INTRODUCTION WHO first produced an Atlas of Mental Health Resources The final proposed set shown below represents the around the world in 2001, with updates produced in 2005 and culmination of this consultation and field-testing process 2011(http.//www.who.int/mental_health/evidence/atlasmnh). nd is made up of the already agreed Action Plan indicators he Atlas project has become a valuable resource on global (shown in green in the summary table) and a complementary information on mental health and an important tool for set of Service development indicators(shown in blue). These developing and planning mental health services within fourteen indicators became the basis for the mental health Atlas questionnaire that was sent to all WHO Member States n mid-2014. Since most of the collate reported on by countries relates to activities or available 2014 UPDATE resources in 2013. the results of this mental Health Atlas survey constitute an appropriate baseline measurement for This new edition of mental Health Atlas, carried out in 2014 the Comprehensive Mental Health Action Plan 2013-2020. assumes new importance as a repository of mental health information in WHO Member States because it is providing Subsequent to this baseline data collection in 2014, a much of the baseline data against which progress towards Mental Health Atlas survey will be sent to country focal the objectives and targets of the Comprehensive Mental points periodically, so that progress towards meeting the Health Action Plan 2013-2020 is to be measured. A total targets of the Action Plan can be measured over time of six global targets have been established for the four objectives of the Action Plan to measure collective action and achievement by Member States towards the overall goal of the Action Plan(see the left-hand section of Table 1 to the right). As stated in the Action Plan, the indicators underpinning the six global targets represent only a subset of the information and reporting needs that Member States require to be able to dequately monitor their own mental health policies and programmes. Thus it was agreed that the WHO Secretaria would prepare and propose a more complete set of indicators for Member States to consider and if approved, use this the basis for data collection and reporting to WHO MENTAL HEALTH ATLAS 2014
12 MENTAL HEALTH ATLAS 2014 INTRODUCTION WHO first produced an Atlas of Mental Health Resources around the world in 2001, with updates produced in 2005 and 2011 (http://www.who.int/mental_health/evidence/atlasmnh). The Atlas project has become a valuable resource on global information on mental health and an important tool for developing and planning mental health services within countries. 2014 UPDATE This new edition of Mental Health Atlas, carried out in 2014, assumes new importance as a repository of mental health information in WHO Member States because it is providing much of the baseline data against which progress towards the objectives and targets of the Comprehensive Mental Health Action Plan 2013-2020 is to be measured. A total of six global targets have been established for the four objectives of the Action Plan to measure collective action and achievement by Member States towards the overall goal of the Action Plan (see the left-hand section of Table 1 to the right). As stated in the Action Plan, the indicators underpinning the six global targets represent only a subset of the information and reporting needs that Member States require to be able to adequately monitor their own mental health policies and programmes. Thus it was agreed that the WHO Secretariat would prepare and propose a more complete set of indicators for Member States to consider and if approved, use this as the basis for data collection and reporting to WHO. The final proposed set shown below represents the culmination of this consultation and field-testing process, and is made up of the already agreed Action Plan indicators (shown in green in the summary table) and a complementary set of Service development indicators (shown in blue). These fourteen indicators became the basis for the Mental Health Atlas questionnaire that was sent to all WHO Member States in mid-2014. Since most of the collated data that has been reported on by countries relates to activities or available resources in 2013, the results of this Mental Health Atlas survey constitute an appropriate baseline measurement for the Comprehensive Mental Health Action Plan 2013-2020. Subsequent to this baseline data collection in 2014, a Mental Health Atlas survey will be sent to country focal points periodically, so that progress towards meeting the targets of the Action Plan can be measured over time
MENTAL HEALTHATLAS 2014 TABLE 1: CORE MENTAL HEALTH INDICATORS BY MENTAL HEALTH ACTION PLAN OBJECTIVE AND TARGET Action Plan Objective Action Plan Target Action plan Indicators Service development indicators OBJECTIVE 1 Target 1.1 80%of countries will have Existence of a national policy/plan Financial resources: Government To strengthen effective developed or updated their policies for mental health that is in line with health expenditure on mental health leadership and governance for plans for mental health in line international and regional human mental health with international and regional rights instrumen human rights instruments(by the Human resources: Number of year 2020) mental health workers 50% of countries will have Existence of a national law covering 2c leveloped or updated their law mental health that is in line with Capacity building: Number and for mental health in line with international and regional human proportion of primary care staff international and regional human rights instruments trained in mental health ights instruments (by the year 2020 OBJECTIVE 2 Target 2 Participation of associations of Service coverage for severe mental Number and propor tion of persons persons with mental disorders and To provide comprehensive disorders will have increased by with a severe mental disorder who family members in service planning integrated and responsive 20%(by the year 2020) received mental health care in the and development mental health and social care services in community-based 2 Service availability: Number OBJECTIVE 3: Target 3.1: 3.1 of mental health care facilities at 80% of countries will have at Functioning programmes of different levels of service delivery To implement strategies for least two functioning national multisectoral mental health promotion and prevention in multisectoral mental health promotion and prevention in 2f mental health promotion and prevention Inpatient care: Number and programmes(by the year 2020) proportion of admissions for severe mental disorders to inpatient mental Target 3.2: 3.2. health facilities that a)exceed one The rate of suicide in countries will Number of suicide deaths per year year and b)are involuntary e reduced by 10%(by the year OBJECTIVE 4. Target 4: Service continuity: Number 80% of countries will be routinely Core set of mental health indicators of persons with a severe mental To strengthen information collecting and reporting at least routinely collected and reported disorder discharged from a mental systems, evidence and research a core set of mental health every two years or general hospital in the last year for mental health indicators every two years through ho were followed up within one their national health and social month by community-based health information systems(by the year services persons with a severe mental nts or income support INTRODUCTION
INTRODUCTION 13 MENTAL HEALTH ATLAS 2014 TABLE 1: CORE MENTAL HEALTH INDICATORS, BY MENTAL HEALTH ACTION PLAN OBJECTIVE AND TARGET Action Plan Objective Action Plan Target Action Plan Indicators Service development indicators OBJECTIVE 1: To strengthen effective leadership and governance for mental health Target 1.1: 80% of countries will have developed or updated their policies or plans for mental health in line with international and regional human rights instruments (by the year 2020). 1.1. Existence of a national policy/plan for mental health that is in line with international and regional human rights instruments 2a. Financial resources: Government health expenditure on mental health 2b. Human resources: Number of mental health workers 2c. Capacity building: Number and proportion of primary care staff trained in mental health 2d. Stakeholder involvement: Participation of associations of persons with mental disorders and family members in service planning and development 2e. Service availability: Number of mental health care facilities at different levels of service delivery 2f. Inpatient care: Number and proportion of admissions for severe mental disorders to inpatient mental health facilities that a) exceed one year and b) are involuntary 2g. Service continuity: Number of persons with a severe mental disorder discharged from a mental or general hospital in the last year who were followed up within one month by community-based health services 2h. Social support: Number of persons with a severe mental disorder who receive disability payments or income support Target 1.2: 50% of countries will have developed or updated their law for mental health in line with international and regional human rights instruments (by the year 2020). 1.2. Existence of a national law covering mental health that is in line with international and regional human rights instruments OBJECTIVE 2: To provide comprehensive, integrated and responsive mental health and social care services in community-based settings Target 2: Service coverage for severe mental disorders will have increased by 20% (by the year 2020). 2. Number and proportion of persons with a severe mental disorder who received mental health care in the last year OBJECTIVE 3: To implement strategies for promotion and prevention in mental health Target 3.1: 80% of countries will have at least two functioning national, multisectoral mental health promotion and prevention programmes (by the year 2020) 3.1. Functioning programmes of multisectoral mental health promotion and prevention in existence Target 3.2: The rate of suicide in countries will be reduced by 10% (by the year 2020). 3.2. Number of suicide deaths per year OBJECTIVE 4: To strengthen information systems, evidence and research for mental health Target 4: 80% of countries will be routinely collecting and reporting at least a core set of mental health indicators every two years through their national health and social information systems (by the year 2020). 4. Core set of mental health indicators routinely collected and reported every two years
INTRODUCTION METHODOLOGY STAGE 2: QUESTIONNAIRE DISSEMINATION AND SUBMISSION The Mental Health Atlas project required a number of In the respective countries, WHO headquarters together wit administrative and methodological steps, starting from the WHO regional and country offices requested ministries of development of the questionnaire and ending with the health or other responsible ministries to appoint a focal point statistical analyses and presentation of data. The sequence to complete the Atlas questionnaire. The focal point was of steps followed was in line with that pursued in 2011 encouraged to contact other experts in the field to obtain is briefly outlined belot information relevant to answering the survey questions Close contact with the focal points was maintained during the course of their nomination and through questionnaire STAGE 1: QUESTIONNAIRE DEVELOPMENT submission. Staff members at WHO headquarters and regional AND TESTING offices were available to respond to enquiries to provide additional guidance, and to assist focal points in filling out As described above, the selection of indicators to be included the atlas questionnaire. The atlas questionnaire was available in the questionnaire was based on consultations with Member on-line, and countries were strongly encouraged to use this States, and developed in collaboration with WHO regional method for submission. However an off-line version of the offices as well as experts in the area of mental health care questionnaire was available whenever preferred measurement. a draft version of the questionnaire was piloted in two countries, and also sent to Regional Advisors for Mental Health as well as other experts for their feedback The questionnaire was modified based on this feedback. the STAGE 3: DATA CLARIFICATION, CLEANING questionnaire was drafted in English and translated into three AND ANALYSIS official United Nations languages-French, Russian and Spanish. The final version sent to countries for completion Once a completed questionnaire was received, it was canbefoundatthementalhealthAtlaswebsite(http://www.screenedforincompleteandinconsistentanswersToensure who. int/mental_health/evidence/atlasmnh) Alongside the high quality data, respondents were contacted again and were questions, a completion guide was developed to help asked to respond to the requests for clarification and to correct standardize terms and to ensure that the conceptualization their responses definition of resources were understood by all respondents a glossary of terms was also developed and shared with Upon receipt of the final questionnaires, data were aggregated, respondents(see Appendix B) analysed and are reported both by WHO region and by World Bank income group. For some sections, for example those dealing with availability of human and financial resources, reporting by income group is more informative, while for others (such as governance) the primary reporting is by WHO region. As of 1 July 2014, low-income economies are defined as those with a gross national income(GNi) per capita of $1,045 or less in 2013; middle-income economies are those with a GNi per capita of more than $1,045 but less than $12, 746: high-income economies are those with a gNi per capita of $12, 746 or more Lower-middle-income and upper-middle- income economies are separated at a gNi per capita of $4, 125. Lists of countries at Appendix A Frequency distributions and measures of y by WHO region and by World Bank income group are provide central tendency were calculated as appropriate for these country groupings. Rates per 100,000 population were calculated for certain data points, using official UN population estimates for 2013 MENTAL HEALTH ATLAS 2014
14 MENTAL HEALTH ATLAS 2014 METHODOLOGY The Mental Health Atlas project required a number of administrative and methodological steps, starting from the development of the questionnaire and ending with the statistical analyses and presentation of data. The sequence of steps followed was in line with that pursued in 2011, and is briefly outlined below. STAGE 1: QUESTIONNAIRE DEVELOPMENT AND TESTING As described above, the selection of indicators to be included in the questionnaire was based on consultations with Member States, and developed in collaboration with WHO regional offices as well as experts in the area of mental health care measurement. A draft version of the questionnaire was piloted in two countries, and also sent to Regional Advisors for Mental Health as well as other experts for their feedback. The questionnaire was modified based on this feedback. The questionnaire was drafted in English and translated into three official United Nations languages – French, Russian and Spanish. The final version sent to countries for completion can be found at the mental health Atlas website (http://www. who.int/mental_health/evidence/atlasmnh). Alongside the questions, a completion guide was developed to help standardize terms and to ensure that the conceptualization or definition of resources were understood by all respondents. A glossary of terms was also developed and shared with respondents (see Appendix B). STAGE 2: QUESTIONNAIRE DISSEMINATION AND SUBMISSION In the respective countries, WHO headquarters together with WHO regional and country offices requested ministries of health or other responsible ministries to appoint a focal point to complete the Atlas questionnaire. The focal point was encouraged to contact other experts in the field to obtain information relevant to answering the survey questions. Close contact with the focal points was maintained during the course of their nomination and through questionnaire submission. Staff members at WHO headquarters and regional offices were available to respond to enquiries, to provide additional guidance, and to assist focal points in filling out the Atlas questionnaire. The Atlas questionnaire was available on-line, and countries were strongly encouraged to use this method for submission. However, an off-line version of the questionnaire was available whenever preferred. STAGE 3: DATA CLARIFICATION, CLEANING AND ANALYSIS Once a completed questionnaire was received, it was screened for incomplete and inconsistent answers. To ensure high quality data, respondents were contacted again and were asked to respond to the requests for clarification and to correct their responses. Upon receipt of the final questionnaires, data were aggregated, analysed and are reported both by WHO region and by World Bank income group. For some sections, for example those dealing with availability of human and financial resources, reporting by income group is more informative, while for others (such as governance) the primary reporting is by WHO region. As of 1 July 2014, low-income economies are defined as those with a gross national income (GNI) per capita of $1,045 or less in 2013; middle-income economies are those with a GNI per capita of more than $1,045 but less than $12,746; high-income economies are those with a GNI per capita of $12,746 or more. Lower-middle-income and upper-middle-income economies are separated at a GNI per capita of $4,125. Lists of countries by WHO region and by World Bank income group are provided at Appendix A. Frequency distributions and measures of central tendency were calculated as appropriate for these country groupings. Rates per 100,000 population were calculated for certain data points, using official UN population estimates for 2013. INTRODUCTION
MENTAL HEALTHATLAS 2014 LIMITATIONS Finally, it is important to acknowledge the limitations associated with self-reported data, particularly in relation to A number of limitations should be kept in mind when qualitative assessments or judgements (often being made by examining the results a single focal point). For example, respondents were asked to provide an informed categorical response concerning th While best attempts have been made to obtain information implementation of mental health policies and laws, and from countries on all variables, some countries could not heir conformity with international (or regional) human rights provide data for a number of indicators. The most common instruments For some of these items it is possible to compare for the missing data is that such data simply do not elf-reported responses to publicly available information(such exist within the countries. Also, in some cases it was difficult as a published mental health policy or budget for a country for countries to report the information in the manner specifically but in other cases the opportunity for external validation is requested in the Atlas questionnaire. For example, some more limited countries had difficulty providing information about the mental health budget in the requested format because mental health Project Atlas is an on-going activity of the WHO. As more care in their country is integrated within the primary care accurate and comprehensive information covering al system, or is broken down using different expenditure or aspects of mental health resources become available and conc are devolved down to the sub-national level, which can greatly refined, it is expected that the database will also become complicate the estimation of consolidated expenditures at a better organized and more reliable. For example, an increasing federal level. There were similar difficulties experienced in umber of countries are implementing the WHO System of relation to the estimation of service use or uptake and also the Health Accounts 2011, which holds out the prospect of better extent of social care and welfare support for persons with estimation of government mental health expenditures. While severe or other mental disorders. The extent of missing data it is clear that, in many cases, countries' information systems can be determined from the number of countries that have o re weak, it is hoped that the atlas may serve as a catalyst have not been able to supply details. Each individual table or for further development by demonstrating the utility of such figure contains the number of countries able to respond to an information for national planning, monitoring and evaluation total of 194 WHO Member States A further limitation is that most of the information provide relates to the country as a whole, thereby overlooking potentially important variability within countries concerning, for example, the degree of policy implementation, the availability of services and the existence of promotion or pre evenson programmes in remote or rural areas versus urban areas Similarly, few of the reported data can provide a breakdown by age or gender, despite the place that equality of access and universal health coverage has in the articulation of the Comprehensive Mental Health Action Plan 2013-2020. This makes it difficult to assess resources for particular populations within a country such as children, adolescents, or the elderly (although such information was secured in relation to mental health promotion and prevention programmes) INTRODUCTION
INTRODUCTION 15 MENTAL HEALTH ATLAS 2014 LIMITATIONS A number of limitations should be kept in mind when examining the results. While best attempts have been made to obtain information from countries on all variables, some countries could not provide data for a number of indicators. The most common reason for the missing data is that such data simply do not exist within the countries. Also, in some cases it was difficult for countries to report the information in the manner specifically requested in the Atlas questionnaire. For example, some countries had difficulty providing information about the mental health budget in the requested format because mental health care in their country is integrated within the primary care system, or is broken down using different expenditure or disease categories. Also, in some countries, health budgets are devolved down to the sub-national level, which can greatly complicate the estimation of consolidated expenditures at a federal level. There were similar difficulties experienced in relation to the estimation of service use or uptake and also the extent of social care and welfare support for persons with severe or other mental disorders. The extent of missing data can be determined from the number of countries that have or have not been able to supply details. Each individual table or figure contains the number of countries able to respond to an item of the questionnaire, or the equivalent percent (out of a total of 194 WHO Member States). A further limitation is that most of the information provided relates to the country as a whole, thereby overlooking potentially important variability within countries concerning, for example, the degree of policy implementation, the availability of services and the existence of promotion or prevention programmes in remote or rural areas versus urban areas. Similarly, few of the reported data can provide a breakdown by age or gender, despite the place that equality of access and universal health coverage has in the articulation of the Comprehensive Mental Health Action Plan 2013-2020. This makes it difficult to assess resources for particular populations within a country such as children, adolescents, or the elderly (although such information was secured in relation to mental health promotion and prevention programmes). Finally, it is important to acknowledge the limitations associated with self-reported data, particularly in relation to qualitative assessments or judgements (often being made by a single focal point). For example, respondents were asked to provide an informed categorical response concerning the implementation of mental health policies and laws, and their conformity with international (or regional) human rights instruments. For some of these items it is possible to compare self-reported responses to publicly available information (such as a published mental health policy or budget for a country), but in other cases the opportunity for external validation is more limited. Project Atlas is an on-going activity of the WHO. As more accurate and comprehensive information covering all aspects of mental health resources become available and the concepts and definitions of resources become more refined, it is expected that the database will also become better organized and more reliable. For example, an increasing number of countries are implementing the WHO System of Health Accounts 2011, which holds out the prospect of better estimation of government mental health expenditures. While it is clear that, in many cases, countries’ information systems are weak, it is hoped that the Atlas may serve as a catalyst for further development by demonstrating the utility of such information for national planning, monitoring and evaluation
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16 RESULTS