2014 MENTAL HEALTH ATLAS World Health ganization
ATLAS MENTAL HEALTH WHO’s Mental Health Atlas series has already established itself as the single most comprehensive and most widely used source of information on the global mental health situation. WHO’s mental health Atlas 2014 provides up-to-date information on the state of mental health services and systems in countries across the world. It covers critical areas of mental health system development, including governance and financing, human resources, service availability and delivery, promotion and prevention, and surveillance. These data serve as a baseline for targets agreed by 194 member states of WHO in the Comprehensive Mental Health Action Plan 2013-2020. ISBN 978 92 4 156501 1 For more information, please contact: Department of Mental Health and Substance Abuse World Health Organization Avenue Appia 20 CH-1211 Geneva 27 Switzerland Email: mhatlas@who.int http://www.who.int/mental_health/ evidence/atlasmnh/
MENTAL HEALTH ATLAS 2014 World health Organization
ATLAS 2014 MENTAL HEALTH
WHO Library Cataloguing-in-Publication Data: The designations employed and the presentation of the material in this publication do not imply the expression of any opinion Mental health atlas 2014 whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area 1. Mental Health Services- statistics. 2. Mental Health Services or of its authorities, or concerning the delimitation of its frontiers atlases. 3. Health Policy -trends. 4.Health Personnel-statistics. or boundaries. Dotted and dashed lines on maps represent 5. Global Health. I World Health Organization approximate border lines for which there may not yet be full sBN9789241565011 NLM classification: WM 17) The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended o world Health Organization 2015 by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions All rights reserved. Publications of the World Health Organization kcepted, the names of proprietary products are distinguished areavailableontheWhowebsitewww.whoint)orcanbe by initial capital letters purchased from WHO Press, World Health Organization, 20 venue Appia, 1211 Geneva 27, Switzerland (tel. +41 22 791 ll reasonable precautions have been taken by the World 3264; fax: +41 22 791 4857; e-mail: bookorders @who. int) Health Organization to verify the information contained in this publication. However, the published material is being distributed Requests for permission to reproduce or translate WHO without warranty of any kind, either expressed or implied. The publications -whether for sale or for non-commercial responsibility for the interpretation and use of the material lies distribution- should be addressed to WHO Press through with the reader. In no event shall the World Health Organization the wHo website be liable for damages arising from its use (www.who.int/about/licensing/copyright_form/en/index.htn Design: Erica Lefstad
WHO Library Cataloguing-in-Publication Data: Mental health atlas 2014. 1.Mental Health Services - statistics. 2.Mental Health Services - atlases. 3.Health Policy - trends. 4.Health Personnel - statistics. 5.Global Health. I.World Health Organization. ISBN 978 92 4 156501 1 (NLM classification: WM 17) © World Health Organization 2015 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Design: Erica Lefstad Printed in France
MENTAL HEALTHATLAS 2014 6 PROJECT TEAMS AND PARTNERS 7 PREFACE 8 EXECUTIVE SUMMARY 12 INTRODUCTION 16 RESULTS 18 1. GLOBAL REPORTING ON CORE MENTAL HEALTH INDICATORS 22 2. MENTAL HEALTH SYSTEM GOVERNANCE 30 3 FINANCIAL AND HUMAN RESOURCES FOR MENTAL HEALTH 38 4. MENTAL HEALTH SERVICE AVAILABILITY AND UPTAKE 46 5. MENTAL HEALTH PROMOTION AND PREVENTION 52 6 COMPARISONS WITH SELECTED MENTAL HEALTH ATLAS 2011 RESULTS 56 REFERENCES 58 APPENDICES 58 APPENDIX A: PARTICIPATING COUNTRIES AND CONTRIBUTORS MENTAL HEALTH SYSTEM GOVERNANCE 64 APPENDIX B: GLOSSARY OF TERMS CONTENTS
CONTENTS 5 6 7 8 12 16 18 22 30 38 46 52 56 58 58 64 PROJECT TEAMS AND PARTNERS PREFACE EXECUTIVE SUMMARY INTRODUCTION RESULTS 1. GLOBAL REPORTING ON CORE MENTAL HEALTH INDICATORS 2. MENTAL HEALTH SYSTEM GOVERNANCE 3. FINANCIAL AND HUMAN RESOURCES FOR MENTAL HEALTH 4. MENTAL HEALTH SERVICE AVAILABILITY AND UPTAKE 5. MENTAL HEALTH PROMOTION AND PREVENTION 6. COMPARISONS WITH SELECTED MENTAL HEALTH ATLAS 2011 RESULTS REFERENCES APPENDICES APPENDIX A: PARTICIPATING COUNTRIES AND CONTRIBUTORS MENTAL HEALTH SYSTEM GOVERNANCE APPENDIX B: GLOSSARY OF TERMS MENTAL HEALTH ATLAS 2014
PROJECT TEAM AND PARTNERS At WHO Headquarters, a team comprising Dan Chisholm Fahmy Hanna and Grazia Motturi provided the central technica leadership and administrative support to the project, includir Atlas is a project of the World Health Organization(WHO development of the questionnaire and an associated Headquarters, Geneva and is supervised and coordinated by completion guide, management of the online data collection Shekhar Saxena. Mental health Atlas 2014 is the latest in a ystem, validation of information and responses, liaison with series of publications that first appeared in 2001, with Member States and WHO regional and country offices, as well subsequent updates published in 2005 and 2011 as analysis of data and preparation of this report. They received inputs and advice from the following colleagues In WHO Member States, key project collaborators were the Natalie Drew, Tarun Dua, Alexandra Fleischmann michelle mental health focal points in Ministries of Health, who provided Funk, Vladimir Poznyak, Chiara Servili, Mark van Ommeren and information and responses to the atlas survey questionnaire Taghi Yasamy. The contribution of Antonio Lora, Peter Ventevogel and to follow-up queries for clarification. a full list of Julian Eaton, Yulia Bakonina, Melissa Harper, Elise Gehring collaborators is provided as Appendix A of this report. Pooja Pradeep, Shelly Chopra and Alessandra Trianni to particular aspects of data collection, processing, or analysis are also Key collaborators from WHO regional offices, who contributed acknowledged to the planning and collation of data and liaised with focal points in Member States, were: Sebastiana Da Gama Nkomo The development of the Atlas 2014 questionnaire was overseen (WHO Regional Office for Africa); Jorge Rodriguez, Devora and approved by an expert group, consisting of Florence Kestel (WHO Regional Office for the Americas); Khalid Saeed Baingana, Harry Minas, Antonio Lora, Crick Lund, Pratap (WHO Regional Office for the Eastern Mediterranean); Matthijs Sharan and Graham Thornicroft. The proposed set of selected Muijen and Elena Shevkun(WHO Regional Office for Europe): indicators were subsequently field-tested in Chile, South Africa, Nazneen Anwar (WHO Regional Office for South East Asia); Vietnam, and for this stage thanks go to Sifiso Phakathi, Xiangdong Wang, Yutaro Setoya and Marie Villanueva (WHo Melvyn Freeman, Alfredo Pemjean, Harry Minas and Ritsuko Regional Office for the Western Pacific The contribution of each of these team members and partners, which has been crucial to the success of this project, is very warmly acknowledged MENTAL HEALTH ATLAS 2014
At WHO Headquarters, a team comprising Dan Chisholm, Fahmy Hanna and Grazia Motturi provided the central technical leadership and administrative support to the project, including development of the questionnaire and an associated completion guide, management of the online data collection system, validation of information and responses, liaison with Member States and WHO regional and country offices, as well as analysis of data and preparation of this report. They received inputs and advice from the following colleagues: Natalie Drew, Tarun Dua, Alexandra Fleischmann, Michelle Funk, Vladimir Poznyak, Chiara Servili, Mark van Ommeren and Taghi Yasamy. The contribution of Antonio Lora, Peter Ventevogel, Julian Eaton, Yulia Bakonina, Melissa Harper, Elise Gehring, Pooja Pradeep, Shelly Chopra and Alessandra Trianni to particular aspects of data collection, processing, or analysis are also acknowledged. The development of the Atlas 2014 questionnaire was overseen and approved by an expert group, consisting of Florence Baingana, Harry Minas, Antonio Lora, Crick Lund, Pratap Sharan and Graham Thornicroft. The proposed set of selected indicators were subsequently field-tested in Chile, South Africa, Vietnam, and for this stage thanks go to Sifiso Phakathi, Melvyn Freeman, Alfredo Pemjean, Harry Minas and Ritsuko Kakuma. The contribution of each of these team members and partners, which has been crucial to the success of this project, is very warmly acknowledged. PROJECT TEAM AND PARTNERS Atlas is a project of the World Health Organization (WHO) Headquarters, Geneva and is supervised and coordinated by Shekhar Saxena. Mental health Atlas 2014 is the latest in a series of publications that first appeared in 2001, with subsequent updates published in 2005 and 2011. In WHO Member States, key project collaborators were the mental health focal points in Ministries of Health, who provided information and responses to the Atlas survey questionnaire and to follow-up queries for clarification. A full list of collaborators is provided as Appendix A of this report. Key collaborators from WHO regional offices, who contributed to the planning and collation of data and liaised with focal points in Member States, were: Sebastiana Da Gama Nkomo (WHO Regional Office for Africa); Jorge Rodriguez, Devora Kestel (WHO Regional Office for the Americas); Khalid Saeed (WHO Regional Office for the Eastern Mediterranean); Matthijs Muijen and Elena Shevkun (WHO Regional Office for Europe); Nazneen Anwar (WHO Regional Office for South East Asia); Xiangdong Wang, Yutaro Setoya and Marie Villanueva (WHO Regional Office for the Western Pacific). 6 MENTAL HEALTH ATLAS 2014
PREFACE WHOs Mental Health Atlas series has already established itself Global targets have been established for each of these objec as the single most comprehensive and most widely used tives to measure collective action and achievement by Member source of global information on mental health situation. This States towards the overall goal of the Action Plan. Atlas is the new edition of Mental Health Atlas, carried out in 2014 mechanism through whi assumes new importance as a repository of mental health global targets, as well as a set of other core mental health indi- information in WHO Member States because it is providing cators, are being collected In collecting this information, the much of the baseline data against which progress towards the mental health Atlas 2014 questionnaire covers critical areas of objectives and targets of the Comprehensive Mental Health mental health system development, including governance and Action Plan 2013-2020 is to be measured. The Action plan financing, human resources, service availability and delivery, contains four objective promotion and prevention, and surveillance (1) To strengthen effective leadership and governance Subsequent to this baseline data collection in 2014, a Mental for mental health Health Atlas survey will be sent to country focal points periodi- cally, so that progress towards meeting the targets of the (2 To provide comprehensive, integrated and responsive Action Plan can be measured over time mental health and social care services in community- (3 To implement strategies for promotion and prevention Dr Shekhar Saxena in mental health Director, Department of Mental Health and Substance Abuse To strengthen information systems, evidence and World Health Organization, Geneva, Switzerland research for mental health PREFACE
Global targets have been established for each of these objectives to measure collective action and achievement by Member States towards the overall goal of the Action Plan. Atlas is the mechanism through which indicators in relation to agreed global targets, as well as a set of other core mental health indicators, are being collected. In collecting this information, the mental health Atlas 2014 questionnaire covers critical areas of mental health system development, including governance and financing, human resources, service availability and delivery, promotion and prevention, and surveillance. 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. Dr Shekhar Saxena Director, Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland WHO’s Mental Health Atlas series has already established itself as the single most comprehensive and most widely used source of global information on mental health situation. 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. The Action Plan contains four objectives: (1) To strengthen effective leadership and governance for mental health (2) To provide comprehensive, integrated and responsive mental health and social care services in communitybased settings (3) To implement strategies for promotion and prevention in mental health (4) To strengthen information systems, evidence and research for mental health PREFACE 7 PREFACE
EXECUTIVE SUMMARY WHO's mental health Atlas project dates back to 2000, when a first ssessment of available mental health resources in WHO Member States was carried out(WHO, 2001). Subsequent updates have been published since then (WHO, 2005: WHO, 2011) The 2014 version of mental health Atlas continues to provide up-to-date nformation on the availability of mental health services and resources across the world, including financial allocations, human resources and t specialised facilities for mental health. This information was obtained via a questionnaire sent to designated focal points in each WHO Member State Latest key findings are presented to the right
8 EXECUTIVE SUMMARY WHO’s mental health Atlas project dates back to 2000, when a first assessment of available mental health resources in WHO Member States was carried out (WHO, 2001). Subsequent updates have been published since then (WHO, 2005; WHO, 2011). The 2014 version of mental health Atlas continues to provide up-to-date information on the availability of mental health services and resources across the world, including financial allocations, human resources and specialised facilities for mental health. This information was obtained via a questionnaire sent to designated focal points in each WHO Member State. Latest key findings are presented to the right
MENTAL HEALTHATLAS 2014 KEY FINDINGS GLOBAL REPORTING ON CORE MENTAL FINANCIAL AND HUMAN RESOURCES FOR HEALTH INDICATORS MENTAL HEALTH 171 out of WHO's 194 Member States(88%)at Levels of public expenditures on mental health are least partially completed the atlas questionnaire very low in low and middle-income countries(less he submission rate exceeded 80% in all WHO than US$ 2 per capita). a large proportion of these Regions funds go to inpatient care, especially mental hospitals a 60% of Member States were able to report on a set of five core indicators that covered mental a Globally, the median number of mental health health policy and law, promotion and prevention yorkers is 9 per 100,000 population, but there is programmes, service availability and mental health extreme variation(from below 1 per 100,000 workforce: population in low-income countries to over 50 in high-income countries a 33% of Member States regularly compile mental health service activity data covering at least the public sector. MENTAL HEALTH SERVICE AVAILABILITY AND UPTAKE MENTAL HEALTH SYSTEM GOVERNANCE a The median number of mental health beds per 100,000 population ranges below five in low and policy or plan for mental health; 51% have a stand income countries; equally large disparities exist for alone mental health law. In many countries, outpatient services and welfare support however, policies and laws are not fully in line with human rights instrumen and persons with mental disorders and family MENTAL HEALTH PROMOTION AND members are only partially involved PREVENTION a 41%of WHO Member States have at least two functioning mental health promotion and prevention programmes: out of more than 400 reported programmes, over half were aimed at improving mental health literacy or combating stigma EXECUTIVE SUMMARY
EXECUTIVE SUMMARY 9 MENTAL HEALTH ATLAS 2014 KEY FINDINGS GLOBAL REPORTING ON CORE MENTAL HEALTH INDICATORS p 171 out of WHO’s 194 Member States (88%) at least partially completed the Atlas questionnaire; the submission rate exceeded 80% in all WHO Regions; p 60% of Member States were able to report on a set of five core indicators that covered mental health policy and law, promotion and prevention programmes, service availability and mental health workforce; p 33% of Member States regularly compile mental health service activity data covering at least the public sector. MENTAL HEALTH SYSTEM GOVERNANCE p 68% of WHO Member States have a stand-alone policy or plan for mental health; 51% have a standalone mental health law. In many countries, however, policies and laws are not fully in line with human rights instruments, implementation is weak and persons with mental disorders and family members are only partially involved. FINANCIAL AND HUMAN RESOURCES FOR MENTAL HEALTH p Levels of public expenditures on mental health are very low in low and middle-income countries (less than US$ 2 per capita). A large proportion of these funds go to inpatient care, especially mental hospitals; p Globally, the median number of mental health workers is 9 per 100,000 population, but there is extreme variation (from below 1 per 100,000 population in low-income countries to over 50 in high-income countries). MENTAL HEALTH SERVICE AVAILABILITY AND UPTAKE p The median number of mental health beds per 100,000 population ranges below five in low and lower-middle income countries to over 50 in highincome countries; equally large disparities exist for outpatient services and welfare support. MENTAL HEALTH PROMOTION AND PREVENTION p 41% of WHO Member States have at least two functioning mental health promotion and prevention programmes; out of more than 400 reported programmes, over half were aimed at improving mental health literacy or combating stigma
EXECUTIVE SUMMARY In a new development, Atlas is also being used to track substantial, suggesting that the global targets can be progress in the implementation of WHO's Mental Health Action successfully reached if progressive development is made in Plan 2013-2020. Specifically, mental health Atlas 2014 is relation to mental health policies, laws, programmes and roviding baseline values for agreed Action Plan targets information systems across WHO Member States. However, further rounds of mental health Atlas will enable monitoring of Atlas 2014 does not provide sufficiently robust data progress towards meeting these targets by the year 2020 to establish a baseline for the target on service coverage Other data sources suggest that the current rate of service Baseline values for the year 2013 are given in the Table to the coverage for severe mental disorders remains low, which right for each of the six Action Plan targets, based on Atlas indicates that substantial additional effort will be needed to 2014 findings. They show that the percentage of countries achieve target 2 on service coverage. ulfilling the condition of these targets is already quite MENTAL HEALTH ATLAS 2014
10 MENTAL HEALTH ATLAS 2014 In a new development, Atlas is also being used to track progress in the implementation of WHO’s Mental Health Action Plan 2013-2020. Specifically, mental health Atlas 2014 is providing baseline values for agreed Action Plan targets; further rounds of mental health Atlas will enable monitoring of progress towards meeting these targets by the year 2020. Baseline values for the year 2013 are given in the Table to the right for each of the six Action Plan targets, based on Atlas 2014 findings. They show that the percentage of countries fulfilling the condition of these targets is already quite substantial, suggesting that the global targets can be successfully reached if progressive development is made in relation to mental health policies, laws, programmes and information systems across WHO Member States. However, Atlas 2014 does not provide sufficiently robust data to establish a baseline for the target on service coverage. Other data sources suggest that the current rate of service coverage for severe mental disorders remains low, which indicates that substantial additional effort will be needed to achieve target 2 on service coverage. EXECUTIVE SUMMARY
MENTAL HEALTHATLAS 2014 MENTAL HEALTH ACTION PLAN 2013-2030: BASELINE VALUES FOR GLOBAL TARGETS Action Plan Objective Action Plan Target Baseline value for 2013 OBJECTIVE 1: Target 1.1: 88 countries, equivalent to 56% of those To strengthen effective leadershi 80% of countries will have developed or updated countries who responded, or 45% of all WHO and governance for mental health their policies or plans for mental health in line Member States. Value is based on a self-rating with international and regional human rights checklist(see Section 2.1 of report) instruments(by the year 2020). Target 1.2: 65 countries, equivalent to 42% of those 50% of countries will have developed or countries who responded, or 34% of all WHO dated their law for mental health in line Member States. Value is based on a self-rating with international and regional human rights checklist(see Section 2.2 of report) instruments(by the year 2020). OBJECTIVE 2. Target 2: Not computable from Atlas 2014 data, but To provide comprehensive, integrated and Service coverage for severe mental disorders will expected to be less than 25%, based on responsive mental health and social care have increased by 20%(by the year 2020). treatment gap and service uptake studies. services in community-based settings OBJECTIVE 3 Target 3.1: 80 countries, equivalent to 48% of those To implement strategies for promotion 80% of countries will have at least two countries who responded, or 41%of all WHO and prevention in mental health functioning national, multisectoral mental health Member States. Value is based on a self- promotion and prevention programmes(by the completed inventory of current programmes year 2020) (see Section 4 of report) Target 3.2: 11. 4 per 100,000 population. Value is based The rate of suicide in countries will be reduced on age-standardized global estimate(see WHO by 10%(by the year 2020) report on suicide, 2014) OBJECTIVE 4 Target 4: 64 countries, equivalent to 42% of those To strengthen information systems, 80% of countries will be routinely collecting and countries who responded, or 33% of all WHO evidence and research for mental health reporting at least a core set of mental health Member States. Value is based on a self-rated indicators every two years through their national ability to regularly compile mental health specific health and social information systems (by the data that covers at least the public sector (see year 2020) Section 1 of report) EXECUTIVE SUMMARY
EXECUTIVE SUMMARY 11 MENTAL HEALTH ATLAS 2014 MENTAL HEALTH ACTION PLAN 2013-2030: BASELINE VALUES FOR GLOBAL TARGETS Action Plan Objective Action Plan Target Baseline value for 2013 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). 88 countries, equivalent to 56% of those countries who responded, or 45% of all WHO Member States. Value is based on a self-rating checklist (see Section 2.1 of report). 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). 65 countries, equivalent to 42% of those countries who responded, or 34% of all WHO Member States. Value is based on a self-rating checklist (see Section 2.2 of report). 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). Not computable from Atlas 2014 data, but expected to be less than 25%, based on treatment gap and service uptake studies. 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) 80 countries, equivalent to 48% of those countries who responded, or 41% of all WHO Member States. Value is based on a selfcompleted inventory of current programmes (see Section 4 of report). Target 3.2: The rate of suicide in countries will be reduced by 10% (by the year 2020). 11.4 per 100,000 population. Value is based on age-standardized global estimate (see WHO report on suicide, 2014). 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). 64 countries, equivalent to 42% of those countries who responded, or 33% of all WHO Member States. Value is based on a self-rated ability to regularly compile mental health specific data that covers at least the public sector (see Section 1 of report)