Module 8: Improving Mental Health Care

Goals, Strategies, and Considerations

The World Health Organization (WHO) recommends an “optimal mix of services pyramid”, in which mental health care services that cost the least and are the most frequently needed (e.g. self-care and informal community care) form the base of the pyramid, while more expensive services needed by a smaller fraction of the mentally ill population (e.g. long-term inpatient care facilities) are at the top of the pyramid. To develop this mix of services, the WHO recommends that countries:(1)

Through its Mental Health Global Action Programme (mhGAP), the WHO has proposed multiple strategies to improve mental health care delivery. The four core strategies listed by the mhGAP are:(2)

Implementing the WHO’s recommendations will require investment by the global health community, including governments, donors, multilateral agencies, and consumer groups. Chisholm et al. (2007) investigated the level of investment required to scale up mental health care in 12 countries for which data from the WHO-Assessment Instrument for Mental Health Systems (AIMS) were available. The countries studied included four low-income countries (Ethiopia, Nepal, Nigeria, and Vietnam), seven lower middle-income countries (Albania, China [Hunan province], Iran, Morocco, Paraguay, Thailand, and Ukraine), and one upper middle-income level country (Chile). The researchers chose targets for improvement based upon levels of service coverage for mental illness achieved in high-income countries; targets were set at 80% improvement in coverage of services for people with schizophrenia and bipolar affective disorder, 25% improvement in coverage for hazardous alcohol use services, and 33% improvement for coverage of services for depression. To reach these targets within ten years, total expenditures in the low-income countries would need to rise ten-fold, to about $2 per person per year by 2015, and total expenditure in the lower middle-income countries would need to increase between three-fold and six-fold, to about $3-4 per person per year. This would likely require an “initial period of large-scale investment”, a $0.30-0.50 per person per year spending increase, followed by a gradual increase in spending of about $0.10-0.25 per person per year. Although this model does not include targets for scaling up services for childhood mental disorders, and is based on data from a small sample of countries, it can be adapted by other countries to guide investment in mental health care services.(3) 

Chisholm et al. (2007) emphasize that mental health indicators must be carefully selected to monitor the scaling-up process, to ensure that countries can measure their progress and compare their mental health care status to that of other countries. Chisholm et al. (2007) offer a set of 11 indicators to quantify progress towards four recommended mental health goals:(4)

In addition, the scaling-up process must be accompanied by research funding to investigate the efficiency and effectiveness of treatment and prevention interventions for mental illness. In particular, Chisholm et al. (2007) argue that funding should be concentrated on research efforts to “develop and assess interventions for people with mental disorders that do not need to be delivered by mental health professionals, and to assess how health systems can scale up such feasible and effective interventions across all routine-care settings”.(5) One strategy to scale up mental health interventions in routine-care settings is to integrate mental health care into primary care services. Incorporating aspects of mental health care into the primary care setting is expected to provide a more holistic approach to health care, enable earlier detection and treatment of mental illness, increase ease of access to mental health care, and reduce the stigma associated with seeking psychiatric care.(6) In order to ensure effective and high-quality mental health services, the integration of mental health care into primary care services must be accompanied by adequate resources and specialized education and training for primary health care professionals.

While the WHO’s recommendations for scaling up health care offer a general set of strategies for improvement, nations should implement culturally sensitive strategies for optimal mental health care delivery. For instance, in Japan, where deinstitutionalization began in the mid-2000s, family members have historically played a central role in providing care for relatives with severe mental illness. Due to the extensive involvement of family members in mental health care, assertive community treatment (ACT) has been recommended as an essential component of improving mental health care in Japan. This is partially because ACT provides comprehensive mental health care to patients, thereby lightening the burden of care on families, while allowing family members to remain involved in the care of their relatives.(7)

In conclusion, to improve global access to mental health care, the scaling up of mental health care services must be closely monitored, sensitive to cultural context, accompanied by extensive research, and supported by adequate funding.  


(1) World Health Organization. “The optimal mix of services for mental health”. Mental Health Policy, Planning, & Service Development. Retrieved 2 July 2012.

(2) World Health Organization. 2003. “Investing in Mental Health”. Retrieved 2 July 2012.

(3) Chisholm, D., Flisher, A.J., Lund, C., Patel, V., Saxena, S., Thornicroft, G., Tomlinson, M. (2007). Scale up services for mental disorders: a call for action. Lancet, 370: 1241-1252.

(4) Ibid.

(5) Ibid.

(6) World Health Organization. “Integrating mental health into primary care”. Retrieved 2 July 2012.

(7) Sono, T., Oshima, I., Ito, J. (2008). Family needs and related factors in caring for a family member with mental illness: adopting assertive community treatment in Japan where family caregivers play a large role in community care. Psychiatry and Clinical Neurosciences, 62: 584-590.