In 1959, WHO warned that efforts to have the mentally ill treated as other sick people who can be cured are likely to remain fruitless as long as the irrational fear of madness is not conquered and as long as all the influential members of the social hierarchy believe that mental health is the business of specialists rather than a concern of the whole community (Brundtland, 2001a).
Unfortunately, some 44 years later, Project Atlas, a database of WHO's Department of Mental Health and Substance Dependence, shows that 41% of 185 countries do not have a national mental health policy and 25% of 170 countries have no legislation on mental health care (WHO, 2002b). In fact, in 15% of countries worldwide mental health laws operate that are at least 40 years old (Thornicroft and Maingay, 2002). In addition, 44% of 184 countries do not have an epidemiological study or data collection system in mental health.
Several societal factors hinder the development of mental health policies. Development of such policies in India, for example, has been circumscribed by an extremely limited number of mental health care professionals, a very limited mental health care service infrastructure (about 30,000 psychiatric beds for a billion population), problems of poverty and only 60% literacy (Murthy, 2003).
Financing of mental health programs is a significant obstacle. The majority of Latin American countries "devote less than 2% of their total health budget to mental health," according to Alarcon (2003), "thus compounding a dismal picture already affected by everyday stress of all kinds (from massive internal migrations to a 'hidden epidemic' of domestic violence or from socio-political unrest to the ever-present risk of natural disasters)."
Like funding, mental health resources are in short supply. Often, the resources and services are 1% to 10% of what is needed (Brundtland, 2001a).
Throughout the world, a wide disparity exists in the type and numbers of the mental health workforce. In low-income countries, the median number of psychiatrists is 0.06 per 100,000 population and the median number of psychiatric nurses is 0.1 per 100,000. In high-income countries, the median number of psychiatrists is nine per 100,000 population and the median number of psychiatric nurses is 33.5 per 100,000 (WHO, 2001). Yet, nearly one-half of the world's population has access to one psychiatrist or less per 100,000 population; some countries (e.g., Bangladesh and Nigeria) may have access to less than one psychiatrist for every 1 million people (WHO, 2001). By comparison, the United Kingdom has one adult psychiatrist per 50,000 and the former Soviet Union has one psychiatrist per 10,000 to 20,000 (Jenkins, 2003). In Latin America, "the estimated figures of 1.6 psychiatrists, 2.7 psychiatric nurses, 2.8 psychologists and 1.9 social workers per 100,000 are far below those of Europe or the United States" (Alarcon, 2003). Some thought has been given to training traditional healers, the primary source of assistance for some 80% of rural inhabitants in developing countries, as case finders and referral sources (WHO, 2001).
Equally disturbing is the scarcity of psychotropic medications. According to WHO, at least one-fourth of countries do not have the three most commonly prescribed medications used to treat schizophrenia, depression and epilepsy at the primary care level. In Latin America, most of the countries have policies related to the supply and provision of psychotropic agents, yet more than one-third experience significant problems in implementing those policies (Alarcon, 2003). In many low-income countries, nurses are likely to be given the responsibility for prescribing and managing medicines, so it is important to make sure that they receive basic training and continuing education program support.
Although it is widely accepted that community care generally is more effective, as well as more humane, than inpatient stays in mental hospitals, community care facilities have yet to be developed in about half the countries in the African, Eastern Mediterranean and Southeast Asian regions. In other regions, these facilities are absent in at least one-third of the countries. Nearly two-thirds of the world's psychiatric beds are still in psychiatric hospitals (WHO, 2002a).
As this brief introduction indicates, the challenges are daunting, but many organizations and governments are forging partnerships and initiating change. In 2001, WHO devoted both its annual health day and annual health report to mental health. The report reviewed the burden of mental disorders and the principal contributing factors, looking at service provision and planning, obstacles to treatment, prevention approaches, and recommendations for change. As a follow-up, WHO created the Mental Health Global Action Program, a five-year, $34 million program aimed at building strategic partnerships "for sustainable capacity building for mental health action in countries." The International Mental Health Consortium is working to identify reasons for the success and failure in mental health care reform and to develop the key elements of a national mental health care policy (Abas et al., 2003). The European Commission has produced a public health framework for mental health (Jenkins, 2003; Lavikainen et al., 2001). Through its involvement and collaboration on scientific meetings throughout the world and its many publications, the World Psychiatric Association promotes the dissemination of scientific information.
Enormous progress is possible when health care professionals, international and national organizations, patients/consumers, advocacy groups, governments and media commit to proactive strategies to secure real gains in mental health care.