The work paper highlights the evolution of the public financial decentralization in Romania, based on analysis of legislative changes that occurred after 1991.These changes have had an important impact on local budgets and on local government responsibilities. In the context of increasing local financial independence, local authorities had to demonstrate their ability to take on the tasks of local interest from central government powers. The effect is prompt and timely response to citizen needs.
The right to participation is the "the right of rights"--the basic right of people to have a say in how decisions that affect their lives are made. All legally binding international human rights treaties explicitly recognize the essential role of participation in realizing fundamental human rights. While the substance of the human right to health has been extensively developed, the right to participation as one of its components has remained largely unexplored. Should rights-based health advocacy focus on participation because there is a relationship between an individual's or a community's active involvement in health care decision-making and the highest attainable standard of health? In the context of the human right to health, does participation mean primarily political participation, or should we take the right to participation to mean more specifically the right of persons, individually and as a group, to shape health care policy for society and for themselves as patients? Decentralization of health care decision-making promises greater participation through citizen involvement in setting priorities, monitoring service provision, and finding new and creative ways to finance public health programs. Between 1999 and 2008, Indonesia decentralized health care funding and delivery to regional governments, resulting in substantial exclusion of its poor and uneducated citizens from the health care system while simultaneously expanding the opportunities for political participation for educated elites. This article explores the tension between the right to participation as an underlying determinant of health and as a political right by reviewing the experience of Indonesia ten years after its decision to decentralize health care provision. It is ultimately argued that rights-based advocates must be vigilant in retaining a unified perspective on human rights, resisting the persistent tendency to separate and prioritize the civil and political aspects of participation over its social component.
Aleksander Berentsen, Mariana Rojas Breu, Shouyong Shi
Many countries simultaneously suffer from high inflation, low growth and poorly developed financial sectors. In this paper, we integrate a microfounded model of money and finance into a model of endogenous growth to examine the effects of inflation on welfare, growth and the size of the financial sector. A novel feature is that the innovation sector is decentralized. Financial intermediaries arise endogenously to provide liquidity to this sector. Consistent with the data but in contrast to previous work, reducing inflation generates large growth gains. These large gains cannot be easily reproduced by imposing a cash-in-advance constraint in the innovation sector.
Informal payments are a frequently overlooked source of local public finance in developing countries. We use microdata from ten countries to establish stylized facts on the magnitude, form, and distributional implications of this "informal taxation." Informal taxation is widespread, particularly in rural areas, with substantial in-kind labor payments. The wealthy pay more, but pay less in percentage terms, and informal taxes are more regressive than formal taxes. Failing to include informal taxation underestimates household tax burdens and revenue decentralization in developing countries. We propose a simple model of information and enforcement constraints that parsimoniously explains the patterns in the data.
This paper provides an in-depth analysis of the relationship between fiscal decentralization and pro-poor outcomes based on the role of fiscal incentives. The literature on the relationship between fiscal decentralization and pro-poor outcomes is not well established in this area. A conceptual model is developed to explore in more detail this relationship, while endeavoring to illuminate the complexity of the issues involved for policy makers in developing countries. Four types of fiscal incentives are explored: namely, resources, responsibility, autonomy, and accountability. The paper then assesses the effectiveness of the Vietnamese system of fiscal decentralization for achieving pro-poor outcomes through a devolved system of fiscal incentives. The paper suggests that evidence from the Vietnamese case indicates that fiscal decentralization may contribute to poverty reduction outcomes, but does not provide evidence that fiscal decentralization is in and of itself inherently pro-poor. Rather, the lesson from Viet Nam is that if poverty reduction is an explicit objective for government, the system of fiscal decentralization should target pro-poor outcomes through an appropriate system of fiscal incentives. Since 2002, budgetary reallocation and income redistribution linked to poverty outcomes has been more strongly associated with equalizing fiscal transfers than with devolved finances in general. This represents a broadly correct approach to target poverty outcomes in a territorially unbalanced country like Viet Nam. Targeted transfers contribute to pro-poor outcomes by increasing the level of resources available to finance poverty spending. However, increasing the level of fiscal transfers for poverty spending will not ensure that fiscal transfers are then spent efficiently. In order to better realize these efficiency objectives, the government can promote greater fiscal and administrative decentralization of resources and responsibility to district- and commune-level governments. Further gains in this area must also be supported by greater levels of fiscal autonomy and fiscal accountability at the local government level.
The paper examines the progress being made in local finance reforms and indicates pathways to advance those reforms. A summary of the effects of decentralization is given as a contextual background for the discussion of local finance reforms. The inefficient tax assignment has constrained the mobilization of local tax revenues even as local government units have become very dependent on the intergovernmental fiscal transfer, called the internal revenue allotment. The paper raises the importance of revisiting the internal revenue allotment formula. It identifies the local finance reforms currently being undertaken and reports the progress being made at the local and national level. The final section comments on the outstanding issues in local finance reform and gives some recommendations.
This book explores the important topic of fiscal decentralization in Asian countries, and focuses on how government finance and administration are being reformed to bring budgetary decisions closer to voters. The focus on Asia is especially important because all countries in this region have been undergoing serious fiscal reforms in the past decade. They include one of the biggest decentralization reforms in Indonesia, significant reforms in democratic Philippines and Vietnam which are in transition, and Japan, whose fiscal reconstruction program is covered extensively. India and China, which are also covered, are very special cases because of their size and because their policies must fit decentralization into a significant economic growth scenario.
The internal public audit procedures have been applied since recent time in our country and this strongly influences the managers’ and employees’ perception of the internal audit relevance. The internal audit is perceived as “another form or a new form of control” due to the fact that the audit departments were organized, especially in the local public administration and in the decentralized public institutions, with the support of the internal control structure and with the participation of the personnel who was in the past responsible for control activities. This error of perception impairs the internal auditors’ work and the organization management. The sources of the research are the annual reports of UCAAPI regarding the internal public audit activity between 2004-2007, available on the site of the Ministry of Economy and Finance. The obtained results partly confirm the hypotheses of the research.
Open access
Risk Management in Financial Firms
Education, Management, Technology, Human Resources
In this article, the determinants of health care expenditure per capita in Spanish regions are analysed. The coexistence of several models concerning the degree of spending power decentralization and financing systems makes Spain a singular case and allows us to draw conclusions relevant for other countries decentralizing their health care systems. Analysing the Spanish case also serves to show a number of pitfalls affecting econometric estimation of the effects of income and demographic structure on health expenditure. Because the reliability of parameter estimates is a key issue in the literature on the determinants of health expenditure, these potential problems should be taken into account when estimating and interpreting results.
Both theory and experience in a variety of circumstances around the world suggest strongly that if fiscal decentralization is to produce sustainable net benefits in developing countries, subnational governments require much more real taxing power than they now have. Students of public finance have studied the subject, and practitioners in developing countries have installed many different versions of subnational government tax. In most developing countries there are potentially sound and productive taxes that subnational governments could use: personal income tax surcharges, property taxes, taxes on the use of motor vehicles, payroll taxes, and even subnational value‐added taxes and local “business value” taxes may all be viable options in particular countries. Still, there is no general consensus about what works and what does not. In this review paper, we try and pull together enough evidence to suggest the way forward. We also develop the argument that given political realities one cannot usually decentralize significant revenues to subnational governments without having in place an intergovernmental transfer system to offset at least some of the disequalizing effects that would otherwise occur. Nor does it make sense to think of decentralizing exactly the same package of tax choices to all subnational governments regardless of their scale and scope of operations.
This research is concerned with how bank lending relationship affects small and medium-sized enterprise financing. We particularly focus on the effect of this contractual feature on their specific asymmetric information problems. We contribute in several ways to the fields of corporate finance and financial intermediation. First, we find evidence that firms which work with more likely to provide lending relationship banks, decentralised ones, use less trade credit, social and fiscal debt and leasing. They appear to access more easily to bank credit. Second, we note that small and mediumsized enterprises choose their main bank for their ability to deal with the kind of information they can provide. Firms with hard information prefer to borrow to centralized banks and firms with soft information prefer to borrow to decentralized ones. Those which can't work with a bank of good type are more credit constrained. Third, we show that bank lending relationship improve collateral efficiency in credit contracts. It allows banks to offer separating equilibrium based on two dimension contracts: interest rate and collateral level. The information transfer during the relationship prevents agency costs associated with collateral. So good project holders can credibly signal themselves giving more collateral to obtain lower interest rate. By doing this, banks limit credit rationing in this context
Thorsten Beck, Asli Demirgüç‐Kunt, María Soledad Martínez Pería
Using data from a survey of 91 banks in \n 45 countries, the authors characterize bank financing to \n small and medium enterprises (SMEs) around the world. They \n find that banks perceive the SME segment to be highly \n profitable, but perceive macroeconomic instability in \n developing countries and competition in developed countries \n as the main obstacles. To serve SMEs banks have set up \n dedicated departments and decentralized the sale of products \n to the branches. However, loan approval, risk management, \n and loan recovery functions remain centralized. Compared \n with large firms, banks are less exposed to small \n enterprises, charge them higher interest rates and fees, and \n experience more non-performing loans from lending to them. \n Although there are some differences in SMEs financing across \n government, private, and foreign-owned banks - with the \n latter being more likely to engage in arms-length lending - \n the most significant differences are found between banks in \n developed and developing countries. Banks in developing \n countries tend to be less exposed to SMEs, provide a lower \n share of investment loans, and charge higher fees and \n interest rates. Overall, the evidence suggests that the \n lending environment is more important than firm size or bank \n ownership type in shaping bank financing to SMEs.
Being able to make payments conveniently and securely is an essential ingredient in modern life and commerce. It enables economic livelihoods and supports many social relationships, communal support actions, and public welfare programs. Yet most people and micro enterprises in developing countries must rely on physical delivery of cash or actual goods to make payments. This imposes large costs and risks on those beyond the reach of modern payment networks. Access to payment facilities is a major enabler for achieving universal access to finance. In this paper the author further develop a broad vision for financial inclusion sketched out in Mas (2008), where payments can be easily made through an electronic network. What makes visioning such a payments utility possible is the technology author have today, which can be used to bridge distances, close information gaps, contain settlement risks, and generally reduce transaction costs. The author is confident that today's technology can do the job. Now the challenge is to develop attractive services that engage customers and workable business models that enable decentralized, largely private, and institutions to build this payments utility.
The design of the decentralized co-operative governance system, conditioned and \nregulated by the South African constitution is of critical importance for policy design and \nimplementation. The division of powers falls within a unitary form of government. This \nstudy, which is about the processes, mechanisms and modalities of public policies \ndesign and implementation uses the public finance and health sectors, as a case study \nor lens through which policy design and implementation is examined within a \ndecentralized cooperative governance system. The study is per se not about the public \nhealth system, but rather a review and an analysis about how the decentralization and \ncooperative governance nature, practice and dynamic of government system, influences \nand condition the policy processes and practice on finance and health, separately and \ncollectively within the public health system. \nIn its attempt to unbundle the health function, but also reform the public health system, \ncentral and provincial governments have introduced a number of reforms. These reforms \nwere ostensibly driven by different policies and programmes originating either from the \npublic finance or public health sectors with significant consequences for the provinces. \nMoreover, these different policies also outlined structural and functional responsibilities \nand authority among the central and provincial government departments. The \nimplementation of these policies was at times based on different interpretations of policy \ndesign and implementation responsibilities and authority between the central and \nprovincial governments within co-operative governance system. \nThe argument of this study is that despite intentions implicit to public policy, co-operative \ngovernance system is contested at a central government level within the public health \nsystem, as well as between levels of government and the public health and finance \nsectors. This dissertation explores the nature of the relationship between the central and \nprovincial governments by exploring co-operative governance in the health sector on \npolicy and financing processes and mechanisms. The central question is how does \ndecentralized co-operative governance really work in the public health system? \nA case study method was used to conduct this research. Data was collected over a four \nand half year period using a variety of data collection methods, including semi-structured \nin-depth interviews; documents and reports analyses; policy content review and \nanalyses; and revenue and expenditure reviews and analyses. \nThe study’s findings are: \na) the functional and structural decentralization of policy-making and implementation \nwithin the co-operative governance system contributes to undermining the cooperative \ngovernance relationship between the public finance and health sector and \ncentral and provincial governments; \nb) the central government is using its overriding powers to “impose co-ordinated \nsolutions” to problems within the co-operative governance system, leading to \nsituations where ‘imposed co-ordination’ is considered as ‘co-operative governance’; \nc) the theory provides a classical distinction between state control, supervision and \ninterference models. This dissertation shows that, depending on the policy context \nand circumstances, the uniqueness of South Africa’s co-operative governance \nsystem allows the central government to mobilize any of these models to achieve its \npolicy intentions, whether written or unwritten; and \nd) the classical arguments of decentralization, particularly within a devolved system of \nco-operative governance where greater autonomy and authority are given to subnational \ngovernments, are found wanting within the South African governance \nsystem, given both the policy-making and fiscal resource strength of the central \ngovernment relative to the provinces. \nThis dissertation leads me to conclude that the South African practice of co-operative \ngovernance in the health system is actually imposed co-ordination and that provinces \nare de facto administration outposts of central government policies, programmes and \nservice delivery responsibilities. Therefore in reality there is no autonomy and \nindependence of the provinces from the central government as envisaged in the \nConstitution of the Republic of South Africa. In fact, provinces only exist, in terms of their \nconstitutional competencies as far the central government allows it to exist given its \nplenipotentiary powers over both micro and macro matters affecting institutions, fiscus \nand social policies.
On January 8, 1997, the former President of Brazil, Fernando Enrique Cardoso signed the National Water Resource Policy into law (Law No. 9.433, 1997). The key principles of the National Water Policy include: an integrated approach with the river basin as the planning unit, water as a fragile and finite resource, water as an economic good, and finally, decentralized and participatory management of the resource (Formiga and Scatasta, forthcoming). The legislation provided for the implementation of bulk water pricing with the resulting revenues meant to finance the activities mandated by basin committees in the watershed area of Rio Paraíba Do Sul (in Rio de Janeiro and São Paulo, and also in the state of Minas Gerais, that basin committee is Comitê para Integraςão da Bacia Hidrográfica do Rio Paraíba Do Sul (CEIVAP) (Abers and Keck, 2004). To improve the sustainability of many different resources it is a widely accepted concept that charging a fee for something will spur sparing use by the target audience, particularly if the price is high. One-hundred percent of the collected monies have been invested within the basin; mainly designated to the following: non-structural institutional interventions, sediment control projects, and municipal wastewater treatment. Payments from agriculture and small hydroelectric plants have been mostly symbolic or non-existent and payments from other sectors have not been high enough to maintain a sustainable system. Convincing those that have not been actively participating is central to the success of this initiative: this paper will explain a framework called Social Marketing which is becoming more widely used throughout the globe to inspire behavior change. Social Marketing is a tool that can be used to persuade more users to pay the cobrança.
Open access
Water resources management and optimization
Conservation, Biodiversity, and Resource Management
Pursuant to the Local Self-Government Act adopted in February 2002, the fiscal decentralization has been carried out without the institutional decentralization of functions of the central tax administration, whereby only the affirmation of the self-government authorities has been done in the part of financing the budges of self-government units, but not in the part of administering the original local public revenues. The Local Self-Government Financing Act created a legal ground for decentralization of functions of the central tax administration (Tax Administration). Further concretization of competence of the local tax administration shall be done by the Amendment Act to the Tax procedure and Tax Administration Act.
A family of core extensions for cooperative TU-games is introduced. These solution concepts are non-empty when applied to non-balanced games yet coincide with the core whenever the core is non-empty. The extensions suggest how an exogenous regulator can sustain a stable and efficient outcome, financing a subsidy via individual taxes. Economic and geometric properties of the solution concepts are studied. When taxes are proportional, the proportional prenucleolus is proposed as a single-valued selection device. An application of these concepts to the decentralization of a public goods economy is discussed.
The education financing in Brazil is conditioned by its federalist political organization which involves three autonomous spheres of government: the Union, the States and the Municipalities. Due to the diversity of economical, political and social conditions of regions and states, the Union takes over, according to the Federal Constitution of, the supplying and redistributing functions in relation to the other federal units. Nevertheless, in the sit was observed a growing centralization in the process for the definition of education financing policies by the federal government, resulting in decentralization of responsibilities, in a context facing the advance of the minimalist conceptions of State. This article considers the education financing policies in the scope of the federative relations in Brazil, taking into consideration the scenery where the educational policies have been developed after the and the contradictions which have resulted from the country’s political organization model.
Two papers in this volume focus on public finance and decentralization as central to resolving India's systemic public health crisis. However, some states and districts have achieved success despite serious financial and administrative deficits; this suggests that factors such as political commitment, community participation, human resource management, women's empowerment, and governance may be as or more important. The success of the National Rural Health Mission will depend on state and local institutional capacity, including strong partnerships with civil society organizations and private-sector actors. Increased resources and decentralization will not be sufficient by themselves.
Three years ago, a process of reform to the Statutes of Autonomy of some of the 17 Autonomous Communities that make up the model of politically decentralized State, designed by the Constitution of 1978, begun in Spain. Doubtless, the one that has sparked off more controversy in the legal and also the political grounds has been the Statute of Catalonia, approved since 2006. The subjects of greatest relevance have been those related to the incorporation of a Letter of Rights; the material and functional determination of the competences for the exercise of the self-government, as well as the relationships with the State, the European Union, and the financing system.
Due to the very large number of local units in the Republic of Croatia, the system of collecting income is mainly insufficient for quality and functional financing of public needs on the local and regional levels. It is therefore necessary to continue the search for new models of regulating financial relations between the state and local units. The executed decentralization of the financing of local and regional self-government is not sufficient. Because of the new work and activities that have fallen into the jurisdiction of counties (as regulated by Amendments to the Act from 2005), it is necessary to increase the state's allocation of funds from common taxes for the units of the local and regional self-government, to increase the autonomy of the local and regional units in the introduction of their own incomes, especially taxes, to take care about the implementation of functional decentralization, and to stimulate local and regional governments in the realization of a larger non-fiscal income of their own. It is a fact that some countries in the European Union have begun with the reorganization and reduction of their local self-government precisely because of too high financial payments for the needs of the local self-government. However, so long as the Republic of Croatia retains the existing organization of local governments, it should also provide for its financing. The local or regional self-government units' own sources of income should be their principal sources of financing.
The 2001 World Health Report made plain the global challenge posed by poor mental health. Worldwide, 20% of individuals may experience mental health problems during their lifetime, and such disorders account for approximately a third of all years lived with a disability 1. The consequences of poor mental health range far and wide, of course; they are associated with higher rates of non-mental health-related comorbidity and premature mortality. Some mental health problems are also associated with poor employment experiences, poor personal relationships, strain on families, and a higher-than-average risk of homelessness and contact with the criminal justice system. The 2001 report helped to raise awareness of the importance of mental health. The need to promote and maintain good mental health and well-being as integral elements of health policy is now quite widely recognised in high-income countries. For instance, the European Commission published in 2005 a Green Paper on mental health 2 and all 52 Member States in the European Region of the World Health Organization (WHO) endorsed a Declaration and Action Plan at Helsinki earlier that same year 3,4. In the United States, a Presidential Commission called for investment in actions to ensure that mental health receives the same level of attention as physical health problems, specifically recommending actions to tackle suicide and reduce stigma, as well as interventions to promote child mental health 5. Positive actions can also be seen in the Pacific region, where, for instance, New Zealand has a ten-year national mental health strategy 6, with implementation monitored by a separate Mental Health Commission. The picture in many other parts of the world is much less encouraging. Although there has been some recent focus on the need to tackle the mental health consequences of major disasters such as the Asian Tsunami 7, policy attention and resources in many low- and middle-income countries are still directed largely at communicable diseases. The purpose of this paper is to reflect on some of the challenges faced in low- and middle-income countries and the role that economic evidence could play in strengthening the policy case for investment in mental health. There is obviously a need to improve our understanding of the cost-effectiveness of specific interventions within the health care system. But there is also a pressing need to expand the role of economic analysis in looking at non-health sector interventions that can have a direct impact on mental health or can indirectly help with the uptake and maintenance of treatment. The ways in which services are delivered are of critical importance and also need evaluation. In particular, we shall argue that non-governmental organizations (NGOs) can be key players in the funding, coordination and delivery of services. The burden of mental illness is predicted to increase from its current level of 12% of global disease burden to approximately 15% by 2020; much of this additional burden is projected to occur in low-income countries 8. The consequences of poor mental health in low-income countries may be even worse than in high-income ones, because of the absence of social protection safety nets, compounded by the high levels of stigma and superstition 9. The cycle between poor mental health and poverty in low-income countries has been observed in several studies 10–12. Poor maternal mental health also has long-term adverse consequences for infants in low- and middle-income countries, limiting their own lifetime opportunities 13. Communicable diseases, the focus of much health policy in poorer countries, are also inextricably linked and exacerbated by poor mental health; interventions to prevent and treat mental health problems could help in the management of these conditions, as for instance in the case of HIV/AIDS 14,15. The economic costs of poor mental health are well documented in high-income countries, conservatively estimated to account for between 3% and 4% of gross domestic product (GDP). Few estimates have been made outside the developed world. One exception is a study in Kenya 16 that estimated that the total costs per patient for 5,678 individuals with mental health problems hospitalised in 1999 were US$ 2,351. This included out of pocket costs to family members of US$ 51 and productivity losses of US$ 453. Total economic costs for this group alone were more than US$ 13.3 million, equivalent to 10% of the Ministry of Health's budget; yet these figures would have been substantially larger if costs had also been included for those individuals who were not institutionalised or were treated by traditional healers. To put this in context, the average income per head of the population in Kenya is just US$ 580 per annum, and more than half the population live on less than US$ 1 per day 17. Other examples can be found in India, where the overall costs for outpatients with schizophrenia have been found to be similar to those of people living with another long-term condition, diabetes; a key difference between them, however, is the much greater contribution of indirect costs to overall costs (63% versus 29%) in the case of schizophrenia. This included not only the costs of lost opportunities to work for the individuals with the illness and their families, but also the loans taken out to meet the costs of treatment and money spent on repairing damage to property. In total the annual cost per outpatient treated for schizophrenia was estimated to be US$ 274 18. Another Indian study where free access to essential drugs was provided as part of community outreach services for people with schizophrenia reported that these led to a number of improvements in quality of life over an 18-month period. The impact on cost was modest, with the investment in community outreach services partly offset by a reduced need for caring by family members 19. This impact on family caregivers can be considerable. In Ethiopia, Shibre et al 20 looked at the impact of schizophrenia on 300 family caregivers in traditional rural communities. Relatives experienced financial difficulties, constraints on their social life, reduced opportunities to work and strained family relationships. These problems were particularly challenging for female caregivers. Similarly, a study of 66 caregivers in Zimbabwe reported that two-thirds experienced financial difficulties, especially as food consumption by their relative increased 21. Some people have argued a moral case for greater investment in mental health, given the high number of individuals affected and the ensuing profound consequences 22. Such a case obviously needs substantiating with evidence that targeting more investment on mental health will be effective in preventing or treating mental disorders, and that it represents a cost-effective use of a country's scarce resources. In turn, this generates a need for economic analyses to support clinical and strategic decision-making. Of course, decisions should never be made on the basis of cost or cost-effectiveness alone, and other factors such as fairness, human rights and ethics are usually highly relevant. There has been significant growth in the evidence base on the effectiveness and cost-effectiveness of interventions aimed at treating the consequences of poor mental health (particularly drug therapies) 23–26. Increasingly, economic analyses are being undertaken in low- and middle-income countries 27–31, but the overwhelming majority of studies are from high-income countries. This is not surprising: between 1992 and 2001 only 4% of articles in journals on the ISI Web of Science databases were on mental health issues; of these a mere 6% were from low- and middle-income countries 32. Similarly, Patel and Kim 33 found, from their review of publications between 2002 and 2004 in six leading journals, that only 3.7% of papers were from low-income countries. Unfortunately, economic evaluation findings do not transfer easily between countries, because infrastructures, resources, incentives and cultures can be very different. There is therefore a need to develop the evidence base on the effectiveness and cost-effectiveness of interventions in low- and middle-income countries through additional empirical studies. Practically, however, even with a substantial injection of funding, this evidence base will take some time to emerge, given the human and infrastructure capacity constraints within countries 34. In the meantime, how can economics best be used to inform policy making? In the absence of empirical evidence, careful use of economic “models” which seek to adapt evidence on effect to take account of different local circumstances and cost structures can play a role. The most significant such endeavour is the ongoing work of the WHO CHOICE (Choosing Interventions that are Cost Effective) Programme. CHOICE aims to assess the cost-effectiveness of a wide range of interventions for conditions that make significant contributions to the burden of disease in a range of epidemiological and geographical settings. The core aim is to feed information into the policy process 35. Thus far, the CHOICE programme has looked at schizophrenia, bipolar disorder, depression and panic disorder. It has estimated, for example, that cost-effective interventions can be provided for US$ 3–4 per capita in low-income settings of Sub-Saharan Africa and South East Asia, or around US$ 10 in middle-income regions such as Eastern Europe. These are typically a combination of older off-patent antipsychotic or mood stabilising drugs plus psychosocial therapy. It has also been estimated that, globally, between 300 and 500 million healthy years of life could be gained for each additional US$ 1 million invested. Around one third of the gains would be for severe mental disorders, schizophrenia and bipolar disorder, with the most cost-effective interventions being for depression and panic disorder 36. Welcome though the CHOICE programme is, it has largely on health care interventions to improve mental health there is in high-income countries a of evidence to the role of employment and living There is an need to assess the cost-effectiveness of and many of which outside the health for in the or There is also very evidence from low- and middle-income countries on how poverty and factors impact on the of mental health policy and these have an to mental health policy the substantial adverse impact of poor mental health and the evidence base on the of cost-effective there many in to ensure that mental health receives a level of investment in low- and middle-income countries and that, services are there is access to mental health may have to be a for national policy and of this was the that the World World Report that poor mental health was a major to the global burden of but its essential services for health services not seek to mental disorders, even though their overall burden was that of and HIV/AIDS This some and was in a of the it the case that in low- and middle-income countries the focus of much health policy has been communicable that to premature most and have been such as the by aimed at greater access to drug for The the contribution of good health economic and several health-related yet mental health is by its the of papers for the Commission which the between of economic growth and poor mental health This is exacerbated by This has to a of attention from policy and the in leading to a of resources, poor of information and if greater to mental health, a key on the of services and their as to meet needs is the of epidemiological This is not to low-income one recent review could not on mental disorders in of the European Member States Unfortunately, the infrastructure to such information is not in the of needs it is not to on epidemiological The of all need to be yet it for people with mental health problems and their to have an to in or inform the policy a there is a that policy to that can some of the of mental disorders, such as lost opportunities to work or to in There is also the risk that policy to the challenges of on the health care may the to mental health in may be not in many low-income countries One study from Zimbabwe that over of health care in the and of treatment for depression of health care may be compounded by the of mental with some studies that many that such conditions do not or be treated also that only physical or conditions are than the for more than 2 of the population less than of their total sector health care on mental health The majority of countries in Africa are in this of the world population in low-income countries have access to community care services on of mental health services is but at of people with severe mental health problems do not treatment within in some low-income countries One recent in found that only of people with disorders some of treatment for mental health problems during a In where the overwhelming majority of people with schizophrenia are by the it has been estimated that over still do not make use of services where there is a to mental health, the level of resources will be on the of the even if more than of the total health is to mental health, this will not to much in of overall resources if the overall level of national income is The need to or to make also that services have to be mental health services may be particularly in such to drug the WHO found that, by 20% of all countries were not at one one antipsychotic and one This is to be helped by the of World this can of drugs and the of drugs be by the there are some to these for national and which are life there are for mental In a number of free have been between the and some countries. These can be even than for instance the of protection There are also human especially health have to with the of high countries that can and conditions to these but challenges the middle-income countries of the a major to be the high rates of suicide and disorders, which may partly from economic and social mental health services are being put as resources for health the health by many people to in health care typically do not for long-term mental health The for mental health in many low- and middle-income countries that access to many services is on at the of Around of low-income countries reported to be the for mental health with only 3% of high-income countries this of is as it not take account of costs through with traditional healers. This on is and as it of services by those with which is especially given the between poverty and poor mental health for services may to poverty or if from at very to reduce some of the associated with poor mental health are number of challenges in use of resources have been out on by et al these may also be to health they are to be more to in mental health their impact may be in low- and middle-income countries, where human and financial resources are scarce and where there are many on resources. of these have been the of information on effectiveness and and the level of resources to mental health treatment and Another key is the poor of resources, which are in The to be to a mental health can be in one Indian study a key for the of use of antipsychotic was the need for individuals to have to more than 10 to their outreach 19. In some rural of South Africa there is only one per million population particularly from rural to can also as a to treatment. in is with the of that million people for may also be different disorders or for example, depression has been as a to schizophrenia within the health of countries There is also the that resources are used to support services that do not epidemiological needs or the of or the evidence base on effectiveness and The WHO has the of mental health where mental health is into the health countries which to on care are to be an of services. is a it may to and resources as best to meet population Health may be highly with for or local management of In countries where most resources are within a highly as in the it can be to resources from to The uptake of community outreach services also be poor because of the problems of food of and financial resources. To ensure a of treatment is may with food one in Zimbabwe that more than 10% of family could not to for the additional food for with mental health problems 21. It is therefore to ensure that resources are not and for to not only clinical but also some of the factors that the use of services. there is as in India, local structures need to have the to ensure that are to mental health. may also be by a number of different not only health, but also employment and social Poor coordination and between and local and can the of services. In for example, the of and community services for mental health was to a of coordination also need to be that of services or greater investment not that there will be improvements in mental health in may take several years to in of treatment and policy may therefore be to on of the health where more and can be even if the need for is is the need to ensure that there is a long-term to as to support individuals over time within their communities. one need is to improve access to information on effectiveness and cost-effectiveness of interventions to treat mental health understanding of population needs is also Other information that need to be and cost-effective ways to mental health to care and other and awareness and to tackle some of the consequences of the information and more use of scarce resources would some to strengthening the for mental health. a understanding of how resources are to mental health and other health would also be In many where national health are there is high on of for health Some into the ways that and organizations are in in health and other would help if a case is to be for more investment in mental health. opportunities for mental health and other to in the of would also be particularly as many of these papers to focus on physical health. that have helped the of physical and mental health in different settings also help the case for greater resources for mental health in mental health can also physical health. with that focus on physical health help their in mental health and psychosocial One review of that many they not have the to mental health needs and were in of greater with that in the mental health It is also to expand the role of economic analysis to at the cost-effectiveness of to tackle risk factors for poor mental health, such as poor living conditions, financial economic and levels of For instance, to mental health be through the of in low-income the of such will not be to mental health alone, that a all health would be The in which effective interventions are delivered to mental health-related is also of One is the and of health There is a substantial of in looking at to the of delivery and the need to services different be from care to In the to additional will be as to to services community services are developed and which seek to ensure have to be as to also mental health care as with the in may also The high on is a major to access to and countries should be health on or social major however, is that the structures for do not in low-income countries such as very local community a also need Although the CHOICE programme take into account the of uptake of economic in low- and middle-income countries have this are the to such as of it be to tackle these and if services are delivered by but there is a of information on the effectiveness or cost-effectiveness of the services they as it has been in high-income countries, services that can meet the needs of local in ways that services do with and their with local through the of greater uptake and use of services with To and how are These are key to which we now countries report that they have some in the of mental health. health services were of care in many countries, more or have also to play significant These organizations may be or support from local or other Some may also play significant in and policy it is to that specifically focus on mental health. One recent looked at that mental health services disasters as well as services. Of organizations on the United only reported being in mental health of these had in at one long-term but only were to mental health There are the mental health and the Mental Such organizations may not only raise and for mental health, but also help to services. Another is which in with health to help mental health services at care level in several programme countries in Africa and India, and can some of the to the of mental health policy and for by to raise awareness of the importance of mental health and by for access to services in low-income communities. community or which within local with key and their families, is used because of the challenges in at a high level into on the The community that can help on social in to support the work of health and health can be of to ensure use of and as well as and can also as between traditional and For example, has with traditional as one of their in where some of these have to some people with mental health problems to health services Such between the and the opportunities for health especially to their access to can help in a understanding of how to meet mental health needs in community a greater level of contact with people with mental health problems within local health care local health may make at or levels for drugs and other services to meet these local with can also be for the of mental health services. can as to to for greater In one where for example, the was that a mental health and programme would help to mental health the This has very to a of million US$ for mental health in and a World of Health developed with in to develop community in the and Mental health problems are a major to the global disease they are associated with premature and profound on and they substantial costs to the the of cost-effective interventions in high-income countries and some more but evidence in low- and middle-income countries, mental health and care have been widely with levels of investment in interventions for health where is access to and of services may be even if are of course, they are combination of some to mental health, has to these of within a highly of human rights and to of resources have a in which the to prevent and mental health problems has far largely been these challenges a analysis of the cost-effectiveness of interventions can play a role in this Such analysis needs to interventions that the of mental disorders a understanding is also of the health and the and in which interventions are to be analysis is also of more to risk factors for poor mental health, such as of access to and will have that mental health, and with other are such as those with communicable diseases. of the implementation process is In countries where health are and where mental health is a can play some of the of with can be more this help the case for investment in mental health. have with some in the of HIV/AIDS and maternal and child health. is more or different in looking at mental health problems in the same and in the same The experience from such as that even can have some which in that the of people with poor mental health in low-income countries is not as as is at the policy the key difference between mental disorders and other health is that the are more as a because they are as less mental health only to the attention of local policy a global such as the Asian Tsunami or a high local such as the in The in the of people who had been within a Commission provided the for mental health policy and by and and even the of But as these from it is for mental health to and for the that investment in mental health can economic as well as quality of life is to its on the for economic This is to effective mental health care with in the
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Mental Health Treatment and Access
Health disparities and outcomes
Child and Adolescent Psychosocial and Emotional Development