Blockchain Papers

Alba González-Moreira, Camino Ferreira, Javier Vidal

<p style="text-align:justify">The educational transition between early childhood education and primary education is a complex moment of change with repercussions throughout the academic life of the students. For this reason, it is important to seek continuity between both educational stages. A successful transition produces for the social, cognitive and emotional well-being of the student. The aim of this study is to find out how transition-related factors apply in ten European Union (EU) countries. The factors analyzed are the age of onset of transition, the teacher–student ratio, types of clustering, financing of the stage, responsibility, and both initial and in-service teacher training. The methodology followed in this study is documentary analysis and the main source of data search has been the European Commission's Eurydice portal. The results show differences in stage change within each country, especially in the explicit consideration of a transition period. The main conclusion is that there is a great difference between the northern and southern countries. The main differences between countries in the transitions from early childhood education to primary education in the EU are in the years of compulsory education, the teacher/student/unit ratio, the initial teacher training, and the decentralization of education.</p>

Angela Akol, Ingunn Marie Stadskleiv Engebretsen, Vilde Skylstad, Joyce Nalugya · 6 authors

BACKGROUND: Robust health systems are required for the promotion of child and adolescent mental health (CAMH). In low and middle income countries such as Uganda neuropsychiatric illness in childhood and adolescence represent 15-30 % of all loss in disability-adjusted life years. In spite of this burden, service systems in these countries are weak. The objective of our assessment was to explore strengths and weaknesses of CAMH systems at national and district level in Uganda from a management perspective. METHODS: Seven key informant interviews were conducted during July to October 2014 in Kampala and Mbale district, Eastern Uganda representing the national and district level, respectively. The key informants selected were all public officials responsible for supervision of CAMH services at the two levels. The interview guide included the following CAMH domains based on the WHO Assessment Instrument for Mental Health Systems (WHO-AIMS): policy and legislation, financing, service delivery, health workforce, medicines and health information management. Inductive thematic analysis was applied in which the text in data transcripts was reduced to thematic codes. Patterns were then identified in the relations among the codes. RESULTS: Eleven themes emerged from the six domains of enquiry in the WHO-AIMS. A CAMH policy has been drafted to complement the national mental health policy, however district managers did not know about it. All managers at the district level cited inadequate national mental health policies. The existing laws were considered sufficient for the promotion of CAMH, however CAMH financing and services were noted by all as inadequate. CAMH services were noted to be absent at lower health centers and lacked integration with other health sector services. Insufficient CAMH workforce was widely reported, and was noted to affect medicines availability. Lastly, unlike national level managers, lower level managers considered the health management information system as being insufficient for service planning. CONCLUSION: Managers at national and district level agree that most components of the CAMH system in Uganda are weak; but perceptions about CAMH policy and health information systems were divergent.

B. C. Partridge

Do adolescents have the decisional capacity of adults? Or, are they in crucial ways still immature, that is, are they deficient decisionmakers? This question has been answered in quite different ways in medical versus criminal law. In medical law, an exception from the requirement of parental consent was crafted to allow adolescents to make decisions in restricted circumstances associated with quasi-medical emergencies. Over the last few decades, this exception has grown into an almost blanket acceptance of the decisional capacity of adolescents under the age of 18 and generally over the age of 14 to give valid consent to treatment. At the same time, a seemingly contrary view of the decisional capacity of minors developed in American criminal law, especially around cases such as Eddings v. Oklahoma (1982), Johnson v. Texas (1993), Roper v. Simmons (2005), Graham v. Florida (2010), Jackson v. Hobbs (2012), and Miller v. Alabama (2012). These Supreme Court decisions recognize adolescents as having a substantive lack of maturity and an underdeveloped sense of responsibility that distinguishes adolescents from adults. The Court in Graham v. Florida (2010) noted, for example, that “developments in psychology and brain science continue to show fundamental differences between juvenile and adult minds . . . [in] parts of the brain involved in behavior control” (560 U.S., at __ [slip op., at 17]). The result is that courts have accepted the view that the decisional capacity of adolescents is not fully developed and that as a consequence adolescents cannot have the same degree of criminal culpability as adults. In evaluating the decisional capacity of minors, one thus faces the challenge of how to harmonize these two quite different trends in the assessment of adolescent decision making. This issue of The Journal of Medicine and Philosophy brings together psychological and neurophysiological data with philosophical–bioethical reflections on what should count as decisional capacity or decisional agency. Some of the articles address as well the issue of the authority of parents over their children and how this bears on the question of whether adolescents under the age of 18 should generally make medical decisions without the involvement of their parents. The conclusions one reaches on these matters regarding adolescent decisional capacity and parental authority will determine the concrete character of medical law and public policy. In particular, it will determine whether the default position should be that of presuming that minors over the age of 14 do or do not possess decisional capacity equivalent to that of adults. Where one places the burden of proof will also turn on empirical data regarding the contribution of authoritative, even authoritarian, parenting to the successful maturation of minors into adults, for this will give a further indication of the importance of parental involvement. This issue of The Journal of Medicine and Philosophy opens with a paper from a psychologist who has been involved in developing briefs to the Supreme Court (Miller, 2012) that have influenced holdings that recognized the diminished legal culpability of adolescents (Miller v. Alabama, 2012). Laurence Steinberg in his article “Does Recent Research on Adolescent Brain Development Inform the Mature Minor Doctrine?” argues that, because adolescents are less mature than adults, when making decisions characterized by emotional arousal and peer pressure as when committing crimes, culpability is diminished (Steinberg, 2013). However, Steinberg also argues that recent studies of the adolescent brain and of behavioral development do not undermine the mature minor doctrine. Instead, the data indicate important ways in which the doctrine should be applied. First, Steinberg stresses the difference between adolescents and children, making plausible the old rule of 7’s (i.e., infants under 7 years, children 7–14, and adolescents over 14). He holds that adolescents in the right circumstances have decisional capacity equivalent to that of adults. Second, Steinberg takes the view that healthcare practitioners can enhance the ability of adolescents to make informed and knowledgeable decisions by being involved in the decisional process and by creating a context that circumscribes impulsive decision making (i.e., decision making that does not take into account long-term as well as short-term consequences of alternative courses of action). Thus, given peer pressure and circumstances in which impulsive decision making is not counteracted, adolescents lack adult decisional capacity and, therefore, adult culpability with regard to criminal acts. However, Steinberg argues that in the context of most medical decision making, adverse influences on the decisional capacity of minors can be counteracted so that adolescents can function as mature minors. In contrast, Evan Wilhelms and Valerie Reyna advance grounds to restrict the mature minor exception to quasi-emergency situations. They come to this decision because they find a more fundamental qualitative difference between adolescent and adult decision making. In “Fuzzy Trace Theory and Medical Decisions by Minors: Differences in Reasoning between Adolescents and Adults,” they report data that show that it is not merely impulsive behavior or even the failure of adolescents to take into account long-term as well as short-term consequences that makes adolescents bad decisionmakers (Wilhelms and Reyna, 2013). More importantly, it is their failure to grasp the gist of what is at stake in making a decision. Wilhelms and Reyna develop their argument through engaging “fuzzy trace theory”: Fuzzy trace theory (FTT) is a comprehensive theory of reasoning, judgment, and decision-making that integrates the prior standard reactive model with documented cognitive developmental differences to explain risk-taking behavior in adolescents. . . . According to FTT, deliberative, analytic reasoning and impulsive reactivity are distinct routes to risk taking, and, surprisingly, the former accounts for a great deal of risk-taking in adolescence. . . . Thus, adolescents are not just more emotional and impulsive than adults; their understanding of the gist of such decisions is not mature. (Wilhelms and Reyna, 2013, 272) The point is that it is “gist processing” that appears to be a necessary condition for mature decision making. Even when adolescents can intellectually analyze and lay out long-term as well as short-term consequences of their decisions, they still fail crucially to apprehend what is at stake in the decisions they face. Although adolescents are capable of encoding mathematical probabilities about risks and rewards, they still do not have the mature appreciation for the meaning of those risks and rewards, and their implications for their future adult lives. Put another way, it could be said that some adolescents know “the price of everything but the value of nothing.” (Wilhelms and Reyna, 2013, 279) Adolescents, in short, differ qualitatively from adult decisionmakers, so that Wilhelms and Reyna “conclude that circumstances in which adolescents are equivalent to consenting adults are unusual” (Wilhelms and Reyna, 2013, 270). They, therefore, recommend that “if [mature minor] exception is necessary for an emergency situation, the physician or medical experts involved should emphasize the bottom-line gist of risks involved during the process of consent or deciding on treatment options” (Wilhelms and Reyna, 2013, 279). The next essay in this issue, “The Mature Minor: Some Critical Psychological Reflections on the Empirical Bases” (Partridge, 2013), takes a position closer to that of Wilhelms and Reyna than to that of Steinberg. This essay concludes that there are grounds to bring into serious question the advisability of exempting minors from parental authority and guidance, save in emergency or quasi-emergency circumstances, given the qualitatively different character of adolescent decision making. These differences are not just due to differences in decisional behavior, such that adolescents tend more than adults to be impulsive decisionmakers, who often inadequately take account of the long-term consequences of their choices and who very frequently fail fully to apprehend the significance of near- and long-range consequences of decisions. In addition, the brains of adolescents are simply different from those of adults. One can through brain imaging literally see the differences. When adolescents make decisions, there is a greater engagement of limbic structures with less of an engagement of prefrontal cortical areas in comparison with adults making the same decisions. These data justify a strong but rebuttable presumption that, in general, minors lack mature decisional abilities, and that they would benefit from the guidance of those who know them well, in particular parents and guardians. A second body of data is also relevant, which shows the importance of effective parenting for the maturation of adolescents (Baumrind, 1989; Adaljarnardottir and Hafsteinsson, 2001; Huver et al., 2007). These findings indicate that one should be more concerned about false positives than false negative determinations of decisional capacity, given the benefits from parental involvement. Here matters are complex, in that the character of the family in the West is changing, with some 41% of children in the United States now being born outside of a traditional marriage (Martin et al., 2011, 2). Any actual approach to adolescents will need frankly to take into account their social context. The papers by Rachelle Barina and Jeffrey Bishop, by Mark Cherry, and by Ana Iltis locate the examination of the mature minor exceptions more explicitly within moral and bioethical concerns. In their paper, “Maturing the Minor, Marginalizing the Family: On the Social Constitution of the Mature Minor, Sexual Politics, and the Family,” Barina and Bishop address the historic and social context in which the formation of the mature minor doctrine develops, and in doing so illustrate the adversarial nature between the goals of the state and the contextual role played by families. Barina and Bishop embed their analysis of this development within a “phenomenological account of the care of the body in the family” and its subsequent application to reproductive health policy. They argue that, legally and medically, the concept of the mature minor does not actually depend upon the notion of maturity. Instead, the invocation of the doctrine of “mature minor” in the context of adolescent reproductive health has become a means to assert better health outcomes for the state. A careful consideration of maturity is unnecessary because contraception is an unqualified good in the case of every teen. Socially destructive and expensive health risks, more than the adolescent’s mature ability to understand and appreciate health information, merit the provision of reproductive health services without parental consent. (Barina and Bishop, 2013, 306) They also argue that the focus on public health to the exclusion of all other factors creates a clear conflict between state interests and parental authority. In so doing, the state is interrupting the conveyance of “the moral, social, and existential goods that belong to the particular family within which the child’s life-world is formed.” (Barina and Bishop, 2013, 309) Mark Cherry takes a stronger stand against the universal application of the mature minor doctrine in his paper “Ignoring the Data and Endangering Children: Why the Mature Minor Standard for Medical Decision Making Must Be Abandoned.” Unlike Steinberg who is able to reconcile the apparent differences in the medical and legal understanding of adolescent decision making with the neuropsychological evidence, Cherry contends clearly that the mature minor doctrine must be abandoned. In his analysis of the neuropsychological data, Cherry argues in support of the Supreme Court’s interpretation that adolescents make decisions qualitatively differently than adults. He writes: Current trends in pediatric decision making in support of the “mature minor” standard constitute moral and legal movement in direct opposite to what the science bearing on the matter demonstrates to be reasonable and the United States Supreme Court judges to be constitutionally appropriate. To put the matter bluntly, the “mature minor” standard for medical decision making ignores the scientific data and endangers children. (Cherry, 2013, 326) Ana Iltis examines both the decisional capacity of adolescents as well as the authority of parents over their children and the implications this has for adolescents giving consent. In her paper, “Parents, Adolescence, and Consent for Research Participation,” Iltis (2013) concludes that adolescents often do not possess a decisional capacity that will allow sufficient appreciation of information so as to be able to give valid consent for participation in research, and indeed for consent to medical treatment generally. In part, she embraces this conclusion because of data that show that, although adolescents understand the information relevant to making a treatment decision, their appreciation or evaluation of reasonable and foreseeable consequences is usually different from that of adults. Here, Wilhelms and Reyna’s reflections through fuzzy trace theory regarding the importance of getting the gist of what is at stake in a decision may be crucial. Iltis advances as well a second claim, a moral one, that minors even if they are mature are still children, and that there are, therefore, strong principled arguments for recognizing parents as being in authority to guide their children. We confront again the complexity of the issues at stake in assessing the status of the mature minor. In controversy are not merely the facts of the matter regarding how adolescents make decisions but also moral and social issues, namely, how we should regard the relationship between children and their parents. The intersection of these two areas of contention compounds the disputes in pediatric bioethics regarding the status of children. The articles in this issue are not unanimous on any point. However, all the authors appear to concur that judgments regarding the decisional capacity of an adolescent will depend on the particular adolescent and the particular context. There are clearly significant variations among persons with respect to decisional capacity. In addition, persons do not take a uniform journey from infancy to mature adulthood. Some persons become mature decisionmakers much earlier than others, while others appear never fully to achieve this status. Sorting matters out will in part require further philosophical reflection on what we want to mean by mature decisionmakers. That is, we will need to reflect on the moral issue as to what characterizes a person who has decisional capacity. Bernat, Culver, and Gert (1981) in reflecting on the definition of death developed a distinction among concepts of death, criteria for death, and tests for death. A concept of death for them is a philosophical issue, a view of what it means to be dead (e.g., loss of personhood). A criterion of death involves an intersection of philosophy and physiology (e.g., a neurological criterion such as the irreversible cessation of all functions of the brain as an indicator of death). Tests for death are the actual diagnostic determinations employed by physicians in declaring death. We will likely need to fashion similar distinctions with regard to competency, so as to be clearer as to what should be compassed by the concept of decisional capacity as well as what should serve as criteria for crucial elements of decisional capacity such as, perhaps, “gist-processing.” We will need as far as possible to determine the necessary and sufficient capacities that can serve as criteria for competent decision making. Then we need to determine what one should look for when making the judgment that a person under the age of 18 but over the age of 14 has decisional capacity. These essays point the way to further work.

David McDaid, Martín Knapp, Shoba Raja

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