Financing mental health services in low- and middle-income countries

Abstract

Mental disorders account for a significant and growing proportion of the global burden of disease and yet remain a low priority for public financing in health systems globally. In many low-income countries, formal mental health services are paid for directly by patients out-of-pocket and in middle-income countries undergoing transition there has been a decline in coverage. The paper explores the impact of health care financing arrangements on the efficient and equitable utilization of mental health services. Through a review of the literature and a number of country case studies, the paper examines the impact of financing mental health services from out-of-pocket payments, private health insurance, social health insurance and taxation. The implications for the development of financing systems in low- and middle-income countries are discussed. International evidence suggests that charging patients for mental health services results in levels of use which are below socially efficient levels as the benefits of the services are distributed according to ability to pay, resulting in inequitable access to care. Private health insurance poses three main problems for mental health service users: exclusion of mental health benefits, limited access to those without employment and refusal to insure pre-existing conditions. Social health insurance may offer protection to those with mental health problems. However, in many low- and middle-income countries, eligibility is based on contributions and limited to those in formal employment (therefore excluding many with mental health problems). Tax-funded systems provide universal coverage in theory. However, the quality and distribution of publicly financed health care services makes access difficult in practice, particularly for rural poor communities.

Barriers in the mind: promoting an economic case for mental health in low‐ and middle‐income countries

“…Even this figure of 40% is undoubtedly conservative, as it does not take account of costs incurred through consultation with traditional healers. This reliance on out-of-pocket payments is both inefficient and inequitable, as it discourages utilization of services by those with limited incomes, which is especially worrisome given the close links between poverty and poor mental health (52). Paying for services may lead to poverty or indebtedness if families borrow from moneylenders at very unfavourable terms.…”

“…A major challenge, however, is that the structures for revenue collection often do not exist in low-income countries (52). Less ambitious initiatives, such as very local community insurance schemes, might represent a way forward.…”

Effect of somatization disorder on social and work place functioning among upper socio-economic class adults attending outpatient clinic in national hospital, Abuja, Nigeria

“…Given the dearth of mental health specialists in most countries, care for somatization disorder is provided mainly by primary care providers [10]. Consequently, a large proportion of patients with psychological disorders do not receive appropriate treatment [8].…”

“…Dearth of data on the outcome of treatment trials in the developing countries has persisted even in the light of the findings on the public health importance of mental disorders [10].…”

Política de Saúde Mental no Brasil: evolução do gasto federal entre 2001 e 2009

“…European researchers 2,4,6,7 point to a better cost-effectiveness relationship of community-based care compared to hospital care.…”