International funding for mental health: a review of the last decade

Abstract

Mental health represents one of the most significant and increasing burdens to global public health. Over the past decade, the once invisible field has gained recognition on the global health agenda and this increased recognition is expected to increase international funding for mental health. Our review found that few studies have been conducted as to the level of international funding for mental health and there is a need for a differentiated assessment. We conducted such an assessment of global development-related assistance for mental health between 2006 and 2016 and established categories to serve as a baseline for future measurement. We found that development assistance specifically dedicated to mental health accounted for just 0.3% of all development assistance for health. Given the limited public expenditure on mental health by national governments in low- and middle-income countries, renewed efforts by the international community and development partners to substantially increase funding for mental health are critical.

global health, health care financing, mental health, Organisation for Economic Co-operation and Development

Introduction

Over the past decade, the field of mental health has gained recognition on the global health agenda.¹ This is demonstrated by several key milestones achieved in recent years, such as The Lancet’s 2007 series on global mental health, the subsequent establishment of the Movement for Global Mental Health and the launch of the Mental Health Gap Action Programme by the World Health Organization (WHO) in 2008.^2–4 More recently, global mental health has garnered further international attention as evidenced by the inclusion of mental health and well-being in the Sustainable Development Goals and by the 2016 meeting on mental health as a global development priority, jointly hosted by the WHO and the World Bank Group.^5,6 This growing attention to global mental health is coupled by an increasing burden of disease attributable to mental, neurological and substance use (MNS) conditions. Between 2006 and 2016, the global burden of MNS conditions increased by 14.9%, accounting for 9.7% of all disability-adjusted life years.⁷

The increased international focus on mental health is expected to increase resources for mental health, especially in the form of aid from international donors. It is therefore essential to measure current development contributions for global mental health in order to monitor future increases in resource allocation. Since the present landscape of support for global mental health is not well documented, we sought to conduct a comprehensive review.

In the past three years, four studies have performed analyses of official development assistance for mental health (DAMH). All of the studies reviewed demonstrated a low level of DAMH and highlighted the ongoing need for increased funding towards global mental health.^8–11 While data sources and target populations varied between the aforementioned studies, no estimate of DAMH amounted to more than 1% of the total development assistance for health (DAH).^8–11 With consistently low estimates of DAMH across previous studies, we sought to conduct a comprehensive study of DAMH that includes mental health projects from all Organisation for Economic Co-operation and Development (OECD) sectors over the course of a decade. Expanding on the efforts of previous studies, findings should be placed within the global context of total DAH and should demonstrate a detailed understanding of the distinctions within DAMH.

This article systematically assesses development-related assistance for mental health over the past decade (2006–2016). We seek to provide a general overview of the status of contributions to global mental health, highlighting current progress. Moreover, the analysis offers a baseline measure of financial support for mental health over the past decade to which future contributions can be compared.

Our article aligns with the WHO Mental Health Action Plan (2013–2020) objectives of strengthening effective leadership and governance for mental health and to strengthen information systems, evidence and research for mental health.¹² The analysis is pertinent to the current global health development agenda and has also been performed against a growing mental health burden. MNS conditions are the greatest contributor to global years lived with disability.¹³ This is furthered by a documented increase in the burden of mental health globally over the years this analysis considers.

This analysis demonstrates that increased disease burden attributable to MNS conditions has not been adequately supported by the international development and aid sectors. The financial burden to address mental health then falls on domestic actors, many of whom also contribute only very small amounts of funding, as demonstrated in the recent 2017 WHO Mental Health Atlas.¹² Addressing the burden of MNS conditions will require increased financial commitments from multiple stakeholders, including international donors, multilateral agencies and national governments—particularly in low- and middle-income countries (LMICs).¹⁴

Review criteria

Total DAMH over the course of a decade (2006–2016) was investigated using the Creditor Reporting System (CRS) Microdata Aid Activities database from Qwery Wizard for International Development Statistics (QWIDS) of the OECD.¹⁵ Records were obtained in May 2018.

All gross disbursements between 2006 and 2016 were analyzed in 2015 U.S. dollars (US$) (constant prices). Where required, dollar amounts provided in other values were converted to constant 2015 US$ using the OECD consumer price index.¹⁶

Projects related to mental health were identified using keywords developed by Gilbert et al.⁸ We added several additional terms to broaden the range of MNS conditions comprising this analysis, including the term self-harm (see Supplemental Table 1). Each keyword search was conducted across all development sectors reported in the database. Results were compiled and duplicate records eliminated. Analysis was conducted using Excel software (Microsoft, Redmond, WA, USA). If information was provided in a language other than English, Google Translate was used.

Due to the basic search functionality, which identifies any use of key terms in all completed fields, and the variation in detail provided for each project, particular care was needed to ensure that identified projects were relevant to the intended search. First, projects obtained due to alternate (unrelated to health) usages of keywords were eliminated. Second, retained projects were systematically assessed for appropriateness of inclusion using the ‘Project Title’, ‘Short Description’, and ‘Long Description’ categories included in the CRS database. Due to the variety of projects found, it was imperative to conduct the review project by project to establish the degree of mental health focus in each identified project.

Projects were classified into two categories: development projects dedicated solely to mental health, i.e. projects that specifically pertain to mental health or services for individuals with MNS conditions, and development projects that mention mental health, i.e. projects that include some mental health–related objectives among other non-mental health–related objectives. Research focus was determined using the ‘Purpose Name’ category provided within the CRS database. Examples of projects and corresponding categorizations are presented in Table 1.

Table 1.

Examples of official development assistance projects identified through the keyword search of the OECD CRS database. Examples are categorized by reason for elimination or retention

Category	Sector	Example
Eliminated: alternate meanings	Government and civil society	The Asia Foundation conducts an annual survey (Institutionalizing the Survey of the Afghan People) for the collection of information across all 34 provinces in the country on security, reconciliation, economy, and governance to assess the mood and direction of the country
	Emergency response	Emergency response to benefit families affected by tropical depression number 16 in the Department of Yoro
Eliminated: not applicable to mental health	Health, general	High dependency unit
	Basic health	The Centre aims at improving access to surgical and trauma services and contributing to the rehabilitation of a medical system that has been severely weakened by Ebola
	Government and civil society	To obtain information and knowledge on the psychological, cultural and economic characteristics of consumers in Mozambique, in order to enhance laws and legislations aimed at protecting consumers
Retained: ‘projects that included mental health’	Emergency response	…in order to reduce the high morbidity and mortality rates and prevent the impairment of cognitive development among women and children
	Conflict, peace and security	Provision of psychosocial services, medical care and livelihood support to survivors of trauma, people with disabilities and immediate family members in post-conflict areas
	Education	Inclusion of children and youth with physical and mental disabilities
Retained: ‘projects dedicated to mental health’	Health, general	To train and evaluate the effectiveness of non-psychiatric nurses, non-psychiatric clinical officers, community health workers and traditional and faith healers and expert patients in identifying, managing (including referring) patients with mental disorders
	Agriculture	Promotion of girls and women with mental disabilities through organic agriculture project
	Other social infrastructure and services	OLG Health Foundation provides medical care for children and adolescents with autism and promotes awareness of autism in the Niger Delta
Retained: ‘projects dedicated to mental health’ focused on research	Government and civil society	This research will evaluate alcohol control policy and legislation in five African countries to provide evidence-based research to policymakers, researchers, and lobby groups working to reduce alcohol use
	Population policies and reproductive health	A cluster randomized controlled trial of a stepped care intervention for depression in primary care
	Unallocated	The study aims to provide estimates of psychiatric morbidity and functional impairment in the Cambodian population, and their burden for society

To supplement our review of DAMH we performed a basic scoping review of major bilateral donor agencies and large multinational pharmaceutical companies. On the historical basis of large drug donations for areas such as neglected tropical diseases, we enquired if the area of mental health is receiving similar attention. Fifteen bilateral donor agencies and 10 pharmaceutical companies were assessed for a prioritization of mental health–related objectives as an area of focus through a brief investigation of company websites and corporate responsibility reports where available. Other areas of focus, e.g. human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) and non-communicable diseases (NCDs) excluding mental health, were also assessed.

Results

Official development assistance

After removal of all duplicate records (i.e. any record identified in two different keyword searches) our search yielded 9205 projects—across all sectors of development assistance—reported between 2006 and 2016 whose project title or description included any of the search terms. However, after assessment for appropriateness of inclusion in the analysis, a significant number of records obtained were eliminated because their objectives were not pertinent to mental health (see examples in Table 1). In total, 1449 records totaling US$1263.0 million were eliminated; 7756 projects that involved mental health remained for analysis.

As per the OECD, official sector expenditures for refugees in donor countries can be counted as official development assistance for the first 12 months of stay within the receiving donor country.¹⁷ Upon review of the 7756 projects, 22 projects categorized by the OECD as ‘Refugees in donor countries’ were removed from the core analysis, leaving 7734 projects for systematic analysis. Although this category of OECD expenditure has been in place since 1992, there has been a significant increase in funding targeting refugees in donor countries in recent years in response to the refugee crisis (P. Blanchard [OECD], personal communication, 21 February 2019).

As described in the review criteria, two categories of projects were created to better characterize this analysis of global DAMH. Development projects that include mental health, but not as a primary or specific project objective (e.g. provision of food aid, primary health care services, etc.) were noted and categorized as ‘development projects that mention mental health’ (4813 projects), while projects with specific mental health objectives were categorized as ‘development projects dedicated solely to mental health’ (2921 projects).

Between 2006 and 2016, US$2451.0 million was allocated across the 7734 projects involving mental health. Of that US$2451.0 million, only US$409.1 million (16.7%) was allocated to development projects dedicated solely to mental health; the remaining US$2041.9 million (83.3%) was allocated to development projects that mention mental health but were not exclusively focused on mental health or individuals with MNS conditions.

Projects dedicated solely to mental health

Of the US$409.1 million in DAMH allocated to development projects dedicated solely to mental health, the large majority of funding (96.0%) supported mental health programs and projects; only 4.0% was allocated to mental health research (the database does not accommodate basic research). The greatest single amount allocated was US$5.8 million for community psychosocial and mental health services in the West Bank and Gaza in 2009.

Projects that mention mental health

Of the US$2041.9 million allocated to projects that mention mental health, the greatest single amount allocated was US$36.4 million in 2006 for a reconstruction project following the 1999 Marmara earthquake in Turkey, which included mental health services for victims in addition to extensive reconstruction efforts and emergency preparation. Figure 1 shows yearly disbursements in global DAMH from 2006–2016. Disbursement of DAMH increased slightly over the course of the last four years; total DAMH disbursed per annum was greatest in 2016 at US$308.3 million. However, funding for projects dedicated solely to mental health remained low across the decade, ranging from US$21.7 million in 2006 to US$55.0 million in 2015.

Figure 1.

Yearly disbursements in global DAMH from 2006 to 2016 (2015 constant US$ millions). The darker areas indicate disbursements from projects dedicated to mental health while the lighter areas demonstrate the amount disbursed globally for projects that mention mental health.

To establish the priority for mental health in the context of all sectoral DAH, mental health was compared with other subsectoral expenditures. The OECD separately categorizes expenditures for the health sector and expenditures for the population policies/programs and reproductive health sector. Both sectors were included to fully represent all health-related official development assistance.

Figure 2 shows the health and population policies/programmes and reproductive health disbursements by OECD-assigned subsectors for 2006–2016. Through our keyword search and project-by-project analysis across all OECD sectors, any project that was determined to be DAMH was recategorized as mental health to avoid duplication.

Figure 2.

Development assistance dedicated to mental health as a part of DAH per OECD assigned subsectors. Respective percentages are a reflection of the total value of 2006–2016 cumulative gross disbursements in constant US$ millions per each subsector. Development assistance dedicated to mental health, as identified in this review, is differentiated as a subsector of OECD health development assistance. Mental health forms the smallest subsector, at 0.3% of all OECD health sector development assistance for 2006–2016. Within the 0.3%, only half of projects were identified as health sector by OECD. Our percentage represents a wider scope of projects than may be found through looking just within OECD-defined health sectors.

Development assistance dedicated solely to mental health accounts for the equivalent of just 0.3% of all official DAH. Including development projects that mention mental health, total DAMH is equivalent to 1.7% of all official DAH from 2006 to 2016.

Figures 3a and 3b illustrate where all identified development projects that are dedicated to mental health or that mention mental health fall across OECD-defined subsectors. Of the projects that were dedicated solely to mental health, 44.8% by value came from the health sector. Projects that mention mental health present a different distribution across OECD-defined sectors, with just 22.6% by value coming from the health sector and the majority coming from the emergency response or population policies/programmes and reproductive health sectors.

Figure 3.

(A) Distribution of development assistance disbursements for identified projects dedicated to mental health, allocated per OECD-defined sectors. (B) Distribution of development assistance disbursements for identified projects that mention mental health, allocated per OECD-defined sectors.

Trends within mental health development assistance were further examined and categorized based on the main area of project focus. Three key areas of focus were identified among development assistance from projects that mention (but are not solely dedicated to) mental health: provision of social services and other health care; emergency response, conflict and natural disaster response; and HIV/AIDS management. Of the US$2 billion (US$2041.9 million) DAMH for development projects that mention mental health, US$718.9 million (35.2%) was allocated to the provision of mental health services in conjunction with social welfare services (e.g. primary education, vocational training) or other medical services and US$611.0 million (29.9%) was allocated to emergency response, i.e. natural disasters, conflict or violence. DAMH for development projects that mention mental health also allocated US$459.8 million (22.5%) in HIV/AIDS projects that included psychosocial support or other mental health services. The remaining US$252.2 million (12.4%) of development projects that mention mental health included broad areas of focus such as reconstruction projects, human rights and gender-based violence advocacy as well as legal and legislative processes.

Bilateral donor agencies and pharmaceutical companies

Based on a review of leading bilateral donor agencies’ websites listing key areas of focus or priorities, only the Austrian Development Agency (ADA) and the Swiss Agency for Development and Corporation (SDC) mentioned mental health within their global health and development portfolio (Table 2).^18,19 It should be noted that the CRS database findings of this analysis demonstrated that several bilateral donor agencies provided one-off funding for specific projects that involved mental health; however, only 2 of 15 bilateral donor agencies assessed specifically list mental health as an area of focus.^18–33

Table 2.

Areas of focus or priority for bilateral donor agencies as identified through review of organization websites

Bilateral donor agencies

Five of ten pharmaceutical companies included in the ancillary review mention mental health in their corporate social responsibility work.^34–43 However, two of these five companies focused their efforts specifically on mental health in a singular program in an upper-middle or high-income country: Abbott Laboratories in Russia and Bristol-Myers Squibb in the USA.^34,35

Discussion

Between 2006 and 2016, US$2451.0 million was allocated across 7734 projects involving mental health to any degree, of which only US$409.1 million (16.7%) was allocated to projects dedicated to mental health. Total DAMH disbursed per annum was greatest in 2016. Yet allocations to mental health remained consistently low across each year of the last decade.

Cumulative development assistance dedicated to mental health between 2006 and 2016 accounted for 0.3% of all DAH. This is low, particularly when compared with other sectoral priorities. For example, ‘STD control including HIV/AIDS’ accounted for almost 50% of development assistance for health between 2006 and 2016. HIV/AIDS accounted for 4.1% and 2.4% of global disability-adjusted life years in 2006 and 2016, respectively.(reference 7) Meanwhile MNS conditions accounted for 8.4% and 9.7% of global disability-adjusted life years in 2006 and 2016, respectively, yet total DAMH is less than any other OECD DAH category.⁷ While the allocation of official development assistance is not expected to be equivalent to the global disease burden, these figures serve as an indication of the priority placed on mental health in the development agenda.

The distribution of projects dedicated to mental health and those that mention mental health across OECD-defined sectors presents further variation between the categories differentiated by this article. While Figure 3a shows nearly 45% of DAH dedicated to mental health comes from the health sector, Figure 3b shows the emergency response and the population policies/programmes and reproductive health sectors as leading contributors to DAH that mentions mental health. Many of the projects in these sectors mention mental health services (such as psychosocial support) alongside the provision of food, shelter and hygiene or clinical HIV/AIDS services. It should also be noted that 97% of projects represented by the population policies/programmes and reproductive health sector in Figure 3b were further categorized by OECD as ‘STD control including HIV/AIDS’.

By including projects that were otherwise excluded from the core analysis due to OECD categorization as ‘Refugees in donor countries’, total DAMH would increase to 2.6% of all DAH. Yet being focused in European donor countries, this value was not considered appropriate to include in our results. All but one of these excluded projects involved some element of mental health alongside accommodation, language classes and social and legal services, thus being an upper estimate of DAMH.

Furthermore, the estimate of total DAMH presented in our analysis should be considered an upper limit of actual contributions to global mental health. Many of the projects incorporated into total DAMH reported in this article included mental health as a small component of other health and humanitarian work projects. Thus the total amount presented for projects that mention mental health is an inflated reflection of true global financial contributions towards mental health.

While this review focuses mainly on international contributions to mental health, domestic involvement must also be considered. The WHO Mental Health Atlas 2017 was consulted for a current picture of national support for mental health action across LMICs. In considering the WHO African, South-East Asia and Western Pacific regions, domestic government expenditure on mental health is estimated to be US$0.1–1.1 per capita.¹² Although there has been a positive increase in mental health legislation across the WHO member states, demonstrating that progress is being made, there is an enormous need for increased funding of mental health at both the domestic and international levels.¹²

Across the 15 bilateral donor agencies reviewed, only 2 specifically identify mental health as a funding or donation priority. The majority of bilateral donor agencies included in this analysis list communicable diseases—particularly HIV/AIDs, malaria and tuberculosis—alongside reproductive, maternal and child health as key areas of focus. These areas of focus may be ongoing priorities stemming from the Millennium Development Goals. In light of the inclusion of mental health as a priority in the Sustainable Development Goals (specifically targets 3.4 and 3.5),⁵ mental health may begin to see increased prioritization and funding from this sector over the coming decade. Of the 10 pharmaceutical companies included in the ancillary review, 5 list mental health as an area of focus.^34–43 However, unlike a mental health focus for bilateral donor agencies, these were generally of a narrower application. This includes two companies’ mental health–related objectives being for a specific upper-middle or high-income country only, therefore not development assistance related.^34,35

The strengths of this review include the project-by-project assessment of appropriateness for inclusion in the analysis, ensuring that only projects related to mental health contribute to the findings and that duplication across OECD categories is avoided. Furthermore, the use of an exhaustive list of search terms across all OECD sectors, as well as analysis over the most recent decade, provides a realistic baseline against which future investment in global mental health can be adequately compared.

The limitations of the study are the use of only English search terms, as well as the single-source financial information provided in the OECD database. Moreover, the amount of information in the database is not consistent across projects—some provide a paragraph of detailed information while others contain only a few descriptive words. Therefore assumptions made regarding the relevance of projects to mental health, as well as the degree of mental health inclusion within projects, could have affected our categorization of disbursements for analysis. Another limitation is the amount of time taken to manually assess OECD projects individually, which may limit the ability of this review to be replicated or the ability of future reviews to consider longer periods of time for analysis. Assessment of websites maintained by bilateral donor agencies and the pharmaceutical industry may not give a complete picture of the organization’s work; however, the listed areas of focus do suggest the general priorities pursued by the organization. The analysis relies on OECD disbursements to present a picture of global mental health funding, thereby not taking into account possible additional funds from private philanthropic donors and international non-governmental organizations (NGOs).

An earlier review of official DAMH by Gilbert et al.⁸ yielded different results than our findings. Our categories differentiated projects and found a lower level of funding for projects dedicated solely to mental health and a higher level of funding for projects that mention mental health.⁸ A further review of DAMH was performed by Charlson et al.⁹ in 2017 utilizing data from the Institute of Health Metrics and Evaluation. Their review found a larger amount of DAMH as a proportion of total DAH for the year 2015. However, their analysis was based on a data set inclusive of private philanthropy. With their finding of private philanthropy contributing 30% of all DAMH in 2015, there are significant differences due to data sources between reviews.⁹ The two other previously mentioned studies focused on DAMH among children and adolescents, a comparison outside the scope of this study.^10,11 Regardless, all articles reviewed emphasize the ongoing need for increased global funding towards mental health.

We conducted a systematic assessment of global development-related assistance for mental health and established categories that can serve as a baseline for future reviews and measurement of potential increases in funding.

Conclusions

Despite a renewed focus on mental health in the past decade by the WHO and development partners, financial assistance for mental health remains inadequate. Development assistance dedicated to mental health between 2006 and 2016 accounted for just 0.3% of all DAH.

Mental health is not currently a priority area for development partners: across 15 bilateral donor agencies, only 2 specifically identify mental health as a funding priority.

Given limited public expenditure on mental health care, particularly in LMICs, coordinated efforts from the international community and development partners—comprised of bilateral and multilateral donor agencies, NGOs, foundations and pharmaceutical companies—are critical to increasing services and care for the prevention and treatment of MNS conditions.

Authors’ contributions

BL and MW conceived the review and designed the review criteria. RG and MW carried out the review, classification of data and analysis. BL, RG and MW drafted the manuscript and critically revised the manuscript for intellectual content. All authors read and approved the final manuscript. BL and RG are guarantors of the paper.

Acknowledgements

The authors wish it to be known that, in their opinion, all three authors should be regarded as joint first authors.

Funding

None.

Competing interests

None declared.

Ethics approval

Not required.

Author notes

Current address: Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK.