Patricio V Marquez

January 21, 2023

It is widely accepted that the world is currently going through a historical moment characterized by a “polycrisis”—a cluster of multiple global emergencies, unfolding simultaneously on an unprecedented scale, impacting all countries. 

In reading the Global Risks Report 2023, released by the World Economic Forum (WEF) on the occasion of its annual event in Davos this past week, I was not surprised to learn that the Global Risks Perception Survey presented in the report ranked “infectious diseases, severe mental health deterioration, and chronic diseases and health conditions”, among the 30 most severe global risks that many expect to play out over the next 10 years. 

The perceptions of risk conveyed in the survey accurately reflect the lingering reality of COVID-19 pandemic aftershocks, where, as noted in the WEF report, “global public health is under growing pressure and health systems around the world are at risk of becoming unfit for purpose.”

More ominously, the WEF report highlights the further risk of a rise in “syndemics”or disease interactions and the social, environmental, or economic factors that promote such interaction and worsen disease, leading to poorer health outcomes.  

Growing importance of mental health

The pandemic also revealed another global public health crisis, as mental health concerns skyrocketed. Rising unemployment, underemployment, changes in work arrangements and burnout, loss of income and rising poverty, altered daily routines, social isolation and loneliness, violence, and the complications from long-COVID imposed a heavy toll on people’s mental health. A 2021 global study published in The Lancet reported a significant increase in the prevalence of both major depressive and anxiety disorders among all genders—a worrisome finding because these disorders were already leading causes of disability worldwide.  In 2019, data from the World Health Organization (WHO) show that nearly a billion people – including 14 percent of the world’s adolescents – were living with a mental disorder.  Suicides accounted for more than 1 in 100 deaths, and 58 percent of suicides occurred before age 50. Mental disorders are also a major risk for developing alcohol and drug dependency, which in turn, further aggravate these disorders. 

The growing burden of mental and substance use disorders has accentuated the urgency of focusing on these often misunderstood and stigmatized conditions that affect people worldwide, in order to develop a better understanding of their complex biological, social, economic, and environmental determinants and the related social pathologies and impacts and to identify ways to effectively deal with them. 

How is mental health treated in healthcare systems?

The findings of a 30-country IPSOS survey conducted in 2021 showed that a large majority of respondents (about 80%) considered that that their mental health and physical health are equally important, but they do not see this reflected in their country’s healthcare system.  Only one-third (35%) felt that the healthcare system in their country treated mental and physical health with equal importance. A larger proportion (42%) felt that the healthcare system treats physical health with greater importance.

These findings are not new, and they have been reported continuously over the past decades. So, why are mental disorders and substance use disorders still treated so much differently than other health conditions such as heart disease, cancer, or diabetes?   And in doing so, do we realize that we are ignoring that mental and substance use disorders are already a major disability burden worldwide, that if left untreated, can negatively affect the management of common co-occurring diseases such as tuberculosis, HIV/AIDS, and cardiovascular diseases?  Or are we failing to grasp, as observed by Prof. Eliot Sorel, that populations across the world are currently impacted by the interplay of multiple shocks and traumas that are contributing to a state of sustained stress, challenging all societal systems and existing social contracts, and are likely to trigger a wave of mental health consequences that will overwhelm fragile health and social systems if their capacity to deal with these  risks is not revamped and strengthened?

How to bring “mental health” into the health system?

In the face of global disruptions, many countries and international organizations are intensifying their focus on resilience.  In a health system, resilience is the ability to prepare, manage (absorb, adapt, and transform), and learn from sudden and extreme shocks.   As countries chart a course to build resilient health systems, adopting and adapting the accumulated lessons from the pandemic experience, it is a societal imperative that the false dichotomy between mental and physical health be overcome once and for all.  This is urgently required to deal with the interaction of global health risks and aftereffects of the pandemic, which stand to be further aggravated and compounded by an evolving polycrisis.

To build resilient health systems, like with any organization, countries need to strategically invest in capabilities, people, processes, structures, and technology, to navigate current and future global health risks. A syndemics approach is required to guide these efforts, focusing on “the biosocial complex, which consists of interacting, co-present, or sequential diseases and the social and environmental factors that promote and enhance the negative effects of disease interaction”.  

To this end, as suggested in different fora over the past decade, four overarching priorities need drive policy action:

1. Promote mental health parity under universal health coverage arrangements

In many countries, a common barrier to achieving parity for mental illnesses and addiction treatment are preexisting conditions clauses that deny or limit health insurance coverage. Similarly, lack of or limited coverage of available services is prevalent in countries with public health systems. Related issues that merit careful consideration include: (i) determination of which conditions to prioritize (e.g., common mental illnesses such as depression and anxiety disorders, addictions, or severe conditions such as schizophrenia); (ii) selection of treatments at different levels of care; (iii) mechanisms to expand equitable access to medicines; (iv) how to fund and reimburse services, reducing cost barriers and eliminating out-of-pocket payments; and (v) quality improvement of mental health services.

2. Integrate mental and physical health in service provision 

Dedicated effort is needed to integrate public health interventions and treatments for mental and substance use disorders into service delivery platforms to overcome the medical profession’s artificial separation of mental and physical ills.   Improving service delivery requires strengthening referral pathways between levels of care, and formal and informal providers to foster communication, information sharing, education and training, multidisciplinary teamwork, and evaluation of service performance. Involving people living with mental conditions and their families in care decisions is critical to overcome stigma and discrimination often associated with these conditions.

3. Leverage new technologies to expand care access

Digital care options through teletherapy and mobile apps have seen explosive growth during the pandemic. They offer alternative service delivery models that can help overcome obstacles to care access, such as transportation barriers, stigma associated with visiting mental health clinics, personnel shortages, and high costs.  These platforms, especially in mobile formats, can offer remote screening, diagnosis, monitoring, and treatment; facilitate remote training for non-specialist healthcare workers; and enhance online peer-to-peer support and self-care.  Online symptom tracking apps are also available and can be used to prompt patients to share data daily which are analyzed with an artificial intelligence (AI) algorithm to identify patterns and alert providers in real time of any warning signs.

4. Mobilize additional funding to bridge resource gaps

Two main approaches are possible:

• (i) Domestic Resource Mobilization.  An overall projected global slowdown in 2023 (1.7%), in the face of elevated inflation, higher interest rates, reduced investment, and disruptions caused by the war in Ukraine, means that domestic budgets will continue to strain, with challenges across sectors. Active government intervention is needed to mobilize and steer additional domestic resources and incentives for greater social inclusion, including through the sustained funding of universal health coverage.  As part of a broader effort to expand the tax base to collect public revenue from different sources, reform tax administration, and improve budgetary processes and allocations to support human capital development, increasing tax rates to hike up the prices on tobacco, alcohol, and sugary drinks, will help.  Beside contributing to expand fiscal space for priority programs and investments that benefit the entire population, these pro-health taxes will help generate public health benefits reducing consumption of the products and the risk of attributable diseases and injuries.  Elimination of fossil fuel subsidies, which impose large fiscal costs while adding to negative environmental and health impacts, and other wasteful subsidies, will also help to expand fiscal space for health. 

• (ii) Leveraging Existing Funding Streams.  Tapping existing global funding mechanisms for health and human capital development, and private investment in firms and corporations offer “entry points”.  For example:  

• The Pandemic Fund, approved in mid-2022 by the World Bank Group’s Board of Directors, with support from the G20, recognizes the need for coordinated action to build stronger health systems and mobilize additional resources for pandemic prevention, preparedness, and response.

• The Global Financing Facility in Support of Every Woman, Every Child (GFF), to address the critical but often overlooked association between maternal depression and childhood stunting, as part of integrated maternal and child health programs.  

• Multilateral and bilateral investments in education and social protection, could be utilized to respond to the unique needs of youth and other vulnerable groups, using initiatives such as the World Bank Group’s Human Capital Project.  This is an important area as the different dimensions of human capital complement each other, starting at an early age: proper nutrition and stimulation, in-utero and in early childhood, have been shown to improve physical and mental well-being and contribute to the development of cognitive and socioemotional skills.

• Health and wellness programs in the workplace.   Firms and enterprises can catalyze private capital to fund integrated physical and mental health workplace programs as a sound investment, yielding significant benefits for their workers and dependents, and improving productivity and competitiveness.  An international good practice is offered by the World Bank Group, where policies and programs are in place to support individuals’ physical and mental health, including awareness building, prevention, and treatment.  The launching of “Better Together: A Mental Health & Well-Being Strategy for the World Bank Group” on May 4, 2022 was a major step forward to improve the organization’s effectiveness by optimizing the health, both mental and physical, and well-being of its staff by defining key areas of intervention to promote an institution-wide culture of health in the workplace. 

Take Away

As countries address the long-neglected mental health agenda as integrated elements of health services provision, we have to be clear that there are already evidence-based public health interventions, medical treatments, and support therapies to be deployed to alleviate the silent suffering of millions of people across the world.  But political will and commitment to stay the course in the pursuit of universal health coverage, including predictable and sustained funding, and scaled up provision of quality services as a right of the population, are required. 

Failure to act is no longer an option, as the human and social toll of inaction is too high to bear and will imperil our future.

Source of Image: 

Stock Illustration ID: 475941217