to

THE RIGHTS OF PEOPLE WITH MENTAL HEALTH CONDITIONS

As The Lancet Commission on Global Mental Health and Sustainable Development

A transition to high-quality, sufficiently funded, evidence-based, rights-based,

The integration of mental health in UHC, if implemented according to a rights-based

ENOCK MALOYA PHIRI: “I CAN FEEL FREE” (MALAWI)

From intention to implementation:

To support this aim, this section will:

KEY PROGRAMMATIC DOCUMENTS ON SCALING-UP AND INTEGRATING MENTAL HEALTH

Document name Document description

tory Brief to the mental health challenges unfolding in a wide array of

Mental Health Among

Lastly, a significant amount of translational research on scaling up mental health provision

AN EXAMPLE SHORT-LIST OF APPROACHES FOR INTEGRATING MENTAL HEALTH IN UHC

WHO Action All resource settings

Implement Implement evidence-based and Implement coordinated Implement intensive and

Strengthen Identify key mental

Wherever possible, address