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A study on the informal economy social policy essay

This article has been cited by other articles in PMC. Introduction This is the second in our series of four articles about mental health and the global agenda. The first paper addressed core conceptual issues in relation to mental health in low- and middle-income countries. The third paper addresses international and national policy challenges to global mental health, 2 while the fourth paper addresses health system challenges to global mental health.

Mental health, poverty and debt Mental disorders impose a significant economic burden, not just on the individuals with the disorders but also on households, communities, employers, healthcare systems and government budgets. While there is abundant research on the economic burden of mental disorders in high-income countries, 45 information on the economic consequences of poor mental health in low- and middle-income countries is limited.

Estimates of these economic costs are likely to be conservative; few take account of the ways in which families mobilise and redirect resources that adversely affect them, worsening and perpetuating socio-economic inequalities.

When aggregated across an economy, these household costs have an important impact on the size and productivity of the labour force and on national income.

Mental disorders perpetuate the cycle of poverty by interfering with the a study on the informal economy social policy essay capacity to function in either paid or non-income roles, leading to decreased social, as well as economic, productivity.

Thus, people with mental health problems are often the poorest of the poor, because neither they nor their family carers may be able to work. Epidemiological studies in low- and middle-income countries increasingly suggest a need for poverty reduction measures: Longitudinal studies in a number of high-income countries demonstrate that untreated mental health and behavioural problems in childhood and youth can have profound longstanding social and economic consequences in adulthood.

These include poorer levels of educational attainment, increased contact with the criminal justice system, reduced employment levels with lower salaries when employed and personal relationship difficulties. Even if a child does receive some schooling, there can be adverse impacts on educational outcomes for children with unrecognised and untreated mental disorders.

There may also be a disruptive impact on classmates. There are also costs for educational systems of children with unrecognised and untreated mental disorders. Poor parental health may also reduce the chances that children come into contact with primary healthcare services, which again may have consequences for their physical and mental health. In summary, although the effects of poor health on poverty are by no means unique to mental illness, their negative impacts are greater than for most acute and chronic illnesses.

These adverse impacts increase the risk of impoverishment for households that fall below the poverty line, and for those already below the poverty line they potentially could lead to starvation. They can also frequently lead to physical illnesses which present to under-resourced primary care services. The need for more health economics research on the cost-effectiveness of actions to address mental illness In spite of the high burden of disease or poor socio-economic outcomes caused by mental illness 17—19 policy makers have not appropriately prioritised investments in mental health in primary care, specialist care or in non-health sectors.

Research to better understand the costs of care, cost-effectiveness of key interventions and relative financing of mental health issues, especially in respect of delivery at the primary care level, is key if new additional funding is to be secured to scale up interventions for addressing mental disorders in low- and middle-income countries.

However, this mode of delivery is not yet the norm in low- and middle-income countries. More research needs to be done, especially in low- and middle-income countries, to demonstrate the costs and benefits of delivering more mental health interventions making use of different organisational and staffing models a study on the informal economy social policy essay primary care services.

The Choosing Interventions that are Cost Effective CHOICE programme led by the World Health Organization has assessed the cost-effectiveness of a wide range of interventions that significantly reduce the burden of disease in a range of epidemiological and geographical settings. Around one-third of the gains would come from managing severe mental disorders, schizophrenia and bipolar disorder, with the most cost-effective interventions being for depression and panic disorder. Benefits of interventions within the education system or support for microcredit and other fair lending schemes to help individuals to avoid falling into unmanageable debt also need to be better understood.

Hence there is an urgent need to assess the cost-effectiveness of prevention and promotion strategies, many of which lie outside the health system and take place for example in the school or work-place. The role of primary healthcare services in liaising with these non-healthcare services also needs careful consideration.

There is also very little research evidence from low- and middle-income countries on how poverty and related socio-economic factors impact on the success of mental health policy and practice.

Research is also needed to demonstrate economic benefits of reduced mortality and morbidity from co-morbid physical health problems in those who are mentally ill.


Other important areas for further economic research and dissemination include, inter alia: Under-diagnosis and ineffective treatment of mental disorders can lead to a high rate of repeat consultations in primary care and in outpatient clinics, placing huge demands on constrained health systems in low-income countries. For example, treatment adherence for TB, HIV and stroke is improved when co-morbid depression is treated.

We now turn to issues of policy development and its implementation, looking at different approaches that have been used, considering how services may be scaled up and looking at the role that primary care can play in this process. This is followed by analysis of steps needed to improve the global architecture for mental health to help support this process.

The need for strategic dialogue around public policy and its implementation To date, three main approaches have been used to improve mental health in low- and middle-income countries. First, the public mental health approach, which focuses on a combination of prevention and treatment of the main categories of mental disorder, as well as their integration into existing health services, particularly primary care.

Second, the human rights approach, which emphasises the de-institutionalisation of people with chronic mental disorders and draws on the traditions in the West, as pioneered in Trieste, Italy in the 1970s and 1980s.

All three approaches are complementary and essential, but need careful implementation, monitoring and evaluation if they are to work effectively. What is most needed is not just greater resources but a careful strategic dialogue and action.

Developing Economies and the Informal Sector in Historical Perspective

Epidemiological transition in low- and middle-income countries means the integration of mental health into health sector reform is crucial to the foundation of functional health systems. Human rights abuses against people with mental disorders are also pervasive in low-income countries, albeit with a different profile from wealthier nations.

Large mental institutions are much less common in SSA than they were in the West, or in the former Soviet Union where they are still widespread. However, the largest human rights issue in SSA related to mental health is the lack of access to any meaningful care.

In low-income countries decentralisation of mental health care to the primary care level would enable better integration of mental health services within the health system, but as we have noted there is limited evidence on how this can be best achieved for mental health or for other high-priority health interventions. Livelihood interventions are increasingly being linked to mental health interventions, as demonstrated by the NGO BasicNeeds UK in Uganda, 27 and to psychosocial interventions such as those offered by the Transcultural Psychosocial Organisation — Uganda 2829 in small pilot projects.

These evaluations should provide much needed evidence on the linkages between mental health and poverty, not just in terms of causation but also in establishing a clearer view of causal links for developing effective interventions.

In both rights-fulfilment and poverty reduction, civil society, particularly through mental health service user movements, has a key role to play, as demonstrated in high-income countries and in other previously neglected disease areas such as HIV. National NGOs tend just to have a presence in the capital city and face unfavourable environments which hinder their ability to scale up interventions. National NGOs are likely to face challenges in ensuring their long-term financial sustainability.

Decentralisation to help improve the effectiveness and client-centredness of planning and service delivery requires appropriate financing at regional, district and primary care a study on the informal economy social policy essay. Regions need a budget to support and supervise district level services, and to engage in intersectoral dialogue, training and service development.

In turn districts need a budget to support and supervise primary care level services and to engage in intersectoral dialogue, training and service development.

  1. Government of Uganda, 2005 52.
  2. The role of primary healthcare services in liaising with these non-healthcare services also needs careful consideration. There may also be a disruptive impact on classmates.
  3. It is relevant to include public mental health in the curricula of all health professionals, certainly of psychiatrists but also of general practitioners and public health physicians. Developing a National Mental Health Policy.

The primary care level needs funds to ensure uninterrupted care delivery and recruitment and retention of the primary healthcare workforce, a study on the informal economy social policy essay well as materials and transport to support and supervise volunteer community health workers to enhance community engagement and intersectoral dialogue at village level.

Potentially the resources required to achieve the above are relatively modest in comparison to the benefits that could be achieved, 2134—36 but careful consideration needs to be given to challenges of implementation in different contexts and settings, including looking at ways in which different actors can be incentivised to work better with each other. What is role of health professionals in scaling up mental health services in primary care? Key to moving towards a more primary care-led mental health system is human resources.

Health professionals such as general practitioners, nurses, public health doctors, psychiatrists, psychiatric nurses and psychologists can play crucial roles within countries for advocacy, leadership, service planning and development, providing support for primary care, intersectoral coordination and training and inclusion of mental health in general district and regional plans. However, especially in low-income countries, their time commitment to publicly funded services is curtailed by the higher monetary rewards from private practice and other income-generating activities.

More realistic remuneration will help partly to address this problem and reduce the brain drain, with professionals being attracted to work in high-income countries. This needs to be combined with attention to the training of students the specialists of the future for leadership roles. It is relevant to include public mental health in the curricula of all health professionals, certainly of psychiatrists but also of general practitioners and public health physicians.

It is particularly important to ensure that students undertaking Masters studies in public health or related sciences are trained in mental health policy, planning and financing.

Public health specialists can develop and run a national mental health programme effectively if they work with psychiatrists, psychiatric nurses, primary care professionals and other stakeholders through a co-ordinating committee. In Uganda, for example, the National Mental Health Coordinator is a public health specialist, and not a psychiatrist; she has been very effective in developing, implementing and over-seeing the mental health programme.

Need for an improved global architecture for mental health Despite compelling evidence on the adverse personal, social and economic impacts of mental illness and the potential benefits that could be gained from readily available cost-effective interventions, appropriate attention to mental health and mental disorders appears to be lacking in most low-income country contexts. The global architecture for mental health is ill-formed, with no effective financing instruments to support implementation of mental health interventions through national health or disease-specific plans.

This has implications for the achievement of the Millennium Development Goals MDGswhich are inextricably linked to mental health.

Recent global initiatives, such as the Global Health Workforce Alliance, which are focusing on strengthening the health workforce, including the training of psychiatrists and psychiatric nurses and their integration into general health careplus the training of community health workers, are providing much-needed resources for mental health training in some countries. However, there is no systematic attempt by the donor community to address health system constraints in relation to mental health.

International donors are discussed in detail in the third article in this series. The new DFID health strategy Working Together for Better Health 37 emphasises the need to strengthen health systems, and efforts such as the International Health Partnership, 38 which aim to better harmonise donor efforts, provide an opportunity to integrate mental health into health systems reform initiatives: DFID-funded projects on the development of mental health policy in Kenya and Tanzania, as well as on mental health reforms in Russia to address situation appraisal, policy development and implementation, have provided much needed evidence on ways in which care delivery can be improved and mental health mainstreamed into health sector reform initiatives.

Serving these people and enabling them to actively participate in society is not only a question of need, but one of human dignity. A human rights approach, supported by the global mental health architecture, as a lever to mental health policy and implementation is addressed in more detail in the final section of this paper.

There is also an opportunity to extend international donor actions, such as DFID-supported general initiatives in relation to health systems, access to medicines Medicines Transparency Alliance MeTA 44 and governance and human rights, to mental health. However, before resources are committed, it is critically important to delineate and understand the architecture for donor-supported global initiatives in relation to mental health, including those currently targeted at mental health and those targeted at physical a study on the informal economy social policy essay or social development but whose efficiency would be strengthened if they also simultaneously addressed mental health.

Primary health care — now more than ever, which strongly reaffirmed the Alma Ata principles of primary health care, including equity, solidarity, social justice, universal access to services, multisectoral action, decentralisation and community participation as the basis for strengthening health systems. This is exactly what is needed for mental health, and there is an opportunity for a critical policy dialogue with the WHO to ensure that mental health is included in all these activities.

Mental health advocates also need to link with other sectors, health initiatives and programmes funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria Global Fundas these three diseases have a considerable burden of associated mental illness.

For example, Zambia has successfully integrated mental health into Global Fund proposals for training of health staff, and Tanzania, Kenya, Uganda and Malawi have integrated mental health into general health service delivery utilising general health service budgets as set out in the national health sector strategic plans and annual operational plans.

These provide good examples of systematic implementation of mental health service delivery within highly resource-constrained environments. Need to strengthen the links between mental health and social development The contribution of better health goes well beyond the reduction of clinical symptoms and disability.

While a renewed approach to mental health in the context of health sector reform is crucial, this needs to be complemented by a multisectoral and multilevel perspective on mental health, to ensure that factors which influence mental wellbeing and its relationship to physical well being, empowerment at family and community levels, livelihoods, workplace productivity, human security and the development of human, social and economic capital are effectively addressed.

An analysis recently explored for the UK in the Foresight project on mental capital and wellbeing shows the importance and benefits of a holistic approach to mental health. It needs to be reflected in structures for planning and financing that can realise an integrative and synergistic role for mental health capacity and expertise across sectors.

Appropriate financing, in line with burden, need and availability of effective interventions, should be allocated to mental health from government, multilateral and bilateral resources, including financing entities such as the Global Fund and philanthropic foundations, for example the mental health training programme for Kenya primary care staff funded by the UK-based Nuffield Trust.

Social, economic, human rights and political challenges to global mental health

The Paris and Accra principles of aid effectiveness commit donors to ensuring country ownership. Exceptions include Uganda, where despite some donor opposition, mental health was included in health policy 49 and in three Health Sector Strategic Plans. While the focus on demonstrating how improved mental health positively impacts on the MDGs globally, DFID and other donors should stress evidence-based policies that foster better prioritisation of mental health.

Country counterparts should be empowered to develop evidence and arguments for the inclusion of mental health in their country health strategies. It is important to learn lessons from targeted communicable disease programmes which have successfully raised large financing and effectively scaled up services for AIDS, tuberculosis and malaria to reach MDGs in many countries.

For example, the Nuffield Trust-funded mental health-related continuing professional development of 3000 primary care workers in Kenya referred to above 4054 is being delivered through the Kenya Medical Training College and the Ministry of Health. The training has a health and social welfare systems approach, with modules that integrate understanding of mental, child and reproductive health, malaria and HIV, health system issues such as health information systems, working with community health workers and traditional healers and annual operational planning.

Human rights as a lever for mental health policy and implementation This is an important lever, which has been effectively used in Western countries, where legal advice is accessible and affordable and where governments have resources to improve services and expand access to mental health services. However, in low- and middle-income countries the effectiveness of the human rights approach in expanding access to mental health services is less evident, partly because of a relative lack of resources and in some countries less democratic systems.

Further, in Western countries the human rights and mental health movement has focused on ending the inhumane incarceration of mentally ill patients in large institutions for long periods of time: Hence there is a difference in the focus of mental health rights activists in high- and middle-income countries and those in low-income countries, unlike other advocacy movements such as those for AIDS, which has clearly benefited from north—south partnerships.