Mental Health Policy Reform: Developing a conceptual overview of content and process

Abstract The global burden of neuropsychiatric disorders is rising worldwide. This burden will be felt most in developing countries which have limited resources to respond. Within the health sector, mental health has traditionally been a low priority in most countries, resources to address the burden are limited and mental illness competes with other serious disease for government attention. Despite high-profile international statements, mental health reform has been slow and mental health has remained a low-level political priority, particularly in developing countries and Newly Independent States. There is growing recognition of the need for mental health development and reform. There is growing consensus that successful delivery of mental health interventions to address the disease burden is constrained not only by resource limitations but also by the absence of policy and planning frameworks to identify and deliver these interventions. This thesis highlights that the preparation and adoption of a policy position and the development of a comprehensive policy document is the outcome of a range of complex interactions between environmental factors and the stakeholders within the policy environment. There is growing recognition within the policy sciences literature that a comprehensive understanding of the overall policy process requires an individual and combined understanding of the content of a policy and the processes involved in achieving policy status and implementing policy. Little is documented regarding the content domains and elements which should be included in a mental health policy and the key variables within the policy environment which impact on the mental health policy development process. As a result there are no universally applicable blue prints or policy formulation tools for mental health policy which recognise the complexity of mental health systems and identify key issues which need to be considered in understanding how to promote mental health onto the policy agenda, how to develop a policy once this has been achieved and how stakeholders can more effectively engage in mental health policy agenda building. This thesis addresses this issue by undertaking three distinct but interlinked tasks. Part 1 contributes new knowledge to the area of mental health policy content. It identifies the key content domains and elements which constitute a comprehensive mental health policy. The domains and elements are validated through an extensive consultative process, undertaken by the author, with key mental health stakeholders in 40 countries in all six WHO regions of the world in 2000 and 2001. Based on this work the thesis develops an innovative conceptual tool for mental health policy makers, The Mental Health Policy Template. Whilst responding most particularly to the needs of developing countries and Independent States, the Template is sufficiently generic to be used in a range of countries, provinces and at district levels. The experience of many mental health reformers in developing countries and Newly Independent States is that raising mental health onto the policy agenda and maintaining it there is an on-going challenge. Conceptual models for understanding mental health policy process are extremely limited. Part 2 of this thesis responds to this situation by drawing on the policy analysis literature, with particular focus on agenda building. It identifies two key variables, Context and Stakeholders and their components. These variables are argued to impact on raising mental health onto the policy agenda. The applicability of these variables and their components is demonstrated through the analysis of two country experiences of mental health policy development and reform. One country, Lithuania is a Newly Independent State and the other, Zambia is a developing country. The information collected for these country studies was developed by a series of country visits and stakeholder consultations by the author between 2000 and 2007. The analysis of the country data suggests that the experiences of two quite disparate countries can be usefully organised using the variables and components identified from the literature and may be applicable across a diverse range of countries. This constitutes new knowledge of the variables which impact on mental health policy process and mental health policy reform. Part 3 of this thesis proposes a conceptual model which synthesises the new knowledge established in Part1 and 2. A Mental Health Policy Development Model is proposed which brings together the policy literature and country experiences. It identifies the key content and process factors which need to be considered in mental health policy development and reform with particular application to developing countries and Newly Independent States. The model can be used by those wishing to more fully understand and undertake mental health policy development and reform. To my knowledge such work has not been undertaken in the area of mental health and constitutes a basis for further development in the field. Finally, the thesis acknowledges the formative nature of the work and makes suggestions for further research to build this knowledge ideally in partnership with other key mental health policy stakeholders throughout the world