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economic aspectsofthe

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Mental Health: Evidence and Research

Department of Mental Health and Substance Abuse


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WHO Library Cataloguing-in-Publication Data

Chisholm, Daniel.

Dollars, DALYs and decisions : economic aspects o the mental health system.

This document has been written by Dan Chisholm in collaboration with Shekhar Saxena and Mark van Ommeren--Acknowledgements.

1.Mental health services - economics. 2.Cost o illness. 3.Cost-benet analysis. 4.Health planning. I.Saxena, Shekhar.II.Ommeren, Mark van. III.World Health Organization. IV.Title.

ISBN 92 4 156333 8 (NLM classication: WM 30)

ISBN 978 92 4 156333 8

World Health Organization 2006

All rights reserved. Publications o the World Health Organization can be obtained rom WHO Press, World HealthOrganization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; ax: +41 22 791 4857; e-mail: [email protected]). Requests or permission to reproduce or translate WHO publications whether or sale or or noncom-mercial distribution should be addressed to WHO Press, at the above address (ax: +41 22 791 4806; e-mail: [email protected]).

The designations employed and the presentation o the material in this publication do not imply the expression o anyopinion whatsoever on the part o the World Health Organization concerning the legal status o any country, territory,city or area or o its authorities, or concerning the delimitation o its rontiers or boundaries. Dotted lines on maps rep-resent approximate border lines or which there may not yet be ull agreement.

The mention o specic companies or o certain manuacturers products does not imply that they are endorsed or rec-ommended by the World Health Organization in preerence to others o a similar nature that are not mentioned. Errorsand omissions excepted, the names o proprietary products are distinguished by initial capital letters.

All reasonable precautions have been taken by the World Health Organization to veriy the inormation contained inthis publication. However, the published material is being distributed without warranty o any kind, either expressed orimplied. The responsibility or the interpretation and use o the material lies with the reader. In no event shall the WorldHealth Organization be liable or damages arising rom its use.

The named authors alone are responsible or the views expressed in this publication.

Printed in Switzerland.


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Economic Aspects of the Mental Health System

TABLE OF CONTENTS

Executive Summary

1. Introduction 11

1.1 Rationaleforaneconomicperspectiveinmentalhealthpolicyandpractice 11

1.2 Economicsformentalhealthplanningandevaluation:asystemsapproach 14

2. Measuringtheburdenof mentaldisorders:

fromDALYstodollars 19

2.1 Epidemiologicalburden:disability-adjustedlifeyears(DALYs) 19

2.2 Economicburden:cost-of-illnessstudies 21

3. Reducingtheburdenof mentaldisorders:

fromglobaltonationalevaluation 23

3.1 WHOframeworkforcost-effectivenessanalysis 23

3.2 Globalevaluationof thecost-effectivenessof interventions 25

3.3 Nationalevaluationof thecost-effectivenessof interventions 30

4. Priority-settingandresourceallocationformental

healthsystemdevelopment 37 4.1 Decision-makingcriteriaforresourceplanningandallocationinhealth 37

4.2 Developmentof apriority-settingframeworkformentalhealthpolicy 39

4.3 Scalinguppriorityinterventions:nancialplanningandbudgetaryallocation 43

5. Conclusion 47

References 49 Appendices 53


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Acknowledgements

ThisdocumenthasbeenwrittenbyDanChisholmincollaborationwithShekharSaxenaandMarkvanOmmeren.Theworkreportedherewascarriedoutbytheteam,MentalHealth:

EvidenceandResearch(Coordinator:ShekharSaxena),Departmentof MentalHealthandSubstanceAbuse,WHO,Geneva.OverallguidanceandsupporthasbeenprovidedbyBene-dettoSaraceno,Director,DepartmentofMentalHealthandSubstanceAbuse.

The document has beneted from comments, advice and support from Jos Bertolote,MichelleFunkandVladimirPoznyak.CollaboratorsfromWHOregionalofcesinclude:ThrseAgossou,RegionalOfceforAfrica;JosMiguelCaldasdeAlmeidaandItzhakLe -

vav;RegionalOfcefortheAmericas;VijayChandra,RegionalOfceforSouth-EastAsia;MatthijsMuijen,RegionalOfceforEurope;MohammadTaghiYasamy,RegionalOfcefortheEasternMediterranean;andXiangdongWang,RegionalOfcefortheWesternPacic.

Feedbackandcommentsonthedraftversionwerereceivedfromthefollowingexperts:Jose-LuisAyuso-Mateos(Spain);TeiWehHu(USA);RachelJenkins(UK);CrickLund(SouthAfrica);AfarinRahimiMovaghar(IslamicRepublicofIran);R.Thara(India);HarveyWhit-

eford(Australia).

Fieldwork,thathasdirectlyorindirectlyenrichedthisdocumentwascarriedoutinChile(investigators:SandraSaldiviaBorquesandMarceloVillalon),Estonia(investigator:Marge

ReinpaandTaaviLai),Mexico(investigator:MariaElenaMedina-MoraandRicardoOro-zco),Nigeria(investigator:OyeGureje),Spain(investigator:Jose-LuisAyuso-Mateos)andSriLanka(investigator:NalakaMendis).

AdministrativesupportwasprovidedbyRosemaryWestermeyer.

ThegraphicdesignwasdonebyMrJean-ClaudeFattier.


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Executive Summary

Economic evidence for mental health action

Ahealthsystemsperspectiveprovidesanintegratedapproachtotheidenticationofin-formationandevidenceneedsfortheplanning,provisionandevaluationofmentalhealthprogrammes.Somerelevantmessagesfromtheeconomicdimensionof thisapproachare:

Informationontheburdenof mentaldisorders,whetherexpressedineconomicorepidemiologicalterms(i.e.inDollarsorDALYs[disability-adjustedlifeyears]),isapo-

tentiallyinuentialmeasureof therelativemagnitudeof mental,neurologicalandsub-stanceabusedisordersatthepopulationlevel,butisaninsufcientbasisforallocating

resourcesandsettingprioritiesforaction/servicedevelopment.Todate,studiesoftheeconomicburdenof thesedisordersusingcost-of-illnessmethodologycanbecharacter-izedbytheirvariablequalityandinconsistentapproachtotheidentication,measure -mentandvaluationof costs.Forsuchstudiestoproduceappropriateandcomparableestimatesofthetrueeconomicconsequencesofmental,neurologicalandsubstanceabusedisordersinthefuture,amajorrethinkappearstobeneeded.

Economicevaluationorcost-effectivenessanalysisofexistingservicearrangements

andcurrent/newinterventionstrategies(includingconsiderationoftheamountofburdenthatcanbeavoided),isanintegralpartof mentalhealthnancingandmentalhealthsystemevaluation,providingacheckonunfairorinefcientpracticeandabasisforrenewedactionorinvestment.Itisanecessarymechanismforidentifyinganefcient

allocationof mentalhealthresources(greatestgainforavailableresources),butaninsuf-cienttoolforsettingoverallprioritiesinthementalhealthsystem.

Forthebroaderprocessofpriority-settinginmentalhealth,theefciencyofparticu-larinterventionsortheircombinationintoservicepackagesneedstobesystematicallyweighedupagainstotherobjectivesorgoalsof thementalhealthsystem-inparticularfairness(withrespecttogeographicalornancialaccesstoservices),povertyreduction

andhumanrightsprotection-plusthefeasibility,acceptabilityandsustainabilityof theirimplementation.


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World Health Organization

Intervention impact and cost-effectiveness

Mentalhealthinterventionsencompassawiderangeof possibleactions,includinglegislativeandregulatoryframeworks,preventionandpromotion,treatmentandrehabilitation.Thereiscurrentlybesteconomicevidenceforthetreatmentendof thisspectrum.Onthebasisof ananalysisof thecomparativeeffectivenessandcostsof keypharmacologicalandpsycho-socialinterventionsforleadingcontributorstotheburdenof mentaldisorders,bothatthegloballevelof 14WHOsub-regions/sixWorldBankregionsandatthenationallevelinsix

WHOMemberStates,anumberofoverallndingscanbestated:

Pharmacologicalinterventions:Currently,thehighacquisitionpriceof newer(atypi-cal)antipsychoticdrugsmakestheiruseinmostlower-incomeregionsoftheworldin-advisableonefciencyoraffordabilitygrounds(althoughthissituationshouldchangeasthesedrugscomeoff patent);conventionalneurolepticdrugshavesimilarefcacyandarecurrentlymuchcheaper.Foranti-depressants,olderandnewerdrugsalsohavesimi-larefcacybutthepricedifferencebetweenoldertricyclics(TCAs)andnewer(generic)SSRIsismuchsmaller-andincertaincountriessuchasIndiaorSriLanka,negligible-meaningthatthetreatmentof choiceismorecontext-specicandcanbedrivenbypa-tientorclinicalpreferences.Long-termmaintenancetreatmentof depressionwithanti-depressantdrugshasamuchlargerimpactonreducingtheburdenof depressionthan

episodictreatment,andalsorepresentsacost-effectivestrategy.First-lineanti-epilepticdrugssuchasphenobarbitalandphenytoinhavesimilarefcacytoothercommonlyusedanti-convulsants(e.g.carbemazaepineorvalproicacid),butarecheapertobuyand

thereforemorecost-effective.

Psychosocial interventions: the relativelymodest additional cost of adjuvant psy-chosocialtreatmentisexpectedtoreapsignicanthealthgains,therebymakingsuchacombinedstrategyforschizophreniaandbipolardisordertreatmentmorecost-effectivethanpharmacotherapyalone.Forpeoplewithdepressionoranxiety,psychotherapyisexpectedtobeas cost-effective asnewer (generic)antidepressants.Clearly, however,thereremainsamajorhumanresourceconstraintinmakingpsychosocialinterventionsmorewidelyavailable.

Affordability:Themostefcientinterventionsforcommonmentaldisorderssuchas

depressionandpanicdisordercanbeconsideredverycost-effective(eachDALYavertedcostslessthanoneyearofaveragepercapitaincome),whilecommunity-basedinterven-tionsformoreseverementaldisordersusingolderanti-psychoticandmood-stabilizingdrugsstillmeetthecriterionforbeingcost-effective(eachDALYavertedcostslessthanthreetimesaverageannualincome).Inotherwords,thereis justasmuchof aneco-nomicrationaleforinvestinginmentalhealthasthereisinotherchronic,non-commu-nicablediseasessuchasdiabetesorhypertension.Someotherinterventions,however,forexamplehospital-basedtreatmentof schizophreniawithneweranti-psychoticdrugs,aresimplynotacost-effectiveuseof resourcesinthecontextof low-ormiddle-incomecountries.


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Essentialpackagesof mentalhealthcare:Acrosssixlow-andmiddle-incomeWorldBankregions,itisestimatedthataselectivepackageof cost-effectivementalhealthin-

terventionscouldbeimplementedatacostofUS$3-4percapitainlow-incomesettingssuchasSub-SaharanAfricaandSouthAsia,anduptoUS$7-9inmoremiddle-incomeregions(LatinAmericaandtheCaribbean;EuropeandCentralAsia).ThismeansthatforeveryUS$1millioninvestedinsuchamentalhealthcarepackage,350to700healthyyearsof lifewouldbegainedoverandabovewhatwouldoccurwithoutintervention.Atthenationallevel,aselectedpackageof careforschizophrenia,depression,epilepsyandalcoholmisuseinNigeriawasestimatedtocost80Nairapercapita(lessthanone

USdollar).

Policy and service implications

Serviceorganization:Mentalhealthservicesconguredaroundacommunity-basedmodelachievesimilarmentalhealthoutcomestohospital-basedservices,butarelesscostlytomaintain.However,shiftingawayfromcurrentlyinefcientstructuresandpractices(includingrelianceonhospital-basedservices)toamoreeffectiveandefcientallocationof resources(towardscommunity-basedservices) impliesapotentiallyradi-calreorganizationof thementalhealthsystem,notonlyintermsofstrategicpolicybutalsointermsof otherdimensionsincludinghumanresourcedevelopment,capitalinfra-

structure(primarycareanddistricthospitals),anddrugprocurement/distribution.Tofacilitatethisshift,bridgefundingislikelytobeneeded.

Financialandhumanresourceneeds: Basedontheuseofefcientinterventions,thenancialimplicationsof scaling-uptheeffectivecoverageof keymentalhealthcarestrategiesneednotbeoverwhelming(lessthanUS$10inmiddle-incomecountries,andwellbelowUS$5percapitainlow-incomecountries;incountriessuchasNigeriaorSriLanka,forexample,itisexpectedtobeintherangeof justUS$1percapita).However,currentbudgetaryallocationstomentalhealthinmanylow-andmiddle-incomecoun-triesareoftenverylow,relativeto theneedforcareandsupport.Accordingly,thereisanevidentneedtoincreasethementalhealthbudgetif thecurrentclinicalandeco-nomicburdenattributedtomentaldisordersistobesignicantlyreduced.Tomatchthe

resourcebaseavailabletothemostcomprehensivementalhealthsystemsintheworld,countriesshouldexpecttoallocateupto10%,andaminimumof 5%,ofthetotalhealthbudgettomentalhealth.

Non-health benefts:Inadditiontothereducedpsychiatricmorbidityassociatedwiththeintroductionofcost-effectivetreatments,thereareanumberof otherbenetsthatowfromtheiruse,mostnotablyreductionsinfamilyburden/informalcare-givingatthehouseholdlevel,andhigherratesof participationinthelabourforce/reducedlevelsof crimeandantisocialbehaviouratthecommunitylevel.Theevidenceunderpinningthesearguments,however,needstobestrengthenedthroughwell-designedresearch.


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1. Introduction

Objectives o report

Tohighlighttheneedforandrelevanceof aneconomicperspectiveintheassessmentof mentalhealthsystemsinWHOMemberStatesandinplanningandimplementingactionfortheirstrengthening.

Toprovideasummaryof resultsfrommentalhealtheconomicanalysesundertakenbothatthelevelof WHOregionsandMemberStates,includingkeymessagesforstrengthen-ingof mentalhealthsystems.

Target audience

Healthplanners,policy-makersandanalystsinWHOMemberStateshavearesponsibil-ityforstrengtheningmentalhealthsystemsandtheirmonitoringandevaluation.

Healthserviceresearcherswithaninterestinmentalhealthsystem,evaluationand

nancing.

1.1 Rationale or an economic perspective in the development and

strengthening o mental health systemsAsanintegralcomponentof health,mentalorpsychologicalwell-beingmakesupavaluablepartofanindividualscapacitytoleadafulllinglife,includingtheabilitytostudy,work

orpursueleisureinterests,andtomakeday-to-daypersonalorhouseholddecisionsabouteducational,employment,housingorothersocialchoices.Disturbancestoanindividualsmentalwell-beingadverselycompromisesthesepersonalandhouseholdcapacitiesandpos-sibilities,oftenonlyinasmall,transientway,butsometimesalsoinamorefundamentalandenduringmanner.

Whetherovertheshort-orlong-term,thepotentialconsequencesofmentalill-healthatthe

householdlevelarenumerous,includingdisturbedmood,thoughtorfunctioningamongaffectedindividuals(ortheircaregivers),andforegoneearningsorsavingsasaresultofimpairedworkabilityorhealthcareexpenditures.Mental ill-healthamongindividualsorhouseholdsexertsapressureoncommunitiesandsocietiestoprovidearangeofhealthandwelfareservicesontheirbehalf (mostoftenfundedfromthetaxesthathouseholdspay),a

consequenceofwhichisthatresourcessodirectedarethennotavailableforotherpotentialchannelsofpublicinvestment.

Economicsisconcernedwiththeuseanddistributionof resourcesamongtheindividualsmakingupasociety,andhowdifferentwaysof allocatingresourcesimpactsontheirwell-be-ing.Economicsentersintothehealthspherebecauseresourcesavailabletomeetallpossible


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societalneedsordemandsforhealthcareandpreventionarenite,meaningthatchoicesordecisionssomehowhavetobemaderegardinghowbesttoallocatetheseresources(typi-

callyinordertogenerateormaintainthegreatestpossiblelevelof healthinthepopulation).Economicsprovidesanexplicitframeworkforthinkingthroughdifferentpossiblewaysof allocatingresourcesinhealth.

Resourceallocationdecisionsinmentalhealtharecomplicatedbythefactthatmentalill-healthiscommon,debilitatingandoftenlong-lasting.Recentepidemiologicalresearchhasclearlydemonstratedtheconsiderable(andpreviouslyunderestimated)epidemiologicalbur-denthatmentaldisordersimposeontheworldasawhole(morethan10%of lostyearsof

healthylifeandover30%of allyearslivedwithdisability;WHO,2001).Theenormityof thisdiseaseburdenisdrivenbytherelativelyhighprevalenceof thesedisorders,theoftenchronicnatureoftheircourseandtheseverityof disabilityassociatedwithmentalill-health.

Lowratesof caserecognitionandeffectivetreatmentservetocompoundtheproblem,par-ticularlyinpoorcountries.

Itisimportanttonotethatdiseaseburdenisnotinitselfsufcientasamechanismforre -sourceallocationandpriority-settinginhealthcare.Adiseasecanplaceaconsiderablebur-denonapopulationbutif appropriatestrategiesorinterventionstoreducethisburdenareabsentorextremelyexpensiveinrelationtothehealthgainsachieved,large-scaleinvestmentwouldbeconsideredmisplaced(sincescarceresourcescouldbemoreefcientlychannelledtootherburdensomeconditionsforwhichcost-effectiveresponseswereavailable).Inother

words,thesizeoftheburdenaloneisnotsufcienttoguideaction.Forpriority-settingandresourceallocation,amorepertinentquestionistoaskwhatistheamountof burdenfrom

aparticulardiseasethatcanbeavoidedthroughtheuseof evidence-basedinterventionsandwhatistherelativecostoftheirimplementationinthetargetpopulation.

Thelasttwodecadeshaveseenanever-increasinginterestin,anddemandfor,economicanalysisofmentalhealthcareandpolicy,fuelledbygovernmentconcernsaboutrisesinhealthcareexpenditures(Singhetal,2001).Considerationsof costandcost-effectivenessenterintohealthcarereformprocesses,priority-settingexerciseswithinandacrosshealthprogrammes,andregulatorydecisionsconcerningdrugapprovalorpricing.Despitetheneedforcost-effectivenessevidence,however,thereremainsarelativepaucityof completedmen-

talhealtheconomicevaluationsfrombothdevelopedanddevelopingcountries(ShahandJenkins,1999).Recently,forexample,resourceowsintoprovidingmentalhealthandpsy-

chosocialassistancetopopulationsaffectedbyemergencieshaveshownamarkedincrease.However,theevidencebasefor(cost-)effectivenessof interventionsinthisareais ratherweak(Mollicaetal,2004).

Mostcompletedeconomicevaluationsinmentalhealthcarehavebeenconcernedwithspe-cictreatmentmodalitiesforpsychosesandaffectivedisorders,inparticularthecost-effec-tivenessof differentpsychotropicmedicationsand,morerecently,variouspsychotherapeuticapproachestothemanagementofthesepsychiatricdisorders(Knappetal,1999;Rosen-baumetal,1999).Manymentalhealtheconomicstudiesundertakentodatesufferfromanumberof technicalshortcomings,includingsmallsamplesizesanduncontrolledstudy

designs.Thereisaconsequentneedtogeneratebetterestimatesofboththecostsandrela-


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tivecost-effectivenessof interventionsinordertousefullyinformmentalhealthpolicyandplanning,bothatthenationalandinternationallevel.

Developmentofsuchaneconomicevidencebaseinmentalhealthcanbeachievedintwoways.Preferably,itwouldbegeneratedviaadditionalempiricalstudiesinarangeof socio-economicsettings(particularlydevelopingcountries,wherecurrentevidenceismostscarce).Well-designedeconomicevaluationsofmentalhealthcareandpreventionstrategiesarecer-tainlyneededandvaluable,buttheyarealsodifcult,time-consumingandexpensivetocarryout(aswellashavinglimitedapplicationbeyondtheimmediateconnesof thestudyloca-tion).Thismeansthatitishighlyunlikelythatasufcientevidencebasewillbegeneratedinthisway,evenwithinthenexttenyearsorso.Alternatively,andmoreimmediately,current

informationgapscouldbelledviaappropriatemodellingof bestavailabledataconcern-ingtheexpectedcostsandeffectsof interventionsinthesedifferentsettings.Thedanger

of thislatterapproachliesintheinevitableassumptionsthatarerequiredtobemadewhenbasingcost-effectivenessestimatesonavarietyof datasourcesfromdifferentresearchset-tings,whiletheattractionis thatpolicy-relevantresultscanbegeneratedrelativelyquicklyandinexpensively.

Inshort,thewideningrecognitionofmentalhealthasasignicantinternationalpublichealthissuehasledtoanincreasingneedtodemonstratethatinvestmentofresourcesintoservicedevelopmentisbothrequiredandalsoworthwhile.Specically,thereisaneedtogenerateev-idenceonmentalhealthcarestrategiesthatarenotonlyeffectiveandappropriatebutarealsocost-effectiveandsustainable.Economicanalysisprovidesasetof principlesandanalytical

techniqueswhichcanbeusefullyemployedtoassesstherelativecostsandconsequencesofdifferentinterventionstrategies.Itseekstoaddressanumberofkeypolicyquestionsaboutthemagnitudeofmentalhealthproblems,therelativeeffectandcostofdifferentinterven-tionstrategiesandthemostappropriateuseofscarceresources(seeTable1below).

Table 1 Mental health policy questions or intervention (cost-)eectiveness

Policy question Research task Evidence generated

1. How signicant is the burden omental disorders?

Estimate burden o diseaseIdentiy other social & economicconsequences o disorders

% o total burden caused by mentaldisorders% o mental disorder burden caused

by dierent conditions (e.g. depres-sion)

2. How eective are interventionsor burden-some conditions?

Estimate current eective coverageAssess impact o new interventions

Comparative ecacy o interventions% o burden averted with currentinterventionsor avertable with better strategies

3. What will it cost to provide eec-tive care?

Calculate ull cost o interventionsEstimate cost o scaling-up coverage

Comparative cost o interventionsat dierent levels o coverage in thepopulation

4. What are the most ecient

strategies?

Integration o costs and eectiveness

Specication o essential packages

Evidence-based priorities or the e-

cient allocation o mental health careresources


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Inaddition,economicconsiderationsenterintothedebatearoundanumberof othermen-talhealthsystemcomponents,inparticularthefairandefcientnancingof mentalhealth

services.Anoverviewof thewayinwhicheconomicconsiderationsrelatetodifferentcom-ponentsofthementalhealthsystemisprovidedinthenextsection.

1.2 Economics or mental health planning and evaluation: a systemsapproach

Notionsof whatismeantbythementalhealthsystemarebynomeansuniversallyagreedupon,andin factdifferaccordingtotheparticularanalyticalviewpointof theinterestedparty.Forexample,someoneresponsiblefordevelopinganinformationsystemformentalhealthmayviewsystemdimensionsandrequirementsdifferentlytoadistrictmentalhealthmanager.Thisdocumentisnottheplacetoelaborateatanygreatlengthonthisissue,butitisneverthelessimportanttoprovideasimpleframeworkinordertothinkthroughthevari-ouswaysinwhichaneconomicapproachmayimpactondistinctactivitiesorfunctionsofamentalhealthsystem.

Theneedforasystemsapproachtomentalhealthpolicyandplanningismadeapparentfromasimpleillustration:cheap,effectivedrugsexistforkeyneuropsychiatricdisorders,includ-ingtricyclicanti-depressants,conventionalneurolepticsandanti-epilepticdrugs,whichare

affordableeventoresource-poorcountries;theavailabilityandprescriptionof thesedrugstothoseinneed,however,isdeterminedbothbytheextenttowhichsuchdrugshavebeen

distributedandbytheabilityofhealthcareproviderstodetectandappropriatelytreattheunderlyingcondition;accesstoanduseof suchmedicationmayfurtherbehamperedbytheprivatecostof seekingandreceivinghealthcare,particularlyifitisout-ofpocket;userfees,providerincentivesandclinicalpracticeareinturninuencedbytheavailabilityof nationallegislation,regulationandtreatmentguidelines.

Onepotentially valuableframeworkforthinking throughthecomponentsof a (mental)health system isthatrecentlyproposedby theWHO,whichoutlinesa numberof goalsandfunctionsconsideredcoretoanyhealthsystem(WHO,2000).Whilehealthimprove-mentisunquestionablytheprimarygoalof ahealthsystem,twoother(social)goalsarealso

proposed:therstisfairnancinginhealth,whichseekstoensurethatthenancialriskseachhouseholdfaceswithrespecttohealtharedistributedfairly,thatis,accordingtotheirabilitytopay;andthesecondhastodowithhowwellthehealthsystemrespondstothereasonableexpectationsof thepeopleitseekstoserve,suchasensuringthequalityof healthfacilitiesandpreservingrespectforthedignityof thesystemuser.Similargoalshavebeenappliedwithinthecontextof mentalhealthpolicyandplanninginanumberof developedanddevelopingcountries,includingthepursuitof improvedpsychologicalwell-beinginthepopulation,qualityimprovementsinmentalhealthserviceprovision,andnancial(aswellashumanrights)protectionforthementallyill(WHO,2004;p.28-29).

Meetingthesegoalsisachievedviaanumberof keyhealthsystemfunctions,includingthe

generationof resources,allocationof thoseresourcesviaappropriatesmodesof nancing,


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theactualprovisionof services,andoverallstewardship(oversight)andevaluationof thesevariousfunctions(WHO,2000).Figure1belowprovidesanoverviewofhowdifferent

strategicactivitiesandfunctionscontributetotheattainmentof thementalhealthsystemsoverallobjectives.

Figure 1 Functions and goals o a mental health system

1.(Re)generate mentalhealth resources Human resources (investment, training)

Financial resources (budgetary allocation)

Infrastructure (capital facilities)

Information (burden, policies, laws)

4.Evaluate m entalhealth system Mental health surveillance

Mental health care evaluation

Mental health service reform

Revise policies / priorities

2. Provi dementalhealthservices Mental health service organisation / delivery

Mental health financing (insurance, payment)

Manage human & other resources

Manage / oversee / regulate system

3.Meetmentalhealth system goals Produce mental health improvements

Protect households from financial risk

Deliver appropriate quality care to users

Reduce inequity via better access to care

Many of these generic health system functions are represented in existing instrumentsformonitoringmentalhealthservicedevelopmentincountries.However,theseindicatorschemesareneithercomprehensiveenoughnorsufcientlyapplicabletoresource-poorset-tings(Saxenaetal,2006).Inresponsetotheselimitations,WHOhasrecentlydeveloped

theWHOAssessmentInstrumentforMentalHealthSystems(WHO-AIMS)(WHO,2005).

WithinWHO-AIMS,thementalhealthsystemisdenedasalltheactivitieswhoseprimarypurposeistopromote,restoreormaintainmentalhealth.Thementalhealthsystemincludesallorganizationsandresourcesfocusedonimprovingmentalhealth,andiscomprisedof sixdomains,eachof whichcanbemappedontothegenerichealthsystemframeworkaboveasfollows:1)Policyandlegislativeframework(RESOURCEGENERATION);2)Mentalhealthservices(PROVISION);3)Mentalhealthinprimarycare(PROVISION);4)Humanresources(RESOURCEGENERATION,PROVISION);5)Publiceducationandlinkswithothersectors(PROVISION);6)Monitoringandresearch(EVALUATION).Itshouldnev-erthelessbeacknowledgedthatWHO-AIMSisprimarilyfocusedonprocessoutcomesre -

latedtosystemorganizationanddeliveryratherthanassessmentofimprovedmentalhealth

statusinthepopulation.Theeconomicissuesunderlyingthefourdistinctfunctionsof the(mental)healthsystemaresummarizedbelow.


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Ingeneralterms,fundingformentalhealthservicesis lowrelativeto identiedneedsforservicesatthepopulationlevel.30%of 184countriesrecentlysurveyedaspartof theAT-

LASproject(WHO,2005)didnothavea speciedmentalhealthbudget(althoughmanyof thesecountriesdomakenancialallocationsformentalhealthcareaspartof devolvedbudgetsdowntostateleveloraspartof primaryhealthcare).Of thosethatdohaveaspeci-edbudget,20%spendlessthan1%of thetotalhealthbudgetonmentalhealth(mostlyinAfricaandSouth-EastAsia).Onlyahandfulof countriesworldwidedevotemorethan10%of thetotalhealthbudgettomentalhealth.

Allhealthnancingsystems,howeverorganized,sharethreekeyfunctions(WHO,2000):

revenuecollection(i.e.hownancialcontributionstothementalhealthsystemarecol-lectedfromdifferentsources,andviawhatmechanism(tax,insuranceetc.);

riskpooling(i.e.hownancialcontributionsarepooledtogethersothattheriskof hav-

ingtopayformentalhealthcareisnotbornebyeachcontributorindividually);

purchasing(i.e.howcontributionsareusedtopurchaseefcientmentalhealthserv-ices).

Concerningrevenuecollection,therearenowgooddataontherelativecontributionof dif-ferentnancingmechanismstowardsthecostof mentalhealthcareprovision,bothatthecountryandregional level(WHO,2005).Whiletax-basednancingisthemostcommonmechanism,itisof particularnotethatout-of-pocketexpenditurebyhouseholdsisalsoa

commonlyusedmechanismforpurchasingmentalhealthservicesincertain,mainlylow-in-come,regionsof theworld.WHOsMentalHealthAtlas(WHO,2005)guresdemonstratethat17.8%of 121countriesreportingonthisaspecthadout-of-pocketpaymentasthemostcommonmethodof nancingmentalhealthcare. Itiswidelyacknowledgedthatout-of-pocketpaymentsarearegressiveformof healthnancing(theypenalisethoseleastableto

affordcare)andrepresentanobviouschannelthroughwhichimpoverishmentmayoccur.

Economicsasadisciplinehasprovidedanumberof importantinsightsintothetheoryandpracticeofrevenuecollectionandriskpooling.Examplesincludethefollowing:

thepotentially'catastrophic'impactof private,out-of-pocketpaymentsontheincomeandsavingsof householdswithamentallyillmember(e.g.arecentstudyinGoa,Indiafoundthat15%ofwomenwithacommonmentaldisorderspentmorethan10%ofhouseholdincomeonhealth-relatedexpenditures;Pateletal,2006);paymentsareoftenmadetolocalorindigenouspractitionersforconsultationsormedicamentsthathavenoproveneffect.

thedetrimentalconsequencesof competitive(non-compulsory)insurancemarketsforpeoplewithchronicmentalhealthproblems,suchas restrictingbenetsorexcludingcoverageforhigher-riskindividuals(FrankandMcGuire,1998);

theadvantagesof pre-paymentmechanismssuchastax-basednancingasamechanismforeffectiveaccessto(relativelyhighcost)mentalhealthcare(Knappetal,2006);and


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thepotentialnancialshortfallsthatmentalhealthservicesundergoingaprocessofdeinstitutionalisationmayface,andtheconsequentneedtoprovidebridgefundingand

newcapitalinvestmentwhilecommunity-basedservicesarebeingsuccessfullyestab-lished.

Service provision

Overandabovetheclinicalorpublichealthinterventionsthatareactuallyprovided,keyaspectsofamentalhealthservicedeliverysystemincludehowitsvariousprogrammes,pro-vidersandfacilitiesareorganized,coordinatedandalso,inthefaceofunderlyingincentives,

howtheyareregulated.Thereareeconomicdimensionstoallof theseaspectsof serviceprovision,forexample:

attemptstorecongurementalhealthservicesawayfromhospital-basedtocommu-nity-basedsettings-forexample,viaassertivecommunitytreatment-carryimportanteconomicimplications,ashasbeendemonstratedinanumberof countriessuchastheUK,theUSandItaly(Cutleretal,2003;Knappetal,1997;ThornicroftandTansella,2004);

reformstothe(generalormental)healthsystemtypicallyleadtochangesintheincen-tivesfacingserviceproviders(ChisholmandStewart,1998;Knappetal,2006);manyof theseincentiveshaveadirecteconomicrationale(forinstance,separationof thepur-chasingofservicesfromtheiractualprovisionisintendedtopromotequalityaswellas

efciencyimprovements),butneedtobecarefullymonitoredinordertopreventmoreperverseincentivescreepingin(suchasexcludingfromhealthplansmentallyillindividu-alsliabletogenerateheavyuseof resources);

specicationoftherespectiverolesofpublic,privateandnon-governmentalproviderscanbenetgreatlyfroma'mapping'of themixedeconomyof mentalhealthcare,pro-vidingasitdoesaninsightintotheinter-connectionbetweeneachsector'scontributiontonancingaswellasprovision(WHO,2003a,p.19-26).

analysisoftheeconomicorresourceimplicationsofmentalill-healthonother(non-health)agencies,includingthecostsof providingsocialcareorwelfaresupport,orthecoststoeducation,housingandcriminaljusticeservices.

Stewardship / oversight

Thelast(butnotleast)ofthefourcorefunctionsidentiedwithintheWHOhealthsystemframeworkrelatestotheoverallmanagementorstewardshipofthesystem,namelyensur-ingthatplanning,provisionandevaluationactivitiestogethercontributetotherealizationof theoverallaimsorgoalsof thesystem.Inthepresentcontext,itcloselyrelatestotheformu-lation,executionandmonitoringofMentalHealthPlans,PoliciesandProgrammes(WHO,2004),whichoffersanumberof stepsforthinkingthroughtheinformationneeds,priorities

andresponsibilitiesof differentstakeholdersinthementalhealthsystem.


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Economicsisbutoneof manydisciplinaryperspectivesthatcontributestothispolicyandplanningframework,andentersintotheprocessviaitscontributiontotheunderstandingof

othersystemfunctions,whichincludethefollowing:

therelativemeritsofnationalorsocialinsuranceoverprivateinsuranceandout-of-pocketexpendituresasequitablemechanismsforsafeguardingat-riskpopulationsfromtheadversenancialconsequencesof psychiatricdisorders;

therespectiverolesof public,private,voluntaryandinformalprovidersandtheirinter-action;

theimpactofclinicalpracticeguidelines,strategicframeworksandnationalmentalhealthpoliciesoncreatinganeeds-based,responsivementalhealthsystem;

the costs and cost-effectiveness of different mental health care and preven-tion strategies, together with an assessment of their feasibility and nancial con-sequences;use of suchdata isbeingincreasinglyusedby regulatorybodies charged

with reimbursement or other allocation decisions (e.g. Rawlins and Culyer, 2004).

2. Measuring the burden o mental disorders:

rom DALYs to dollars

2.1 Epidemiological burden: disability-adjusted lie years (DALYs)

Psychiatricepidemiologyrepresentsacommonstartingpointformanyeconomicanalysesof mentalhealthcareandpolicy,whetheronthebasisof identiedsocio-economicriskfac-torsforpsychiatricmorbidity(suchasincomelevel/poverty,oremploymentstatus),under-lyingincidence,prevalenceandotherdataformodellingeconomicburdenorinterventioncost-effectiveness,orcollaborativestudydesignforclinicalandeconomicevaluations.While

theultimateobjectivesof thetwodisciplines(healtheconomicsandepidemiology)maydif-

ferefciencyconcernsontheonehand,aetiologyandriskfactorsontheotherbothareessentiallypitchedatunderstandingtheconsequencesof diseaseanditstreatmentatthelevelofthepopulation.Assuch,thetwodisciplinescanbeviewedasofferingcomplementaryperspectivesonmentalhealthplanningandevaluation.

Agoodexampleof thelinkbetweenhealtheconomicsandepidemiologyrelatestothees-timationofnationalandglobaldiseaseburden.Inparticular,theGlobalBurdenof Disease(GBD)studysetouttoprovideasetof internallyconsistentestimatesof incidence,preva-lence,durationandcase-fatality for107conditionsandtheir483disablingconsequences,whichcouldbeusedtogeneratesummarymeasureof populationhealthcapableof being

linkedtoresourceallocationdecisions(MurrayandLopez,1996).


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ThemainsummarymeasureusedintheGBDstudywastheDisabilityAdjustedLifeYear(DALY).OneDALYcanbethoughtof asonelostyearof healthylifeandtheburdenof

diseaseasameasurementofthegapbetweencurrenthealthstatusandanidealsituationwhereeveryonelivesintooldagefreeof diseaseanddisability.Thedisabilitycomponentof thissummaryhealthmeasurewasscoredaccordingtotheseverityofthediseasesequela(forexample,disabilitycausedbymajordepressionwasfoundtobeequivalenttoblindnessorparaplegia).

Following theincorporationof disability intodiseaseburdenestimates,mentaldisordersrankedashighascardiovascularandrespiratorydiseases,andexceededallcancerscombinedorHIV (MurrayandLopez,1996).TheGBDstudythus revealedthemagnitudeof the

longunderestimatedimpactof mentalhealthproblems,therebyposingnewopportunitiestopolicyformentaldisorderswithunmetandgrowingneedsinbothdevelopedanddeveloping

countries.

Inhighlightingtheproportionateburdenof diseaseattributabletodifferenthealthcondi-tionsandcausesof mortalityatglobalandregionalpopulationlevels,theGlobalBurdenof Diseasestudyrepresentsafundamentalmoveforwardinbridgingthegapbetweenmortalityandtheimpactof disability.Theresultsof theGBDstudyhavebeenextremelyinuentialandhavebeenwidelyusedasajusticationforgreaterinvestment,notleastinpsychiatryandrelatedeldsasaresultof thehighburdenattributedtothesedisorders.

DALYssharemanyof thecharacteristics(andlimitations)of QualityAdjustedLifeYears

(QALYs).ThekeydistinctionbetweenthetwomeasuresisthatQALYsareanoutputtobegained(qualityof lifebeingapositiveoutcomedomain)whileDALYsareanoutputto

beavertedthroughhealthcareinterventions.Theoutstandingfeatureofbothformsofmeasurementisthattheyofferasetof parametersanddimensionswithwhichtocompareinterventionsfordifferentconditions,aswellasfordifferentinterventionsforaspeciccon-ditionunderinvestigation.Theyalsoprovideanexplicitframeworkwithinwhichtoassesstherelativeburdenof diseaseortherelativeeffectivenessof alternativeinterventions,inthesensethatmethodologicalassumptionsarelaidbaretosee.

However, it is important tobeaware of the limitationsof theDALYapproach and itsdatasources.Forexample,someof thebasicinputsforepidemiologicalestimates(suchas

informationon incidence,durationortreatmenteffect)donotexistformanydevelopingcountries,suchthatestimatesforwholesub-regionsoftheworldmaybeextrapolatedfromneighbouringregions. Justas importantly,andin commonwithotherdiseasecategories,

good-qualitydescriptivedatauponwhichtoassessthedegreeof disabilityduetodifferentmentaldisorderswere(andstillare)largelylacking.Inaddition,theinclusionof co-morbidityintheGBDstudyhasbeenlimited;giventhehighratesof co-morbidityof mentaldisordersandphysicaldisorders,factoringthisphenomenaintofuturecalculationsof diseaseburdenwouldconstituteapotentiallysignicantimprovement.Finally,DALYestimatesoftheburdenof neuropsychiatricdisorderstakeintoaccountneitherthepotentialhealthconse-quencesonpeopleotherthanthediagnosedcase(suchastheburdenonfamilymembersor

caregivers),northenon-healthconsequencesof disease(suchaslostabilitytowork).


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2.2 Economic burden: cost-o-illness studies

Diseaseburdenhasalsobeenestimatedfromaneconomicperspectiveformanyyearsintheformof so-calledcostof illnessstudies,whichhaveattemptedtoattachmonetaryvaluestoavarietyofsocietalcostsassociatedwithaparticulardisorder,oftenexpressedasanannualestimateaggregatedacrossallinvolvedagencies.

Suchstudieshavedirectparallelswithepidemiologicalestimatesof diseaseburden,in thesensethattheprincipalaimistoinuencepolicy-makingandresourceallocationbydemon -stratingtherelativemagnitudeorburdenassociatedwithaparticulardisorder(bymultiplyingcaseprevalencebycostpercase,putverycrudely).Thepotentialadvantageof costofillnessstudiesoverDALY-basedburdenestimatesof burdenis thattheyareabletomeasureinasinglemetric[money]notonlythedirecthealth-relatedimpactof disease(intermsof health

carecostsetc.)butalsoothereconomicconsequencessuchaslostworkorleisuretime,andfamilyorcaregiverburden.

Box 1 Cost o illness and psychiatric disorders

Psychiatric disorders impose a range o costs on individuals, households, employers and

society as a whole. A proportion o these costs are nancially sel-evident, including the

varied contributions made by service users, employers and taxpayers/insurers towards

the costs o treatment and care, and the productivity losses resulting rom work disability

and impaired work perormance. There are a series o urther costs, which although not

so readily quantiable in monetary terms also represent potentially signicant economic

costs, including inormal care inputs by amily members and riends, treatment side-eects

and mortality.

Where a comprehensive estimate o overall economic burden or depression has been at-

tempted, or example, total estimated costs (1990 price levels) amount to 3.4 billion in the

UK, and between $30-40 billion in the US (Kind and Sorensen, 1993; Rice and Miller, 1995). A

common eature o these studies is that the lost productivity costs exceed the direct costs

o care and treatment, sometimes by as much as six or seven times.

Costofillnessstudiesintheareaofmentalhealth,neurologyandaddictionhavebeenfo-cusedonaselectiverangeof disorders(inparticularschizophrenia,depression,epilepsyandalcoholabuse)inonlyahandfulof countries(seeBox1);assuch,theyhavelimitedrelevancetoamoreinternationalperspectiveof theeconomicburdenassociatedwithabroaderrangeof neuropsychiatricconditionsintheglobalpopulation.

Furthermore,thereremainsanoutstandingconcernthattherelianceonthehumancapital

approachtocostinglostproductivityleadstoanover-estimationof thetotalcostburden.

Thehumancapitalapproachassumesthatwhenanindividualisabsentfromworkthereisacorrespondingreductioninnationalproductivity.However,lostworktimecansometimesbe


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made-upwhentheindividualreturnsandreplacementworkerscanbetakenfromthepoolof unemployedlabourtoreplacethosewhoareabsent.Insuchcircumstancesthehuman

capitalapproachwillsubstantiallyoverestimatethecostoflostemployment.Analternativeapproach,theso-calledfriction-costmethod,takesthesecounterbalancinginuencesintoaccountbycountingonlytheproductionlostforthe(friction)periodoverwhichareplace-mentworkerisfound.InanapplicationofthismethodtoCanada,Goereeetal(1999)esti-matedthatthecostof lostproductivityresultingfromschizophrenia-relatedmortalitywas$1.53million,asopposedto$105millionif thehuman-capitalapproachhadbeenused(a70-folddifference!).

Concerningtheindirectcostsof illness,theconventionalapproachhasbeentoestimate

lostlabourproduct(of bothwagedandnon-wagedworkers)arisingfromillnessordeathasaresultof beingdiseased.Theselostproductivitycostsarethenusuallycombinedwith

directhealth-relatedcoststocreateanoverallcostofillnesstosociety(againoftenex-pressedinrelationtogrossnationalproduct).However,sincethelostproductivetimeofhomemakers/informalcaregivers(whichhasaneconomicvalueifnotapaidvalue)doesnotinfactcontributetoestimatesof nationalproduct,itis inappropriatetocombinethiswithothercostcomponentswhicharerelatedtonationalproduct.Contrarytoprevailingpractice,therefore,undernocircumstancesisitappropriatetocombinealldirectandindirecteconomicconsequencesof diseaseintoanoverallestimateandexpressthisvalueintermsof grossnationalproduct.

Onefurtherimportantlimitationof theprevailingapproachtocostof illnessstudies,which

hasparticularrelevanceindevelopingcountrieswherethereisahighproportionof privateout-of-pocketspendingonhealthcare,isthelackofattentionpaidtotheimpactof diseaseandill-healthonhouseholds.Atthehouseholdlevel,costsincurredintheacquisitionofmentalhealthorwelfareservicesshouldrepresenttheresourcesthatcouldhavebeenusedforothertypesofconsumptionorinvestmenthadthediseaseorillnessnotoccurred.Simi-larlyforlosttimeandproductivitycosts,theappropriatemethodwouldbetocomparethedaysworkedbythesickpersonandtheirfamilycomparedtowhatwouldhavehappenedintheabsenceof theillness.Inthementalhealthcontext,however,veryfewstudieshavemeasuredtheconsequencesof illnessonhouseholdproductivity,forexampleintermsof theimpactonlongtermproductivityduetoreductionsinsavingsorreducedinvestmentin

childrenseducation.

Itisimportanttore-emphasisethatcostof illnessandburdenof diseaseestimatesarenotinthemselvessufcientasamechanismforallocatingresourcesorsettingprioritiesformentalhealthcareandprevention;forthosedecisions,thereisaneedtoascertainhowmuchof theburdencanbeavoided,andatwhatcost(seeSection3).Forexample,dementiarepresentsalargeandgrowingcauseof disabilityandprematuremortality,butasyettheproportionof burdenthatcanbeavoidedthroughimplementationof healthcareinterventionremainslowbutcostly.Needlesstosay,suchefciencyconcernsrepresentonlyonesetof criteriafor

healthcaredecision-making,whichwillalsobeinformedbyethicalandothersocialconsid-erations(seeSection4).


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3. Reducing the burden o mental disorders:

rom global to national evaluation

3.1 WHO ramework or cost-eectiveness analysis

UntilrecentlytherehasbeenonlyalimitedconnectionbetweenDALYsasameasureof theburdenof diseaseandtheiruseasanoutcomemeasureincost-effectivenessanalysis,eventhoughsuchalinkisneededtoinformpriority-setting.Thekeyadvantagetoemployingasummarymeasureof populationhealthsuchastheDALYincost-effectivenessanalysis isthatitnotonlyenablescomparisonstobedrawnbetweeninterventionsfordifferentdiseasesortheirattendantriskfactors,butalsodirectlyaddressesthehighlypolicy-relevantquestion

of avoidableburden.Acriticalreasonfortheabsenceof suchalinkhasbeenthatthelackofasufcientframeworkforundertakingpopulation-wideconsiderationof costsandeffectsacrossthehealthsector.

ThroughitsCHOICEworkprogramme(CHOosingInterventionsthatareCost-Effective),WHOhasrecentlydevelopedaformofcost-effectivenessanalysisthatprovidespolicy-

makerswithasetof resultsthataimtobegeneralisableacrosssettings(TanTorresetal,2003).Itdoesthisbyevaluatingthecostsandeffectivenessof newandexistinginterventionscomparedtothestartingpointof doingnoneofthecurrentinterventions,whicheffectivelyeliminatesdifferencesinstartingpoints(e.g.usualcareinNorthAmericaversusSouthAsia

maynotbethesameatall);thishadmadetheresultsofearlierstudiesdifculttotransferacrosssettings.Cost-effectivenessresultscanbeusedtodenethreebroadsetsof inter-ventionsthosewhichimprovepopulationhealthagreatdealforagivensetof resources;thosewhicharenotefcientwaystoimprovehealth;andthosewhichareinbetween.Thisinformationentersthepolicydebatetobeweighedagainsttheimpactof differentinterven-tionmixesonotherobjectivessuchasreducinghealthinequalitiesandrespondingtothe

legitimateexpectationsof populations(seeSection4).

TheapplicationofWHO-CHOICEinasystematicandstandardizedmannerinvolvesanumberofkeyanalyticalstepsthattouchuponadiverseyetinter-relatedsetof disciplinaryareas, includingdemography, epidemiology, clinicaleffectiveness, costanalysisandhealth

economics.Methodsforundertakingthisformof economicanalysisaredescribedindetailelsewhere(TanTorresetal,2003),soonlythekeyprinciplesandproceduresarehighlightedhere(seeBox2).


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Box 2 Analytical steps o generalized cost-eectiveness analysis (WHO-CHOICE)

Step 1:Construct a profle o observed epidemiology. WHO-CHOICE pursues a population-

based, epidemiological approach to CEA. Accordingly, or the disorder and population in

question, the rst analytical step is to generate a prole or model o the prevailing epide-

miological situation. The standard reerence point or such a prole is the latest version

o the Global Burden o Disease study (GBD 2000), which provides empirically-based but

internally consistent estimates o the incidence, prevalence, remission and case-atality or

all leading causes o disease burden globally.

Step 2: Construct natural history models. A particular eature o WHO-CHOICE is its use o

no treatment as a starting point or comparing the relative costs and consequences o di-

erent health interventions. For psychiatric conditions, natural history models can oten be

used. For some mental disorders and in certain regions o the world, it should be noted thatat a population-wide level the current situation is in act a very good approximation o the

no treatment scenario (because so little intervention is taking place).

Step 3: Calculate population-level intervention eectiveness. Intervention eectiveness

is determined via a so-called state transition model, in which members o a population

move or transit through dierent possible states (such as being ill, healthy or deceased).

Key transition rates are the incidence o the disorder in the population, case-atality and

remission. In addition, a disability weight is specied or time spent in dierent states o

(ill-)health. Two situations are modeled, one representing the natural history o disease (no

interventions in operation), the other refecting the population-level impact o an interven-tion (such as reduced illness duration resulting rom use o an antidepressant drug). The

dierence between these two simulations represents the health gain due to the implemen-

tation o the intervention.

Step 4:Construct resource utilization and cost profle(s) or each intervention. An ingre-

dients approach to the costing o health interventions is used, which requires separate

estimation o the quantity o resource inputs needed (such as numbers o health personnel)

and the price or unit cost o those resource inputs (such as the salary o a health proes-

sional). Patient-level resource quantities include hospital inpatient days, outpatient vis-

its, medications and laboratory tests. In addition, programme costs are computed, includ-

ing central planning, policy and administration unctions, as well as resources devoted totraining health providers. Costs are expressed in international dollars (I$), which adjust or

dierences in the relative price o health-related resources across countries and thereby

acilitate comparison across regions.

Step 5: Cost-eectiveness analysis (including uncertainty). Summary results or popula-

tion-level costs, eectiveness and cost-eectiveness include the comparative eciency

o specied interventions, expressed as average and incremental cost-eectiveness ratios

(CERs) o I$ per DALY saved.


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3.2 Global evaluation o the cost-eectiveness o interventions

AlthoughthemethodsofWHO-CHOICEandotherformsofsector-widecost-effective -nessanalysisarewellsuitedtothecomparativeassessmentof awiderangeof potentialstrategiesforimprovingmentalhealth,itsactualapplicationisconstrainedbytheavailabilityofevidenceandinformationsupportingthesedifferentinterventions.Thus,whilethereisincreasinginterestinandagreementonthevitalimportanceofmentalhealthpreventionandpromotioninthepublichealthagendasof manycountries,evidenceof effectivenessforkeyinterventionsremainsrelativelysparseandweak.Likewise,manypeoplewithmentalhealthproblemsindevelopingregionsof theworldconsultwithindigenouspractitioners,butthereisverylimitedevidencetoindicatewhatistheexpectedsizeof effectthatsuchconsultationshaveonhealthoutcome.Todate,therefore,economicanalysisof strategiesforimproving

thementalhealthof populationshaslargelyfocusedonreducingtheburdenofpsychiatricdisordersviaevidence-basedpharmacologicalorpsychosocialtreatment.

Economic evaluationhas yet tobeextensively applied tohealth promotion, althoughanumberoftextshaveappearedwhichdiscusskeychallengesarounditspotentialdeploy-ment,suchasthelimitationsof experimentalstudydesign,thecomplexandlong-termna-tureof anticipatedprogrammebenetsandtheshortageof sensitiveorsuitableoutcomemeasures(Godfrey,2001;Hale,2000). Astheevidencebaseinmentalhealthpreventionandpromotionexpands(WHO,2001;Petticrewetal,2006),sotheopportunitiestoconducteconomicevaluationof thesemodesof interventionwillincrease.Table2identiessomeof thekeydomainsof costandoutcomethatwouldtypicallyneedtobeconsideredwhen

undertakingeconomicanalysisof mentalhealthpromotion.

Table 2 Cost outcome domains or the economic analysis o mental health promotion

Level 1: Individuals(e.g. school children or

workers)

Level 2: Groups(e.g. households or commu-

nities)

Level 3: Population(e.g. regions or countries)

Resourceinputs

Health-seeking timeHealth and social careLiestyle changes (e.g.exercise)

Programme implementationHousehold support

Policy development andimplementation

Processindicators

Change in attitudes orbehaviour



Healthoutcomes

Functioning and quality olieMortality (e.g. suicide)

Family burdenViolence

Summary measures(e.g. DALYs)

Social andeconomic

benefts

Sel-esteemWorkorce participation

Social capital / cohesionReduced unemployment

Social inclusionProductivity gains

Reduced health carecosts


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Inadditiontotheavailabilityof dataoninterventioncostsandeffects,publichealthburdenandimportanceconstitutedafurthercriteriathathasguidedthechoiceof psychiatricdis-

orderstowhichWHO-CHOICEhasbeenappliedtodate.Inthisrespect,schizophrenia,bipolaraffectivedisorder,depressionandobsessive-compulsivedisorder allappearin thetenleadingcausesof disabilityworld-wide(WHO,2001a).Foreachof theseburdensomeconditions,a setof personalinterventionscoveringkeypharmacologicalandpsychosocialtreatmentswasidentiedandreviewed(Table3;seealsoHymanetal,2006);internationalevidencefortheeffectivenessof specichealthcareinterventionswassufcientlyrobustforallof theaboveconditionsexceptobsessive-compulsivedisorder(asaresultof which,panic

disorderwasselectedastheindexconditioncoveringanxietydisorders).Inaddition,WHO-CHOICEanalysishasbeencarriedoutforepilepsy,aleadingcontributortoneurologicalburdenofdisease,andalcoholuse.

Table 3 Interventions or reducing psychiatric disorders in developing countries

Disorder Intervention

Schizophrenia Older (neuroleptic) antipsychotic drugTreatment setting: hospital outpatient Newer (atypical) antipsychotic drugTreatment coverage (target): 80% Older antipsychotic drug + psychosocial treament

Newer antipsychotic drug + psychosocial treament

Bipolar aective disorder Older mood stabiliser drugTreatment setting: hospital outpatient Newer mood stabiliser drugTreatment coverage (target): 50% Older mood stabiliser drug + psychosocial treatment

Newer mood stabiliser drug + psychosocial treatment

Depression Episodic treatmentTreatment setting: primary health care Older (tricyclic) antidepressant drug (TCA)Treatment coverage (target): 50% Newer antidepressant drug (SSRI; generic)

Psychosocial treatment

Older antidepressant drug + psychosocial treatment

Newer antidepressant drug + psychosocial treatment

Maintenance treatment



Panic disorder Benzodiazepines

Treatment setting: primary health care Older (tricyclic) antidepressant drug (TCA)Treatment coverage (target): 50% Newer antidepressant drug (SSRI; generic)

Psychosocial treatment



Estimationmethods,baselineresultsanduncertaintyanalysisforindividualdiseasesortheirriskfactors are reported indetail elsewhere, eitherbyWHO epidemiological sub-region(Chisholm,2005a;Chisholmetal,2004a,2004b,2005)orbyWorldBankregion(Chisholm,2005b;Hymanetal,2006;Rehmetal,2006).Below,keyndingsforfourpsychiatricdisor -

ders(byWorldBankregion)arebrieydiscussedinordertoillustratethesalientmessagesfromsuchaglobalanalysis.


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Population-level effectiveness of interventions

Evenatatreatmentcoveragerateof 80%(i.e.fouroutof everyvecases),theeffectof pharmacologicaltreatmentsforschizophrenia-whetherwitholderneurolepticsornewerantipsychoticdrugs-ismodest(150-250healthyyearsgainedannuallyperonemillionpopu-lation),reectingthefactthatinterventionsdonotreducetheincidenceordurationofthediseasesomuchasmakingadifferencetotheday-to-dayfunctioningof treatedpatients(ap-proximatelya25%improvementovernotreatmentwhentreatedwithantipsychoticdrugs

alone,orcloserto45%whengivenadjuvantpsychosocialtreatmentinaddition;Mojtabaietal,1998;Leuchtetal,1999).However,itneedstobeemphasizedthatthefullconsequencesofthisoften-catastrophicdisease(onfamilylife,socialstatusandtheabilitytobeproduc-tive)arenotadequatelycapturedbyDALYs.

Theadditionofmonthlysessionsofindividual-basedpsychosocialtreatmenttopharma-cotherapyisprojectedtohaveamorepronouncedbenetthanswitchingfromoldertonewerantipsychoticdrugs(Appendix1).Suchatrendisalsoapparentforbipolaraffectivedisorder,butwiththeaddedprojectionthatduetoitsestablishedimpactonreducingsuicide,lithiumisexpectedtogeneratemorepopulation-levelhealthgainthannewermoodstabilis-erssuchasvalproate(Chisholmetal,2005).

Atatargetcoveragerateof 50%,healthyyearsoflifegainedannuallyfromthetreatmentofbipolardisorderandpanicdisorderarebothintherange150-400peronemillionpopula-

tion,whereasepisodictreatmentof depressionwithantidepressantsand/orpsychotherapy

generatemuchlargergains(600-1,200),inlargepartduetothehigherprevalenceofthisdisorderinthepopulation.Proactive,maintenancedepressiontreatmenthashigherreturnsstill(1,200-1,900healthyyearsof lifegainedperyearperonemillionpopulation)becauseinthisscenarioasignicantproportionof recurrentdepressiveepisodeswouldbeprevented(Chisholmetal,2004a).

Intervention costs

ResultsarepresentedbothinUSdollarsandInternationaldollars(I$)fortheyear2000.AninternationaldollarhasthesamepurchasingpowerastheU.S.dollarhasintheUnitedStates;

assuch,itisahypotheticalcurrencythatisusedasameansoftranslatingandcomparingcostsfromonecountrytotheotherusingacommonreferencepoint,theUSdollar.

Theannualcostpercapitaof community-basedoutpatienttreatmentof schizophreniaandbipolardisorderwitholderantipsychoticormoodstabilizingdrugsrangedfrominternation-aldollars(I$)0.80-1.10(US$0.40-0.50)inSub-SaharanAfricaandSouthAsiatoI$3(US$1.80)intheLatinAmericaandCaribbeanandEuropeandCentralAsiaregions.Thecostpercapitafornewer(atypical)antipsychoticdrugsstillunderpatentismuchhigher(I$3-7,orUS$2.60-5.10).Bycontrast,someof thenewerantidepressantdrugs(SSRIs)arenowoffpatentandaccordinglytheirusewasvaluedattheirgeneric,non-brandedprice.Thepatient-

levelcostof treatingasix-monthepisodeofdepressionrangedfromaslittleasI$50(olderantidepressantsinSub-SaharanAfricaorSouthAsia)toI$150-200(newerantidepressants


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incombinationwithbrief psychotherapyinLatinAmericaandCaribbeanandEuropeandCentralAsia).

Cost-effectiveness of interventions

Comparedtothesituationofnotreatment(naturalhistory),themostcost-effectivestrategyforavertingtheburdenof psychosisandsevereaffectivedisordersisexpectedtobeacom-binedinterventionof rstgenerationantipsychoticormoodstabilizingdrugswithadjuvantpsychosocialtreatmentdeliveredviaa community-basedoutpatientservicemodel,withacost-effectivenessratiointheregionof I$3,000(US$1,600-1,800)inSub-SaharanAfrica

andSouthAsia,risingtoI$8,000-10,000(US$3,500-5,000)inmiddle-incomeregions(Ap-pendix2).Currently,thehighacquisitionpriceofsecond-generationantipsychoticdrugs

makestheiruseinmostdevelopingregionsinadvisableonefciencygroundsalone,althoughthissituationcanbeexpectedtochangeasthesedrugscomeoff patentandgenericversionsbecomewidelyavailable.Bycontrast,evidenceindicatesthatthemodestadditionalcostof adjuvantpsychosocialtreatmentreapssignicanthealthgains,therebymakingsuchacom-binedstrategyforschizophreniaandbipolardisordertreatmentmorecost-effectivethanpharmacotherapyalone.

Formorecommonmentaldisorderstreatedinprimarycaresettings(depressiveandanxietydisorders),thesinglemostcost-effectivestrategyisthescaled-upuseof olderantidepres-sants,duetotheirlowercostbutsimilarefcacytonewerantidepressants.However,asthe

pricemarginbetweenolderandgenericnewerantidepressantscontinuestodiminish,ge-nericSSRIscanbeexpectedtobeatleastascost-effectiveandmaythereforeconstitutethetreatmentof choiceinthefuture.Sincedepressionissocommonlyarecurringcondition,therearealsogoodgroundsforthinkingthatproactivecaremanagement,includinglong-termmaintenancetreatmentwithantidepressantdrugs,representsacost-effective(if moreresource-intensive)wayof signicantlyreducingtheenormousburdenof depressionthatexistsindevelopingregionsoftheworld.

Affordability of interventions

Havingidentiedtheexpectedcostof recoveringahealthyyearoflifewitharangeofmen-talhealthcarestrategies,animportantsubsequentquestionrelatestotheaffordabilityoftheseinterventionsindifferentcontexts,bothinabsoluteterms-societymaywellbeunpre-paredtoallocatelargesumsof moneyforoneyearof fullhealthgainedbyanintervention-andalsoinrelativeterms(i.e.whatisthecost-effectivenessof mentalhealthcarecomparedtointerventionsforotherdiseases?).Incountrieswhichhaveestablishedthresholdsforwhatconstitutesanacceptablelevelof costinordertoobtainahealthyyearof life(suchastheUSorUK),theamountisintheorderof$50,000.Thisvalueliessomewherebetweenoneandthreetimesaveragepercapitaincomeinthesehigh-incomecountries,butinlow-incomecountriesthisabsolutevalueof $50,000mightbetenormoretimestheaverageincomeper

capita.Accordingly,WHO-CHOICEfollowsthecriteriaoftheCommissionforMacroeco-nomicsandHealth(2001),whichsuggestedthatahealthinterventioncapableofgenerating


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oneyearof healthylifeatacostthatisbelowaveragepercapitaincomeshouldbeconsideredaverycost-effectiveuseof resources,whileonethatcostslessthanthreetimespercapita

incomeshouldstillbeconsideredmoderatelycost-effective(interventionsabovethreetimepercapitaincomearedeemednotcost-effective).Usingthesethresholds,theresultsof thisanalysisindicatethat:

Themostefcientinterventionsforcommonmentaldisorders(depressionandpanicdisorder)canbeconsideredverycost-effective(eachDALYavertedcostslessthanoneyearof averagepercapitaincome);

Community-basedinterventionsformoreseverementaldisordersusingolderantipsy-choticandmoodstabilizerdrugsmeetthecriterionforbeingcost-effective(eachDALYavertedcostslessthanthreetimesaverageincomepercapita);and

Useof atypicalanti-psychoticsatcurrentinternationalprices-particularlywhendeliv-

eredinhospital-basedsettings-arenotacost-effectiveuseof scarceresources(eachDALYavertedcosts[considerably]morethanthreetimesGDPpercapita).

Packages of care

Theconsiderabledifferenceincost-effectivenessbetweencommonandmoreseverementaldisorders,aswellasbetweenlow-andmiddle-incomeregionsoftheworld,isclearlyshowninFigure2,whichillustratestheratiosof costtoeffectforaselectivepackageof mental

healthinterventions(oneefcienttreatmentperdisorder).

Figure 2 Cost-eectiveness ratios or a basic mental health package in low and middle-incomeregions o the world


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0

Resultsforthisbaselinepackageindicatethat,acrosssixlow-andmiddle-incomeregions,thepotentialtotalhealthgainemanatingfromsuchacombinationof interventionstrategies

isintheorderof 2,000-3,000DALYsavertedperonemilliontotalpopulation,whichcouldbeachievedatanestimatedcostof I$5-6(US$3-4)percapitainlow-incomesettingssuchasSub-SaharanAfricaandSouthAsia,anduptoI$13(US$9)inmoremiddle-incomeregionssuchasLatinAmericaandtheCaribbean.Two-thirdsof thetotalcostsofthispackage,butonlyaboutonethirdof thehealthgainsareattributabletothemoreseverepsychiatriccondi-tions(schizophreniaandbipolardisorder).Approximately225-450healthyyearsof lifecanbegainedforeveryinvestmentof onemillioninternationaldollars.

Numerousotherspecicationsareofcoursepossible,includingestimationofthecostsand

effectsof apackagethatmakesuseof newerpsychotropicdrugs,ordoesnotincludeanypsychosocialtreatment.Suchcomparisonsreveal,forexample,thatsubstitutingolderwith

newerpsychotropicdrugsforthebaselinepackagedescribedaboveisanticipatedtoincreasecostsby100-200%(anextracostof I$4-7percapita),whilehealthgainswouldonlyincreaseby23-32%.

Thesendingsthereforeprovidenewinformationtohealthpolicy-makersregardingtherelativevalueof investinginthetreatmentof thesedisorders,andinsodoingmayhelptoremoveoneof manybarrierstoamoreappropriatepublichealthresponsetotheburdenoftheseconditions.

Thereareneverthelessanumberof importantlimitationsassociatedwithsuchananalytical

approach,including:theaggregatedunitof analysis(whichcanbeaddressedbyundertak-inganalysisatthenationallevel,seebelow);theextrapolationofdataontheefcacyof

interventions(aparticularconcernforpsychosocialtreatmentsthatmaybeinuencedbysocioculturalfactors);andtheinadequatehandlingofcomorbidity(whichismoretherulethantheexceptioninsomedisorders,andwhichmayhaveanadverseimpactonthecost-ef-fectivenessof interventionsbecauseof worsehealthoutcomesand/orhigherconsumptionof healthcareresources).

3.3 National evaluation o the cost-eectiveness o interventions

Country-level contextualisation process

Theexistenceof cost-effectivenessinformationatthehighlyaggregatelevelof WHOorWorldBankregionsisnoguaranteethatndingsandrecommendationswillactuallychangementalhealthpolicyorpracticeatthenationallevel(wherepoliciesaredeterminedandre-sourcesactuallyallocated).Accordingly,thereisaclearneedtoattemptacontextualisationof regionalestimatesdowntothislevel,sincemanyfactorsmayaltertheactualcost-effec-tivenessofagiveninterventionacrosssettings,includingtheunderlyingepidemiologyofdisorders;thepotentiallevelof effectivecoverageinthepopulation;theavailability,mixand

qualityof inputs,especiallypersonnel,drugsandconsumables;andlocalprices,especiallylabourcosts.


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1

Contextualizationof interventioneffectiveness:Thepopulation-levelimpactof differ-entinterventionsataregionallevelhasbeenmeasuredintermsof DALYsavertedper

year.Keyinputparametersunderlyingthissummarymeasureof populationhealthun-dernaturalhistoryconditionsincludethepopulationsdemographicsizeandstructure,epidemiologicalrates(incidence,prevalence,remissionandcasefatality)andthevalueof timespentindifferenthealthstates(suchasbeingacutelypsychotic,relativetofullhealth).Alloftheseparametersaresubjecttorevisionandremodellingatthenationallevel(seecasestudybelow).Thespecicimpactof aninterventionisgaugedbyachangetooneormoreof theseepidemiologicalrates,andisa functionof theefcacyof an

intervention,adjustedbyitscoverageinthepopulationand,whereapplicable,ratesof adherencebyitsrecipients.Dataontheseeffectivenessparameterscanbeobtainedatthelocallevel,basedonreviewsofevidenceandpopulationsurveys(ifavailable)orexpertopinion.

Contextualizationof intervention costs: Interventioncosts at the regional level of analysishavebeenexpressedininternationaldollars(I$).Thiscapturesdifferencesinpurchasingpowerbetweendifferentcountriesandallowsforadegreeof comparisonacrossregionsthatwouldbeinappropriateusingofcialexchangerates.Forcountry-levelanalysis,costswouldbemoreappropriatelyexpressedinlocalcurrencyunits,whichcanbelooselyapproximatedbydividingexistingcostestimatesbytheappropriatepur-chasingpowerparityexchangerate,orestimatedmoreaccuratelybysubstitutingnew

unitpricesforallspeciedresourceinputs(e.g.thepriceof adrugortheunitcostof anoutpatientattendance).Inaddition,thequantitiesof resourcesconsumedcaneasilybe

modiedinlinewithcountryexperiences(reecting,forexample,differencesinaveragelengthofstayinhospital).

Theoutputof suchacontextualisationexerciseisarevised,country-specicsetof averageandincrementalcost-effectivenessratiosforinterventionsaddressingleadingcontributorstonationaldiseaseburden.AsshownbelowinTable4,suchaprocessofcontextualisationforneuropsychiatricconditionshasnowbeencarriedoutinanumberof countries.

Table 4 WHO-CHOICE contextualisation studies or neuropsychiatric conditions

Country Chile Estonia Mexico Nigeria Spain Sri Lanka Thailand

(WHO region) Americas Europe Americas Arica Europe South-East Asia

South-East Asia

Diseases

Schizophrenia 4 4 4 4 4 4

Bipolar disorder 4

Depression 4 4 4 4 4 4

Epilepsy 4

Risk actors

Alcohol use 4 4 4 4 4


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2

Case study: Dening a mental health care package in Nigeria

Despite the existenceof anationalmental health strategy inNigeriaand thewell-docu-mentedprevalenceofmental,neurologicalandsubstanceabusedisordersinthecountry(e.g.Gurejeetal,1995;WHOWorldMentalHealthSurveyConsortium,2004),resourcescurrentlyallocatedtomeettheneedsof personswiththesedisordersareextremelymeagre(considerablylessthan1%of thetotalhealthbudget,itself nomorethan3%of GrossDo-mesticProduct).RecentestimatespreparedfortheWHOsATLASproject(WHO,2005),forexample,revealthatthereareonly4psychiatricbeds,4psychiatricnursesand0.1psy-chiatristsper100,000population.

Inthecontextof prevailingresourcescarcity,butwiththe intentionof stimulatingmen-talhealthpolicydialogue,investmentandservicedevelopmentinNigeria,asmallresearch

projectconductedbytheDepartmentof PsychiatryattheUniversityof Ibadansetouttoestimate the expectedcostsand effects of an intervention package capableof reducingthecurrentburdenassociatedwithpriorityneuropsychiatricproblems(Gurejeetal,2006).Basedonlocalclinicalexperienceandhealthfacilityadmissions/serviceutilizationdata,aswellasepidemiologicaldataontheprevalenceandassociateddisabilityof differentneu-ropsychiatricdisordersinNigeria(Gureje,2002;WHOWorldMentalHealthSurveyCon -sortium,2004),fourpriorityconditionswereidentied(schizophrenia,depression,epilepsyandalcoholabuse).Foreachof theseconditions,aprocessof contextualisationwascarriedoutasdescribedabove:

Demography:Regionalpopulationdata(includingbirthsanddeaths)weresubstitutedwithnationaldataforNigeria(totalpopulation,115million);

Epidemiology:Current diseaseburdengures forschizophrenia, depressive episode,epilepsyandheavyalcoholuse-basedonWHOsGlobalBurdenof Disease2000study

forAfricansub-regionAFR-D-werereviewedand,wheresupportedbygood-qualitylocaldata,revised.Sincenorecentpopulation-widesurveydatawasavailableforschizo-phrenia,andgiventherelativelystableestimatesfoundforthisparticularconditionfromotherAfricanstudies,norevisionwasmadetodefaultregionalvalues.Fordepressionandheavyalcoholuse,however,up-to-datedataavailablefromrepresentativesamplesurveys intheNigerianpopulation(WHOWorldMentalHealthSurveyConsortium,

2004)wereusedtoreviseprevalenceestimates.

Effectiveness:Internationaldatasourcesusedtoestimateinterventioneffectsinregionswerereviewedandalteredtobetterreectlocalevidenceorexpectations.Forexample,parametersunderlyingtheanticipatedimpactofincreasedtaxesonalcoholicbeverages-includingthedistributionofdifferentbeveragetypes,thecurrentrateoftaxationon

thesebeveragesandtheprevailinglevelof untaxedproduction-were tailoredtotheNigeriancontext.Inaddition,plannedratesofpsychiatrictreatmentcoverageinthepopulationwerereducedtomorerealistic,attainablelevels.

Resourceuseandcosts:Foreachdisorderincludedintheanalysis,country-specicval-uesconcerningthefrequencyandintensityof healthcareuptakewereused(e.g.50%


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of acutelypsychoticpatientsareexpectedtobeadmittedtoapsychiatrichospitalward,withanaveragelengthof stayof21days).Estimateswerebasedonlocalexpertopinion,

includingaDelphiconsensuspanelsurveyof 24mentalhealthprofessionalsworkingindifferentpartsof thecountry.Predictedunitcostsinlocalcurrencyunitsforprimaryandsecondarycareservices(Adametal,2003)werevalidatedagainstlocalhospitaldata,whileotherdefaultresourceinputssuchassalariesof healthprofessionals,psychotropicdrugsandlaboratorytestsweresubstitutedwiththeircorrespondinglocalvalues.

Table5providessummaryresultsforaninterventionpackageconsistingof:community-basedoutpatientcareforschizophreniapatientswitholderanti-psychoticdrugsandpsycho-

socialcare(6-8sessionsof individual-basedtreatment30-50%of cases,dependingonsever-ity);primarycaretreatmentofdepressionandepilepsywitholder(tricyclic)anti-depressantsandanti-epilepticdrugs,respectively;androadsidealcoholbreath-testingof drivers.Each

oftheseinterventionswasthemostefcientstrategyoutofallthoseconsideredfortheparticularcondition.

Schizophreniahasthehighestcostpertreatedcase(9,200Nairaperyear,orUS$88attheofcialexchangeratefor2000)butdepressionabsorbsthehighestproportionoftotalcosts(morethanhalf)owingtoitsconsiderablygreaterprevalenceinthepopulation(Naira4,200millionperyear,equivalenttoUS$41.2million).Highestreturnsintermsof healthout-comeandcostperunitof outcomeareforepilepsytreatmentandroadsidebreath-testing(over100,000DALYsavertedperyear,eachatacostof 9,000-11,000Naira[US$100or

less]).Theannualcostof thepackageamountstomorethan9billionNaira(US$88mil-lion),equivalentto81Naira(US$0.77)percapita.

Table 5 Costs and eects o an intervention package in Nigeria

Condition Intervention Coverage

Effectiveness

(DALYs

averted)

Total cost per year

(millions)

Cost per

treated case

per year

Cost per DALY

averted

Naira 1,811 9,215 67,113

SchizophreniaOlder anti-psychotic drug +

psychosocial treatment

(community-based model)

70% 26,980

USD 17.2 88 639

Naira 5,367 4,680 77,109

Depression

Older (tricyclic) anti-

depressant drug in primary

care

40% 69,608

USD 51.1 45 734

Naira 1,113 2,868 10,507

Epilepsy

Older anti-epileptic drug in

primary care 50% 105,946USD 10.6 27 100

Naira 972 - 8,873Hazardous

alcohol use

Roadside breath-testing of

motor vehicle drivers80% 109,490

USD 9.3 - 85

Cost per

capita

Naira 9,263 81 29,686

Total package 312,024

USD 88 0.77 283

Implications of national-level cost-effectiveness analysis for research and policy

Akeyassumptionunderlyingthecontextualisationof regionalWHO-CHOICEresultsdowntothelevelof individualcountriesisthatchangesinthevaluesofkeyinputparameters-suchasthepriceofpsychotropicdrugs,thecostof anoutpatientvisitortheexpectedefcacyof


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4

treatment-mayresultindifferencesintheabsoluteandalsorelativecost-effectivenessof interventions.Inotherwords,re-runningtheanalysiswitharevisedsetof(locally-derived)

valuesmaynotonlyincrease/decreasetheabsolutecostof gainingoneextrayearofhealthylife,butalsoaltertheactualorderingof interventions(forexample,aninterventionexpectedtorepresentbestvalueformoneyattheregionallevelmaynotbeconsideredtobesofol-lowinganational-levelanalysis).Usingthenational-levelresultscurrentlyavailableforthethreemostcommonlyincludedhealthconditions-schizophrenia,depressionandhazardousalcoholuse-itispossibletodirectlyaddressthisquestion(seeAppendix3foracomparisonof cost-effectivenessresultsbeforeandaftercontextualisation),andinturncommentonthe

usefulnessandimplicationsofcontextualisedCEAforhealthpolicy.

Schizophrenia:Regionalanalysisindicatedthatthemostcost-effectivestrategywouldberstgenerationantipsychoticormood-stabilisingdrugswithadjuvantpsychosocial

treatmentdeliveredviaacommunity-basedoutpatientservicemodel.Useofatypicalanti-psychotic drugswasexpectedtobeverymuchmore costlybutonlymarginallymoreeffective,makingtheiruseacost-ineffectivechoice(morethanthreetimesaveragenationalincome).Completednational-levelstudiesinNigeria,SriLankaandEstoniafocussedonasimilarsetof community-basedpharmacologicalinterventions,andinallcasestherankorderof cost-effectivenessdifferedtoregionalresults.Inthelower-in-comesettingsof NigeriaandSriLanka,neweranti-psychoticdrugsrankedworsethan

olderneurolepticdrugs-particularlyinNigeria,wheretheextracostisastronomical-butinEstoniarankedbetter(duetoonlyasmalldifferenceindrugpricebutahighdif-ferentialindrugadherence).Combinedpharmacological-psychosocialstrategies,which

hadalmostidenticalcost-effectiveratiostocasemanagementstrategies,werepreferredchoicestostand-alonedrugtreatmentinEstoniaandNigeria,butnotinSriLanka.Inabsoluteterms,thecostof eachavertedDALYwashigherthanpriorregionalestimatesinNigeria,butlowerinSriLanka.InEstonia,differencesbetweencontextualisedver -suspriorestimatesweredeterminedbyexpectedversusactualpricesof anti-psychoticdrugs.AsshowninFigure3,interventionsusingolderdrugswerehigherthanexpected,whereasinterventionsusingthenewer(atypical)anti-psychoticdrugshadaconsiderably

lowercost-effectivenessthanexpected.

Figure 3 Cost-eectiveness o schizophrenia interventions in Estonia:

prior versus contextualised estimates (EEK = Estonian Kroon; 1 US Dollar = 13 EEK)

786'466

614'450

338'976

333'342

316'613

312'332

241'756

670'104

190'626

519'941

206'938

102'991

0 100'000 200'000 300'000 400'000 500'000 600'000 700'000 800'000 900'000

Older (neuroleptic) anti-psychotic drug

Newer (atypical) anti-psychotic drug

Older (neuroleptic) anti-psychotic drug

+ psychosocial treatment

Newer (atypical) anti-psychotic drug

+ psychosocial treatment

Case management with older drug

Case management with newer drug

Cost per DALY averted (EEK)Contextualised estimates

Prior estimates


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Depression:Themostcost-effectivestrategyfoundattheregionallevelwasepisodictreatmentwitholder(tricyclic)antidepressantsinprimarycare;amoreproactivecare

approachwasexpectedtogenerategreatesthealthgainbutwaslesscost-effective.Inthethreecountriesforwhichresultsarealreadyavailable,pharmacologicaltreatmentwithTCAsremainedmostcost-effectiveinNigeria,butnotinSriLankaandEstonia,wherethenegligiblepricedifferencesbetweengenericSSRIsandTCAsmeansthatthesuperioradherenceprolemodelledforneweranti-depressantsmakesthemthedrugof choice.Acrossthethreecountries,costsandcost-effectivenessweregenerallyhigherthanpriorestimates,dueinlargeparttohighersalariesandthehigheracquisitionprices

of anti-depressantdrugsfoundlocally(thelowestinternationalsupplierprice,adjustedforshippinganddistribution,hadbeenusedintheregionalanalysis).

Hazardousalcoholuse:Regionalanalysisof alcoholcontrolstrategieshadconclud-

edthatthecost-effectivenessof interventionswascloselyrelatedtotherateof heavydrinking,suchthatinregionswithaprevalenceinthetotalpopulationof morethan5%,population-levelinterventionsincludingtaxationandcomprehensiveadvertisingbanswereexpectedtobethemostefcientresponse totheburdenof hazardousalcoholuse,whileinregionswithlowerratesmoretargetedinterventionssuchasbreath-test-ingmotorvehicledriversandbrief adviceforheavydrinkerswereexpectedtobemostcost-effective.ThiswasfoundtobethecaseinEstonia,whereinterventioncost-effec-tivenesscloselyreectedresultsforthe(high-prevalence)WHOsub-regioninwhichit

sits.However,ratesof hazardousalcoholuseinThailand-andtoalesserextentNigeria-donotcorrespondwelltotheirrespectiveregions(forexample,theWHOsub-region

inwhichThailandsitsisdominatedbytheMuslim,low-drinkingpopulationofIndone-sia),andthisresultedinlargediscrepanciesbetweenpriorandcontextualisedestimates.Forexample,taxationandotherpopulation-levelinterventionstrategieswerefoundtobeabsolutelyandalsorelativelymorecost-effectiveintheThaicontextthantheresultsfromtheregionalanalysis(inwhichbrief interventionsandroadsidebreath-testingwererankedmostcost-effective).

Insummary,country-levelapplicationof WHO-CHOICEhasshownthatwhileoverallpol-icymessagestendtomatchthosederivedfromregionalanalysis,country-regiondifferences

withrespecttodiseaseprevalence,prices(particularlydrugs)andtreatmenteffectivenesscanleadtosubstantialchangesintheabsolutecostandcost-effectivenessof mentalhealthcarestrategies.


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4. Priority-setting and resource allocation or mental health

system development

4.1 Decision-making criteria or resource planning and allocation in health

Determinationof themostcost-effectiveinterventionsforasetof diseasesorriskfactors,whilehighlyinformativeinitsownright,isnottheendof theprocess.Rather,itrepresentsakeyinputintothebroadertaskof priority-setting.Forthistask,thepurposeistogobeyondefciencyconcernsonly.Othercriteriaagainstwhichcost-effectivenessargumentsneedtobeconsideredincludetherelativeseverityof differentdiseases,thepotentialforreducingimpoverishmentandprotectionofhumanrights.Thus,priority-settingnecessarilyimpliesa

degreeof trading-off betweendifferentobjectivesof thementalhealthsystem,suchthatthemostequitableallocationofresourcesmaynotinfactbethemostefcientallocation.

Withinthementalhealthsystem,schizophreniatreatmentisanobviousexamplewhereonpureefciencygroundsaloneitwouldbeoverlookedinfavourof cheaperandmorecost-ef-

fectivecareandpreventionstrategiesformorecommonmentaldisorders,butthisdisorderistypicallyincludedasaprioritycondition-asintheNigerianpackage,forexample-becauseof theseverityof thecondition(andconsequentvulnerabilityof effectedpersonstopovertyandhumanrightsviolations),itsfrequentlydisastrouseffectonthewelfareand/orincomeof families,themodestbutstillvaluableimpactof treatmentonindividual-levelsymptomsandfunctioning,andthepotentialimpactonthehumanrightssituationof thepersonwith

thisdisorder.Ultimately,theendallocationof resourcesarisingfromapriority-settingexercise,usingacombinationof qualitativeorquantitativemethods,willreecttheparticularsocio-culturalsettinginwhichitiscarriedoutandthepreferencesof itspopulaceand/oritsrepresentatives

ingovernment.Methodsarenowavailableforelicitingthesepreferencesorvalues-includingquantitativeapproachessuchasdiscretechoiceexperiments(Baltussenetal,2006)andmorequalitativeapproachessuchasDelphiconsensustechniquesorfocusgroups(Kapiririetal,2004)-whichcanbeemployedinordertolayrmerfoundationsforthedecisionsmadeatnationalorlocallevel(seenextsection).Todate,however,mentalhealthresourceallocationdecisionsatthenationallevelhavenotbeendeterminedsomuchbyacontext-specicvalue

base,asbycurrentspendingpatterns,historicalprecedent,advocacymovements,and,attheinternationallevel,byideologicaltrendsinthetheoryandpracticeofpublichealth.

Cost-effectivenessorefciencyrepresentsonesuchtrendinpublichealththathasgrownsubstantiallyoverthelastcoupleofdecades,initiallyinthecontextofindustrializedcoun-triesfacingevertighterbudgetconstraintsinthefaceof creepinginationwithinthehealth

sector,andsubsequentlypropagatedbytheWorldBankandotherinternationalorganiza-tionsworkingwithinthedevelopingworldasameansof maximizingtheuseof verylimitedresourcesforhealth.

AlandmarkpublicationinthisrespectwastheWorldDevelopmentReportin1993,whichrankedanumberof corehealthcareinterventionsaccordingtotheircost-effectivenessandusedtheresultstoproposeaminimumpackageof servicesforuseinlow-andmiddle-in-


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comecountries(WorldBank,1993).Selectingsuchaminimumpackageonthisbasisimpor-tantlypresumesthatinasequentialorderingof possiblecompetingcriteria,considerations

of efciencyshouldcomerst(attheexpenseof criteriadealingwithequity,forinstance).Viewedfromaperspectiveinwhicheconomicreformsandtheburdenofdebtrepaymentsonpoorcountryhealthbudgetsheadsthepoliticalagenda,thismightindeedbeanappropri-aterststep.

Criticsof thisapproach,however,havepointedoutsomeoftheshortcomingsof thisap-proach,includingthelimitationsofsummarymeasuresofpopulationhealthsuchastheDALYtopickupthefullspectrumofhealthbenetsthatmayowfrominterventionsand

itsfailuretotakeintoaccountthefairdistributionof thesehealthbenetsacrossdifferentsocioeconomicgroupsinsociety(i.e.interventionswhichbestaddressthoseingreatestneedmaynotbegivenprecedenceoverthosethatgeneratemosthealthgain).

Whendeterminingwhatwillbenancedfromagivenamountof resources,therefore,theoverallobjectiveshouldbetoensurethathealthinterventionsmaximizethebenetstosoci -ety,whilealsoaccountingforthedistributionofthesebenetsplusotherequityconsidera-tions,whichrevolvearoundtheideasthateachpersonmustbegiventheirdueandequalsmustbetreatedasequals.

Discussionsaboutjusticeorequityatapolicylevelhavetypicallyconcentratedonthedis-tributionorredistributionof(scarce)resources,whichinthecontextofmentalhealthistypicallydeterminedbyneedand expressed intermsof equalaccess toorutilizationof

services(horizontalequity).However,thehorizontalequitycriteriongiveslittleguidanceonhowtodeneprioritieswhendifferentpopulationgroupsexhibitdifferentneeds,andthusislessusefulincomparinghealthinterventionsfordifferentillnesses.Thushorizontalequityiscomplementedbyverticalequityconsiderations(literally,unequaltreatmentforunequalneed),whichcanaiddecisionsonhowtodealwiththeneedsof differentpopulationgroups,suchasthosewithmoreseverementaldisordersorthemostsocio-economicallydisadvan-tagedsectionsofsociety(Jamesetal,2004).

Thejusticationforgivinggreaterpreferencetointerventionsthattargetseverehealthcon-ditionslikeschizophreniaorbipolaraffectivedisorder,evenif theyarenotascost-effectiveasotherinterventions,canbemadebysuggestingthatanimprovementinhealthfromase-verehealthconditionisvaluedmorehighly(byindividualsorbysociety)thanthesamesize

improvementinhealthfora lessseverecondition.Indeed,empiricalndingshaveshownthatpeopleseemtotoleratelowerlevelsof cost-efciencyforthoseinterventionsforindi-vidualswithahigherburdenofillness(Nordetal,1999).Concerningthepoor,horizontalequityimpliesthattheyshouldhavenoworseaccesstocarethananyoneelse,butinmanycountriesthereisinfactadeliberatepolicytonottreatthemasothers,thatis,togiveprefer-encetointerventionsthatmayparticularlybenetthisdisadvantagedgroup(wheredisad -vantagediscouchedintermsofwealthratherthanhealth).Fromthestandpointof equity,inotherwords,resourcesshouldbeallocatedrsttowardstacklingthehealthproblemsof poorpeopleandonlythenbetweendifferentprogrammesorinterventions.Itisalsotoberecognizedthatdecisionsaboutdistributionof publicresourcesaffectpoorerpopulations

morebecauseof theirlargerdependenceonpublichealthcarethantherich,thelatterhaving

theoptionof buyingprivatehealthcarewhenneeded.


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Efciencyandequityconstitutetwoimportantcriteriafordecision-making,directlyaddress -ingkeygoalsof thementalhealthsystem(maximizinghealthoutcomes,reducinginequali-

ties).Resourceallocationdecisionsaffectingchoicesinhealth,however,standtobeinu -encedbyabroaderrangeoffactors.Onealternativestartingpointforpriority-settingthathasbeenrecentlyproposedistoascertaintheextenttowhichthereisajusticationforpublicsectornancing(Musgrove,1999),inwhichanumberof marketfailurescanbeusedasltersfortheappropriatechannellingof publicresourceows.Whenappliedtothemen-talhealthcontext(Beeharryetal,2002),itbecomesclearthatwhilethereareweakgroundsforpublichealthnancingonsomegrounds(forexample,mentaldisordersdonotleadto

pervasivenegativespill-overeffectsinthewaythatsomeinfectiousdiseasesdo),thereareothercriteriarelatedtotheinadequatedemandformentalhealth(duetounder-recognitionandstigma)andpotentialhouseholdimpoverishmentresultingfrommentalillnesswhich,togetherwiththeneedforadequateinsuranceandregulatorymechanisms,makeastrongcaseforpublicnancingofmentalhealthservices.

4.2 Development o a priority-setting ramework or mental health policy

Asdiscussedintheprevioussection,thereareanumberof possiblecriteriathatcanbeusedtomakechoicesinmentalhealth,includingpatient-levelfactors(e.g.severityofillness,age),treatmentcharacteristics(e.g.sizeof effect,cost-effectiveness)andsocietalvalues(e.g.pov-

ertyreduction).Thesecriteriaarenotnecessarilycompatiblewitheachother,whichimpliesthatadegreeoftrading-offmayberequired,forexamplebetweentargetingpeoplewith

themostseverementalhealthproblemsandselect

dollars dalys and decisions

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