Health Policy and Planning Advance Access originally published online on March 13, 2006
Health Policy and Planning 2006 21(3):171-182; doi:10.1093/heapol/czl004
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Financing mental health services in low- and middle-income countries
1Department of Social Policy, 2Personal Social Services Research Unit, LSE Health and Social Care, 3European Observatory on Health Systems and Policies, all London School of Economics and Political Science, UK and 4Centre for the Economics of Mental Health, Institute of Psychiatry, King's College London, UK
Correspondence: Anna Dixon, Department of Social Policy, London School of Economics and Political Science, Houghton Street, London WC2A 2AE. Tel: 020 7955 7515; Fax: 020 7955 7415; E-mail: a.dixon{at}lse.ac.uk
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.
Key Words: mental health services, financing, organized, developing countries, developed countries, fees
1The global burden of disease study identified five major neuropsychiatric disorders: unipolar depression, alcohol use, bipolar affective disorder (manic depression), schizophrenia and obsessive compulsive disorder (Murray and Lopez 1996). The 10th edition of the International Classification of Disease sets out in Chapter V the main groups of mental and behavioural disorders: organic, including symptomatic, mental disorders, mental and behavioural disorders due to psychoactive substance use, schizophrenia, schizotypal and delusional disorders, mood (affective) disorders, neurotic, stress-related and somatoform disorders, behavioural syndromes associated with physiological disturbances and physical factors, disorders of adult personality and behaviour, mental retardation, disorders of psychological development, behavioural and emotional disorders with onset usually occurring in childhood and adolescence, and unspecified mental disorders. WHO's World Health Report 2001, on mental health, focused on depressive disorders, substance use disorders, schizophrenia, epilepsy, Alzheimer's disease, mental retardation, and disorders of childhood and adolescence as these usually cause severe disability when not treated adequately and place a heavy burden on communities (WHO 2001b).
2To date a total of 17 profiles have been completed from which this sample is drawn.
3A co-ordinator in each country, usually the person responsible for mental health in the Ministry of Health, identified a small working party of key informants, and a further multi-disciplinary group of professionals were identified through a purposeful sampling technique.
4Despite a public commitment to new parity legislation by both the President and leading Democrats, Congress has so far failed to get a new bill onto the Statute book.
5However, only mental health conditions that can be treated in a short period of time (under 30 days) are covered by Austrian insurance funds. Other conditions have to be financed through social care budgets with significant out-of-pocket payments (see Zechmeister et al. 2002).
6Even in universal tax-based systems, there may be certain groups of individuals who are excluded, such as illegal immigrants, asylum seekers, refugees and prisoners.