6. Strong leadership and good governance
Strong leadership and good governance can make mental health a priority, set an ambitious direction of travel for the overall mental health system, and marshal often-scarce resources. This chapter looks at the steps OECD countries are taking to make mental health a high level policy priority, invest in delivering a high-performing mental health system, and effectively distributing resources for mental health.
Strong leadership and good governance can make mental health a priority, set an ambitious direction of travel for the overall mental health system, and marshal often-scarce resources. Following the OECD Mental Health Performance Framework, strong leadership and good governance are a key part of a high performing mental health system, underpinned by making mental health a high-level national priority. Investing in delivering a high-performing mental health system, and prioritising efficient and effective distribution of resources, are also priorities. Finally, taking steps at the national level to promote equity geographically, between population groups, and between mental disorders is a primary function of good mental health governance.
Across OECD countries, governments and leaders have been paying more attention to the importance of mental health, in line with many of the principles of the OECD Framework. Such prioritisation, and public leadership by high-profile national figures, can make a big difference to awareness and stigma around mental health, especially when accompanied by targeted messaging. Most OECD countries also have anti-stigma campaigns in place, which though difficult to measure, have in some instances reduced negative attitudes around mental illness, and increased mental health literacy. High-level strategies to transform the mental health landscape, in some cases backed by new funding commitments, have been made in a handful of countries. Nonetheless, on average increasing attention does not appear to have been matched with increasing overall resources for mental health; mental health spending has risen over time, but no faster than overall health spending. At the same time, the mental health sector has been slow to adopt efficiency measures and payment innovation that have become relatively commonplace elsewhere in health systems, and understanding and assessing effective distribution of mental health resources is extremely challenging. While improving the efficiency of resource use can be challenging, many countries are taking steps to try and improve the equity of available resources, especially between key population groups.
“Strong leadership and good governance” is one of the six principles of a high-performing mental health system established by the OECD Mental Health Performance Framework (OECD, 2019[1]). Strong leadership and good governance involve clearly prioritising mental health, setting an ambitious direction of travel for mental health, and marshalling available resources to best deliver a high performing mental health system. Specifically, “strong leadership and good governance” includes five sub-principles:
Invest in delivering a high-performing mental health system;
Promote equity geographically between population groups and between mental disorders.
Making mental health a high-level priority is critical to changing attitudes and awareness
Good governance and leadership in OECD countries is crucial to drive changes in structures and planning for mental health, to prioritise mental health in national policy agendas, and to commit to funding to drive mental health improvements. Strong leadership when it comes to mental health is crucial, too, as part of increasing awareness of the importance of mental health and reducing stigma around mental ill-health.
Attention to mental health from governments, society, news and media, has clearly increased over the past decade. Momentum has been building across OECD countries, and indeed globally, when it comes to mental health:
In 2013, mental health was included in Goal 3 of the Sustainable Development Goals (SDGs), a recognition that the promotion of mental health and well-being are priorities within the global development agenda (United Nations, 2015[2]);
In 2015, OECD countries all signed up to the Recommendation of the OECD Council on Integrated Mental Health, Skills and Work Policy;
In September 2018, at the Third UN High-level Meeting on Non-communicable Diseases, mental disorders were recognised by the WHO as one of the major drivers of death and disability (WHO, 2018[3])
In October 2018, at the first Global Ministerial Mental Health Summit on 10 October 2018, the Declaration on Achieving Equality for Mental Health in the 21st Century concluded that Ministers: “welcome the vision and leadership already shown by some countries in building political sponsorship and momentum at the highest levels of government to address mental health challenges at the global and local level. We commit to harnessing this momentum to further the improvement of mental health promotion, prevention and service provision around the world.” (The Global Ministerial Mental Health Summit, 2018[4]).
This high-level, public-facing prioritisation can make a big difference when it comes to mental health. Mental health has been historically under-prioritised in OECD countries – for example as measured by percentage of health spend relative to burden of disease – and has been, and continues to be, surrounded by significant degrees of stigma (Hewlett and Morgan, 2014[5]; WHO, 2013[6]; WHO Europe, 2015[7]). Changing the place given to mental health in government and international strategies, and in public discourse, are leadership functions that can make a big difference symbolically, and – when backed with appropriate policies and resources – contribute to improving mental health performance.
Are OECD countries making mental health a high-level national priority?
OECD governments have been leading the discourse on improving mental health
Across the world, public figures and celebrities have increasingly been speaking out about their experiences of mental ill-health. The former Prime Minister of Norway Kjell Magne Bondevik became the highest ranking political leader to speak publicly about his own mental illness while in office; Lady Gaga’s ‘Born This Way Foundation’ is committed to supporting the well-being of young people; while the Dukes and Duchesses of Cambridge and of Sussex lead the ‘Heads Together’ campaign to change views on mental health in the United Kingdom and beyond.
At the national level, some OECD Governments have been putting mental health at the centre of not just their health portfolio, but their government and leaders’ portfolios. Speeches focused on mental health from government leadership are one way of signalling importance, and have particular weight given the longstanding stigma associated with mental health (Figure 6.1). Some government administrations have made a focus on mental health a central priority for their mandate. In 23 countries out of 29 OECD countries who responded to the OECD Mental Health Policy Questionnaire, the Prime Minister, President or Minister of Health made a major speech on mental health in the previous year, and in a number of countries the President or Prime Minister had made a major speech on mental health (OECD, 2020[8]).
For example, in 2019, the Prime Ministers of Australia and Canada gave major speeches on mental health announcing new policies and stressing the importance of talking about mental health issues. In Australia, in 2019 Prime Minister Scott Morrison gave a significant speech focusing on student mental health. The speech pointed out that although more than 20% of student have mental health issues, only few would seek help, and more than 50% of students felt embarrassed to talk about mental health issues. The Prime Minister’s speech focused on highlight the mental health support structures that are available to students, and how important it was for students to ask for help if they need it (SBS NEWS, 2019[9]). In Canada, for mental health week in May 2019, the Prime Minister encouraged people to talk more about mental health, stressed that mental health problems can happen to anyone, and that talking about mental health problems more is a critical part of reducing stigma (Prime Minister of Canada, 2019[10]). Canada’s Minister of Health also co-launched the Alliance of Champions for Mental Health and Well-being (the Alliance) with Ministers of Health from Australia and the United Kingdom in May 2018. The Alliance is a coalition of Ministers who collectively amplify the importance of mental health globally and commit to advancing the global mental health agenda through both domestic and international actions. In France, a national roadmap has been started to develop a global strategy for mental health, the French President Emmanuel Macron announced that the ‘Assises de la santé mentale et de la psychiatrie’, a broad national consultation about the future of mental health, mental health care and psychiatry in France, would be held in the summer of 2021.
On average, the share of mental health spending remains low
There remain significant methodological challenges in collecting and comparing mental health spending, in particular scope of what services are included, whether all age groups are included, whether dementia is included, and whether government expenditure or all expenditure is included. Despite these methodological challenges the range in levels of mental health spending is clear; in 2018, mental health spending ranged from around 4% of total health spending (in Estonia, Greece and Poland) to 13.5% in Norway and 15% in France (Figure 6.2). Governments also spend only a small percentage of their health budget on mental health in many countries; in 10 countries less than 5% of spending on health went towards mental health spending. Only five countries (United Kingdom, Canada, Germany, Norway, France) reported spending more than 10% of health spending on mental health.
Note: Reporting methods differ by country, including the range of services covered and whether spending can be disaggregated by age. Therefore, caution should be taken in comparing spending across countries.
1. Includes dementia; 2. Data for England; 3. WHO Atlas 2017 – Percentage of total government health expenditure.
Source: OECD (2020[8]), “Total expenditure on mental health care as a percentage of total health spending “, OECD Mental Health Performance Benchmarking Questionnaires; WHO (2018[11]), “Government’s total expenditure on mental health as percentage of total government health expenditure”, WHO Mental Health Atlas 2017.
Are countries ensuring mental health literacy, and reducing stigma around mental illness?
Stigma is a major barrier to help-seeking, and an additional burden for persons living with a mental health condition
Stigma – labelling, stereotyping thoughts, prejudice, and discrimination (Link and Phelan, 2001[12]) – includes stigmatising attitudes or behaviours in society towards those with mental health issues, as ‘self-stigmatisation’ or ‘internalised stigma’ whereby people may have a negative view of mental health conditions that reduces help-seeking and leads people to ‘hide’ their mental health condition. Indeed, stigma attached to mental health issues is one of the most significant barriers to help-seeking (Clement et al., 2015[13]; Thornicroft, 2008[14]).
High levels of internalised stigma have also been found to reduce adherence to treatment and reduce openness to therapeutic interventions, and even reduce the efficacy of some treatments (Shrivastava, Johnston and Bureau, 2012[15]; Kamaradova et al., 2016[16]; Ansari et al., 2020[17]; Rüsch et al., 2009[18]). In Slovenia, for example, it is reported that only 41.5% of those with psychological problems had sought professional help, a treatment gap that may well be exacerbated by stigma around to mental health issues (Roskar et al., 2017[19]). Common stigma measures include the Social Distance scale (SD), Opinions about Mental Health Illness (OMI), Community Attitudes towards Mental Illness (CAMI, a modified version of OMI), Devaluation-Discrimination (DD), and Depression Stigma scale (DSS, also called Personal and Perceived Stigma of Mental Illness) amongst others (Wei et al., 2015[20]).
Stigma around mental ill-health also contributes to discriminatory attitudes in society, in workplaces, and even in the health system (Thornicroft, 2008[14]; OECD, 2015[21]; OECD, 2015[22]). Lack of understanding around mental health condition can lead to negative stereotypes of mental illness in the media, to reluctance by employers to talk about mental health in the workplace or hire someone with a mental health condition, or even to rejection of someone living with mental illness by their family or friends. Stigma around mental illness can contribute to resistance from communities to having mental health services in their local area. Stigma towards mental ill-health by health care providers also contributes to lower quality of care worse physical health outcomes for people living with a mental health condition (Knaak, Mantler and Szeto, 2017[23]; Henderson et al., 2014[24]).
Stigma, and efforts to reduce stigma, are also closely linked to mental health literacy, which is discussed in Chapter 5 of this report.
Reducing mental health stigma is a priority in OECD countries
Many OECD countries have introduced anti-stigma campaigns around mental health, either at a national or regional level (Table 6.1).
In Australia, to improve the knowledge and attitude on depression, the public awareness activities were organised by the National Depression Initiative, Beyond Blue. This included distributed posters and pamphlet, and a website with information, and TV advertisement.
In Canada, the Mental Health Commission of Canada has a number of programs related to reducing stigma and increasing mental health literacy, including ‘Opening Minds’ and ‘Mental Health Champions’, as well as ‘Mental Health First Aid’ which is a mental health awareness and response training programme. In addition, Bell Let’s Talk is a national level private sector programme aimed at reducing stigma and increasing awareness of mental health issues.
Several countries have anti-stigma campaigns which are implemented locally by municipal or local governments, for example Denmark with the ‘En af Os’ (One of Us) campaign that has been running since 2010. This campaign is organised nationally and regional Psychiatric Information Centres (PsykInfos) works closely with the One of Us staff. The One of Us project focuses on several populations including young people, working-aged people, health care workers, and media. They have provided learning opportunities and materials to educational institutions, workplaces, and journalists to raise awareness of mental health issue because lack of knowledge is one of the important causes of stigmatisation. For example, mass media has a huge impact on stereotypes by providing negative images on those with mental health problems. To improve mental health literacy among journalists, One of Us provides educational materials and information to them. Media in Denmark are also monitored, following the ‘StigmaWatch’ guidelines, following which anyone can report a media item which is considered inappropriate or stigmatising towards mental health conditions.
Lithuania has strengthened the role of public health bureaus in improving mental health knowledge, allocating EUR 2.5 million to municipalities in 2019 (WHO Europe, 2020[25]). The Ministry of Health established a law in 2019 by which public health bureaus should organise training courses for workers on mental health issues. This course aims at improving the employees’ competencies by acquiring skills and knowledge to cope with mental health risks and related problems as an educational intervention. Through this legislation, companies should provide the training course that runs to 40 hours in total. Detailed contents of the course are provided by the Ministry of Health.
As with efforts to improve mental health literacy (see Chapter 5), many efforts to reduce mental health stigma focus on World Mental Health Day on 10 October, where high-profile campaigns are held in multiple countries, and internationally. In Ireland, the Green Ribbon Campaign which is inspired by the green ribbon that is the international symbol for mental health, is a month long roll-out focusing on distributing green ribbons across the population to inspire people to improve their mental health awareness. The campaign has been running for 7 years, and over this period the number of people aware of the campaign increased quite steadily; between 2018 and 2019, the number of people strongly agreeing that it was important to have open conversations about mental health with friends/family/colleagues increased from 20% to 54% (See Change, 2019[26]).
The impact of anti-stigma campaigns is inconsistently, but where stigma has been measured over time attitudes towards mental health have improved
While many countries have been running anti-stigma campaigns around mental health for years or even decades, it is often difficult to establish whether attitudes and stigma around mental health has been changing over time. To track levels of stigma over time, some OECD countries have used national attitude surveys. A wide range of different stigma measurement tools have been developed across the world, of which the most widely used measurement is the Internalised Stigma of Mental Illness Inventory (ISMI) scale, which measures stereotypes about mental health issues in a society (Fox et al., 2018[27]). Other tools include Depression Stigma Scale (DSS), and the Community Attitudes Toward the Mentally Ill Scale (CAMI). Another type of stigma hold among general people is measured by people’s attitude towards those with psychiatric issues and recognition on mental health diseases. At least 11 OECD countries have a national survey to measure attitudes or level of stigma around mental health issues (Table 6.2). However, as the table shows, each country has measured national stigmatising attitudes with different indicators, making comparison of levels of stigmatising attitudes across countries very challenging.
Second, national surveys are not systematically repeated and this makes it difficult to evaluate national trends of literacy or attitudes to mental health issues in a country, nor are they always linked to the evaluation of an anti-stigma programme or campaign. A few countries, including Australia, England and Ireland, have either repeated national attitudes surveys in different years, or evaluated the impact of anti-stigma campaigns. For example, in England, the attitude survey has conducted every year since 2008, in the following year ‘Time to Change’ campaign aiming at reducing stigmatising attitude to mental health issues started. The survey has measured mental health related knowledge and it reported that there was improvement in knowledge, attitude, and desire for social distance (Henderson, Potts and Robinson, 2020[28]). From these surveys, literacy and attitude towards mental health issues, including a desire for social distance have generally improved, although these positive effects are being observed slowly. In addition, a survey in Australia found that stereotype concepts, such as ‘psychiatric disease are dangerous”, still remain (Reavley, Too and Zhao, 2015[29]) and long-term effect need to be improved.
On the other hand, the Czech Republic conducted a national survey on stigmatising attitude in 2015, using the 8-item Reported and Intended Behaviour Scale (RIBS) and compared the result with the attitudes in the population in England. This analysis found that in Czech Republic population readiness to accept a person with psychological issues is lower than that the population average in England (Winkler et al., 2015[30]). Negative attitudes were confirmed by a subsequent national survey using CAMI. This survey found high level of negative attitudes in both the general population and amongst medical doctors (Winkler et al., 2016[31]). However, recent research does show improvement of population attitudes which is being associated with both mental health care reform and a national anti-stigma programme (Winkler et al., Forthcoming 2021[32]). In Canada, change in stigmatising attitude before and after the intervention which shared mental health knowledge assessed by 20-item Opening Minds Scale for Health Care Providers (OMS-HC). This survey concluded that approximately 25% of participants have improved their attitude towards mental health issues and participants perceived that listening to lived experience was the most effective intervention, compared to the other methods (Kopp, Knaak and Patten, 2013[33]). Also in Canada, the Canadian Community Health Survey (CCHS) – Mental Health 2012 included an item on ‘percentage of population with a mental health problem who report having been affected by negative opinions or unfair treatment, due to their mental health problem’, with a rate of 21% of adults reporting in the affirmative in 2012 (Health Canada, 2020[34]).
Australia has carried out an attitude survey three times since 1995 and observed the change of stigmatising attitude related to mental health issues in the country (Box 6.1).
Australia implemented the National Mental Strategy in 1992 to improve the mental health literacy, and since then Australia has conducted a national survey three times, in 1995, in 2003-04, and in 2011. The surveys focused on mental health literacy, stigma, and perceived discrimination, to assess whether there have been changes in recognition, treatment beliefs, stigmatising attitudes and other aspect of mental health literacy in the population. The survey results showed that over time mental health literacy improved, and there were some falls in stigmatising attitude over the years.
Mental health literacy
As a measure of mental health literacy, the rate of people who recognise depression correctly and who understand antidepressant was measured. In 2011, 75% of respondents recognised depression correctly and this rate had increased compared to the previous survey in 1995. Likewise, more respondents in 2011 understood that a GP can provide professional support for depression, and that antidepressants are effective, than in in 1995.
Stigmatising attitudes
2011 survey data showed stigmatising attitudes are found more frequently towards men with mental health illness rather than women with mental ill-health. Additionally, the data showed the desire for social distance people was most common when concerning colleagues and in-laws with a mental illness. Comparing data of 2003/4 and 2011, stigmatisation slightly decreased over time, with data showing some reduction in the desire for social distance from people with mental disorders, together with a decrease in negative beliefs about dangerousness and unpredictability of people with mental illness.
Perceived discrimination
In 2011, 34.7% of respondents reported being treated as less competent once others learned they had psychological illness, while more than 60% of respondents with mental health problems had experienced a negative or offensive attitude from others.
Source: Reavley, Too and Zhao (2015[29]) National Surveys of Mental Health Literacy and Stigma and National Survey of Discrimination and Positive Treatment, Mental Health Commission of New South Wales.
Are countries investing in delivering a high-performing mental health system?
Spending on mental health has increased, but the total share of health spending going towards mental health has stayed stable or even fallen
Mental health has been a long-neglected area, but this is beginning to change; significant attention from some governments and leaders – in Australia, in Canada, in New Zealand, in Norway, in the United Kingdom – is testament to global momentum around mental health. In some cases this has been accompanied by new high-level strategies or funding, in all instances such signals can be an important way to raise awareness and reduce stigma.
National expenditure, reported in national currency, increased in all countries in the last decade, by with an average annual growth in mental health spending of more than 6% in Lithuania and Israel. However, overall government spending on health has also been increasing, and as a percentage of this total health spending the increases in resources for mental health have not been particularly significant. Generally spending on mental health as a percentage of total health spending has not increased significantly, and in some countries – Japan, Norway, New Zealand, the United Kingdom, Lithuania – has declined (Figure 6.3).
Note: Australia (2009-18), Canada (2011-19), Denmark (2011-18), Estonia (2015-17), Greece (2009-18), Ireland (2014-19), Israel (2009-17), Japan (2009-17), Lithuania (2016-19), Netherland (2015, 2017), New Zealand (2009-19), Norway (2013-17), Poland (2009-19), the United Kingdom (England) (2017-18).
Source: OECD (2020[8]), OECD Mental Health Performance Benchmarking Data and Policy Questionnaires.
A number of countries, including New Zealand, England (increase of GBP 1.4 billion between 2015/16 and 2017/18) and Australia (AUD 1.6 billion between 2015-16 and 2018-19), have pointed towards significant increases in mental health funding in recent years (NHS England, 2017[35]; Australian Institute of Health and Welfare, 2021[36]).
However, some reviews of spending have also pointed to real-term falls in mental health spending even when governments are publicly committing to increasing investments. A 2018 review in England, where parity of esteem for mental health has been a guiding principle, funding gaps for NHS mental health providers and NHS acute providers appear to continue, and some mental health providers have seen funding fall (The King’s Fund, 2018[37]).
Mental health has been prioritised in COVID-19 responses
During the COVID-19 crisis, OECD governments have prioritised mental health as part of their COVID-19 response plans, and taken steps to increase mental health support. In particular, countries have introduced new forms of mental health support including informational materials (mostly online), new mental health support phone lines, shifting mental health services to telemedicine formats and in some cases increasing service capacity or entitlement, and in some countries increasing investment in mental health (OECD, 2021[38]). For instance, in April 2020, Health Canada launched the Wellness Together Canada (WTC) portal to provide short-term mental health and substance use supports and services to Canadians during COVID-19. Key objectives were to help address the anticipated increase in mental health and substance use service needs faced by Canadians, and to address disruptions to normal service delivery resulting from the pandemic.
In addition, a few countries have committed to new or increased funding for mental health care in light of the toll that the COVID-19 crisis is taking on mental health. In Australia, the government announced AUD 5.7 billion funding for mental health and aged care under the country’s COVID-19 pandemic plan (Department of Health, 2020[39]). Funding was to be committed to the mental health programs and services under the COVID-19 Mental Health Support Package, to support increased demand for services, and additional funding was provided to the state of Victoria where COVID-19 restrictions were more significant than elsewhere in the country. In Canada, the government invested CAD 11.5 million in community-based programmes to promote the mental health of particularly vulnerable Canadians during the COVID-19 crisis (Government of Canada, 2020[40]).
In Ireland, too, additional funding was provided under the 2021 budget (EUR 38 million) for new mental health services in response to the crisis, along with an additional EUR 12 million for existing needs, a total of a EUR 50 million increase compared to the 2020 budget (Government of Ireland, 2020[41]). The Latvian Government has diverted an additional EUR 7.12 million to mental health services in 2021 in response to the COVID-19 crisis, including funding for mental health specialists, for family doctors providing mental health support, and for psycho-emotional support for medical staff (Baltic News Network, 2021[42]). In February 2021, Chile announced that the budget for mental health would increase by 310% compared to the previous budget (Ministerio de Salud, 2021[43]). This increased funding will be distributed across a range of mental health services, and comes in the context of both an increase in mental health consultations in Chile in recent months and the ‘Programa Saludablemente’ (Health Mind Programme) which was developed in the COVID-19 context to share mental health information and guidance and connect people with mental health services (Gobierno de Chile, 2020[44]).
Prioritising efficient and effective distribution of resources
All health care systems are seeking to deliver a maximum amount of effective care, with limited resources. In the mental health sector where resources are particularly tight, maximising the impact of scarce resources is even more critical. However, assessing how ‘efficient’ mental health care systems are has been a long-standing challenge, limited by loose conceptualisation of efficiency in mental health systems (Lagomasino, Zatzick and Chambers, 2010[45]), heterogeneity in service design even within countries (Gutiérrez-Colosía et al., 2019[46]; Monzani et al., 2008[47]), and above all by a lack of relevant data (Moran and Jacobs, 2013[48]; García-Alonso et al., 2019[49]). This topic is also discussed in Chapter 7, including looking at whether mental health care is delivered in line with best available evidence.
Despite the complexities, it is clear that OECD countries are taking steps to reflect on how limited resources can be used most effectively to deliver mental health care. As even the scope of the OECD Mental Health Performance Framework underscores, the range of policies and interventions that mental health systems include is very diverse – from prevention and promotion activities, to low-threshold services for mild-to-moderate disorders, to community-based care, and acute inpatient services – and setting the right balance is an ongoing challenge for countries. In most OECD countries, national or regional strategies address issues around overall service models, design and balance (Table 6.3).
Although they weren’t seen consistently across all strategies, plans and policy documents, the use of incentives, information collecting and sharing, and a need-focused approach were included in some national and international approaches. The recommendations in the 2017 annual report of the EU Compass for Action on Mental Health and Well-being emphasised financial resources, as well as services organisation, development and quality (EU Compass for Action on Mental Health and Wellbeing, 2017[50]), while the Five Year Forward View on Mental Health (NHS England, 2018[51]) in England placed emphasis on incentives, levers and payment.
In other OECD countries, strategies cover the goals for the mental health system, such as increase integration across sectors (Australia, Canada, England, Ireland, Slovenia), and balancing service provision between primary and specialist care and/or stepped care approaches (Czech Republic, Denmark, Ireland, Japan, Norway, Slovenia, Switzerland, Turkey). In Iceland, a significant part of the recent mental health strategy has been focused on redistributing mental health resources, and the move toward deinstitutionalisation and implement more extensive mental health service provided by the primary health care centres around the country by establishing mental health teams and the increased availability of service provided by psychologist, co-ordination and quality control overseen by Primary Health care Services, development centre. Iceland’s Health Policy running up until 2030 also places strong emphasis on co-ordination of care and providing the correct services at the appropriate time and service level. Japan, Korea and the Czech Republic have also been focusing on redistributing mental health resources outside of inpatient settings, and shifting the focus of care towards community settings as a priority part of mental health reform (Box 6.2).
Pushing for reform from the government, NGOs, and the psychiatric association in the Czech Republic
Similarly to other Central and Eastern European countries, in the Czech Republic, mental health care has historically been highly hospital-focused (Winkler et al., 2017[52]). Since 1989, outpatient care has been expanded, and recently, more community based care was expanded (Höschl, Winkler and Peěč, 2012[53]). However, the hospital-centric approach has continued, with long hospital stays (41.2 days on average in 2017) even as the number of psychiatric beds has fallen (from 1.05 per 1 000 in 2008 to 0.94 in 2017) (OECD, 2019[54]). In the early 2000s, NGOs and the Czech Psychiatric Association were the main actors involved in pushing for mental health reform (Pec, 2019[55]). The Czech Government began to play a more active role in driving for mental health reform from around 2013; the Ministry of Health, assisted by teams of mental health professionals, experts and patients, created the Strategy for the Reform of Psychiatric Care, which was issued in October 2013, and from 2016-17, the government began using EU structural funds for psychiatric care. Recent reforms have included the development of Mental Health Centres (MHC) to offer community mental health care services, which often include integrated professional teams with psychiatric nurses, social workers and psychiatrists. MHCs can also include bed places for emergency cases, and staff undertake out-patients visit (Pec, 2019[55]). However, expenditure on mental health is low, and has between 2006 and 2015; spending on mental health as a percentage of health spending was at 4.14% of health spending in 2006 and had fallen to 4.08% in 2015 (Broulikova et al., 2020[56]). The bulk of 2015 expenditures were also being spent on inpatient care, and as of 2020, despite the considerably reduced long-term hospitalisations and increased community care, the Czech mental health system could still be considered to be highly hospital based (Broulikova et al., 2020[56]).
Japan slowly shifts mental health care from hospital to community
In Japan, mental health care is highly hospital-based. Average hospital stay was 281 days in 2014, which is much longer than that the OECD average in 2014 (OECD, 2020[57]) and 85.9% of the psychiatric beds are occupied according to Ministry of Health, Labour and Welfare data. Ministry of Health Labour and Welfare (MHLW) reported in 2017 that more than 60% of inpatients stay in a hospital more than one year (MHLW, 2017[58]). The vision of reforming mental health service, “from hospital care to community-based care”, was announced in 2004 to reduce the length of hospital stay and strengthen mental health services in communities. The government set the goal in 2004 to reduce the number of psychiatric beds by 20%, and inpatients by 10%. The municipal governments are encouraged to support those with psychological problems to live in a community and focus on building community-based integrated care system. For example, the government supports municipals to ensure communication between medical and community care staff, as well as family care, and peer support. However, the changes have been very slow, due to the strong stigmatisation, besides the systematic barriers, such as insufficient insurance coverage of community care by non-medical professionals (Kasai, 2017[59]). The number of psychiatric beds has reduced by 7.5% from 2004 to 2018, according to the 2004 and 2018 Surveys of Medical Institutions undertaken by the Ministry of Health, Labour and Welfare.
Strengthening community mental health care in Korea
Korea largely relies on psychological care on inpatient service despite that the number of mental health patients is increasing. The length of hospital stay has increased from 114.5 days in 2008 to 168 days in 2017. The number of hospital beds per 1 000 population has increased from 0.81 in 2008 to 1.31 in 2017 (OECD, 2018[60]). Since the Mental Health Act was introduced in Korea in 1995, the number of rehabilitation facilities increased by 5 times from 66 in 2001 to 333 in 2015, however, the number of private mental hospital is still 10 times as that of rehabilitation facilities (Heo, Kahng and Kim, 2019[61]). The number of Mental health Welfare Centres (MHWCs) was increased to lead mental health service in community, however, they are not distributed across the country and better co-ordination is still needed.
Promoting equity geographically, between population groups, and between mental disorders
Multiple population groups have been identified as being particularly vulnerable to mental ill-health, and many have poorer experiences and outcomes of, and less access to, mental health care. Such population groups vary across countries, and include but are not limited to the LGBTQI+ community, indigenous populations, certain ethnic groups including ethnic minorities, older adults, and refugees (Mitrou et al., 2014[62]; Zehetmair et al., 2018[63]; Catalan-Matamoros et al., 2016[64]; Soysal et al., 2017[65]; McCann and Brown, 2017[66]; Meyer, 2003[67]; WHO, 2020[68]). Seventeen OECD countries reported having mental health strategies or plans in place addressing the specific needs of nationally defined population groups (Figure 6.4). Strategies addressing children and young people are most common (15 countries), followed by older adults (7 countries) and LGBTQI+ communities (8 countries). The OECD Mental Health Performance Benchmarking Data Questionnaire included a data sheet requesting data broken down by population group, for example rate of service contacts for nationally defined population groups (OECD, 2020[8]). As of May 2020, 4 countries (Australia, Canada, Japan, and the United Kingdom) were able to provide partial data covering a range of groups, including aboriginal populations, data by ethnic group, foreign-born population, which is being further explored by the Secretariat.
Note: Responses to the question ‘Do you have a specific national or sub-national mental health strategy for different vulnerable population groups? E.g. Older adults, First nation people, ethnic minorities, LGBTQI groups’. While this term appeared to be easy to understand for questionnaire respondents, the term ‘vulnerable population’ can over-emphasise weakness rather than action and empowerment, and imply that all individual members of a given population are vulnerable.
Source: OECD (2020[8]), OECD Mental Health Performance Benchmarking Data and Policy Questionnaires.
Though many countries may have strategies for priority population groups, the comparatively poor outcomes for such groups points to a need to further increase, or at least remain committed to, scaling-up appropriate support and services designed for and with minority and priority groups. To take one pertinent example, in Australia, Canada, New Zealand and the United States and indeed worldwide indigenous populations have higher rates of suicide and psychological distress, suffering from symptoms of anxiety and depression (Hajizadeh, Bombay and Asada, 2019[69]; Hatcher, Crawford and Coupe, 2017[70]). Indigenous Australians shows rates of anxiety and depression between 50% and three times as high compared to the non-Indigenous population (Anthony F Jorm Sarah J Bourchier, 2012[71]). Suicide rates are twice as high compared to the non-Indigenous population, and four times as high for youth (Tighe et al., 2017[72]). Suicide rates among the Inuit, one of the three distinct Indigenous groups in Canada, are among the highest in the world and up to ten times higher than the average suicide rate in Canada (Harder et al., 2012[73]; Kral, 2016[74]). Furthermore, countries need to go beyond strategies focused on priority groups and towards accessible, co-produced services. Fostering a supportive community with focus on local culture, such as support by social or familial network, connection to culture, development of self-identity are all related with better mental health outcomes in Indigenous populations, resulting in less suicidal ideation (Harder et al., 2012[73]; Hatcher, Crawford and Coupe, 2017[70]; Tighe et al., 2017[72]). Canada has pursued this approach with “Culture as a Treatment””, where mental health agencies serve specific cultural practices such as talking circles, pipe ceremonies and smudging (Gone, 2013[75]). In Australia, Indigenous mental health policies focus on self-determination and community governance, reconnection and community life to enhance emotional well-being for Indigenous communities (Dudgeon et al., 2014[76]).
OECD countries have taken some initiatives to create gender specific care, however this remains scarce and opportunities for improvement exist. In England, there have been guidelines developed to advice on clinical management of mental health services for women who have experienced problems in antenatal or postnatal period. The guidelines cover mental ill health such as depression, anxiety disorders, eating disorders, drug- and alcohol- use disorders and severe mental illness. The guidelines are developed to promote early detection and good management of mental health problems to improve women’s quality of life during pregnancy and in the year after giving birth (NICE, 2014[77]). Finland has developed a preventative strategy to recognise that suicide was particularly high amongst young men, which led to the development of the “Time Out! Back on the track” (Aikalisä! Elämä raitelleen) initiative in 2004, which promoted social inclusion amongst vulnerable men. Two-thirds of participants reported that the participation in the programme was worth wile, while about 60% considered it had improved their life situation (Appelqvist-Schmidlechner et al., 2012[78]).
Policy attention needs to be backed with smart and significant investment in mental health services
Mental health is indeed a significant and growing priority for OECD policy makers. At their Ministerial meeting at the OECD in 2017, which led to the development of this report, Ministers highlighted the significant burden of mental ill-health, and that interventions to prevent, treat, and manage mental health are insufficient. Ministers pointed to gaps in effective policies, but also in applying policies that are well-established as effective. Furthermore, at their 5-6 November 2017 meeting in Milan, G7 Ministers of Health highlighted the burden of mental health issues on adolescence, and concerns over the impact of social media on mental health, and asked OECD to “benchmark mental health performance focusing specifically on adolescents” (http://www.salute.gov.it/imgs/C_17_pubblicazioni_2656_allegato.pdf). During the COVID-19 crisis, governments have prioritised mental health as part of their COVID-19 response plans, with countries including Australia, Denmark, Canada and Norway rapidly committing new resources to scaling-up mental health support, often with a focus on particularly vulnerable population groups.
Based on the findings of this report, no mental health system in OECD countries is a top performer across the board. In some areas, for example ‘unmet need for mental health care’, even ‘top performers’ see 50% or more reported unmet need for care (see Chapters 2 and 3). There is room for improvement for all countries. Mental health has been a long-neglected area, but this is beginning to change; significant attention from some governments and leaders is testament to global momentum around mental health. In some cases this has been accompanied by new high-level strategies or funding, in all instances such signals can be an important way to raise awareness and reduce stigma. However, despite growing attention to mental health, and in some cases increases in funding and service provision, OECD countries have not significantly increased funding for mental health.
If OECD countries are going to deliver the kinds of high performing mental health systems that were set out in OECD Mental Health Performance Framework, which was developed by stakeholders from across OECD countries, further investment in mental health is surely needed in most, if not all, OECD countries.
If countries wish to invest additional resources in mental health care, there are a range of different approaches that can be taken. Some OECD countries have committed new funding to mental health services in response to the COVID-19 crisis. As discussed earlier in this chapter these countries include Australia which has committed funding for specific additional mental health services, Canada where the government has committed resources with a particular focus on particularly vulnerable population groups, and Ireland which has committed new funding for both new additional mental health services, and for existing mental health needs. Prior to the COVID-19 crisis, countries had also been introducing targeted mental health resources for example for specific services which were over-stretched, or which were judged to be particularly important for meeting demand for care. This includes countries such as England, which introduced GBP 80 million to address mental health waiting times for psychological therapies and psychosis services in 2015, and Australia which directed AUD 152 million towards headspace services (for young people) which were experiencing high levels of demand in 2019 (OECD, 2020[79]).
Targeted resources for specific mental health services is by no means the only way that countries have gone about increasing mental health funding. Several countries have committed new resources to their mental health systems through comprehensive reform approaches, or new mental health strategies. Amongst these countries, New Zealand’s ‘Well-being Budget’ stands out as a very comprehensive approach to increasing investment in mental health, that not only includes new commitments to services but also commitments to addressing some of the key risk and resilience factors around mental health (Box 6.3).
In 2019 New Zealand announced the world’s first ‘well-being budget’, which focused on ‘taking mental health seriously’, improving child well-being, supporting Māori and Pacific populations, and building a productive nation. The Budget intended to focus policy attention, and resources, an diverse dimensions of well-being including mental health, childhood development, reducing domestic violence, protecting the environment, and reducing inequality. They budget intention state: “Well-being is when people are able to lead fulfilling lives with purpose, balance and meaning to them. Giving more New Zealanders capabilities to enjoy good well-being requires tackling the long-term challenges we face as a country, like the mental health crisis, child poverty and domestic violence. It means improving the state of our environment, the strength of our communities and the performance of our economy” (Government of New Zealand, 2019[80]).
The Budget focused on improving well-being in three ways: breaking down cross-government silos and improving integration; focusing on long-term impacts and policies; tracking progress with broader measures of success.
This ambition was backed with NZD 445 million for mental health services, NZD 40 million for suicide prevention, and commitments to put more nurses in secondary schools, tackle homelessness, and spend NZD 320 million addressing family and sexual violence. Services are being rolled out nationally over five years and will be offered in a range of settings including general practices, kaupapa Māori, Pacific, community and youth settings. Responses will be designed collaboratively with communities to ensure local services meet local need. These services will utilise a diverse workforce, including mental health and addiction workers (including staff with peer and cultural expertise) co-locating with primary health services. It is also expected that services will provide pathways to access cultural and social supports, including those which provide employment and income assistance.
In 2020, in light of the COVID-19 crisis, the Well-being Budget was slightly reoriented, with more significant focus on funding for existing public services, and a pause on new initiatives. The 2020 Budget nonetheless included almost NZD 5.6 billion for the health sector, and NZD 3.9 billion in operating funding for New Zealand’s District Health Boards which represents the largest ever investment in such operating costs (New Zealand Government Budget 2020, 2020[81]).
Investing in programmes to reduce mental health stigma and improve mental health literacy can transform population attitudes
Reducing mental health stigma is a priority in OECD countries, and national or regional campaigns are in place in multiple countries. Though attitudes and stigma are inconsistently measured over time, and anti-stigma campaigns rarely fully evaluated, but where they are evaluations point to important improvements in attitudes. More positive attitudes towards mental health can reduce stigma towards others – helping decrease discrimination towards people with mental health conditions – and also reduce self-stigma, making it more likely for people to seek support if they experience mental distress. England has a particularly long-running mental health campaign, Time to Change, which unlike campaigns in some countries which are focused on one day or one period of the year (e.g. World Mental Health Day) runs diverse activities through the year. The campaign has also been evaluated multiple times, and has found progressive improvement in attitudes towards mental health (Box 6.4).
Time to Change campaign to change attitudes towards mental health in England
‘Time to Change’ in England began in 2007 funded by the Department of Health and Social Care, Comic Relief, and The National Lottery Community Fund. The campaign focused on ending stigma and discrimination related to mental health issues and change people’s attitudes at a national level, recognising that stigma was preventing people from setting support they need. The main focus of the campaign was on creating opportunities to talk about mental health problems in workplaces, at schools, and in the local community. Five years after the campaign was introduced in 2007 it appears to have contributed towards significant improvements in positive attitudes towards mental health (Evans-Lacko et al., 2014[82]). More than ten years after the campaign’s introduction, 2018-19 data shows a 3.1% improvement in attitudes amongst the adult population compared to baseline data from 2016/17, and a 12.7% improvement since 2008 when the programme first started collecting data (Time to Change, 2021[83]).
Since the campaign began, in the general population there were significant increases in positive attitudes related to prejudice and exclusion, and an increase in tolerance for community care (Evans-Lacko et al., 2014[82]). While it is difficult to attribute these changes to the Time to Change campaign alone, some of the attitude changes were most significant after the launch of the campaign, and there was also some positive relationship between campaign awareness and improvement in mental health knowledge and attitudes (ibid). The evaluation found that the campaign represented a potentially cost-effective and low-cost intervention.
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