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Report by thesecretariat

This section contains a synthesis of the main issuesraised by the Ministers during the four roundtables.

World health ministers call for action

Ministers unanimously agreed that it is time tofeature mental health on the world healthagenda and to consider the huge burden of

mental health problems as priorities for nationalaction.The fact that countries have to face otherhealth problems and that their health budgets arelimited can no longer be deterrents to action.Mental health problems are significant contributorsto the global disease burden, have huge economicand social costs, and cause human suffering. Newdevelopments persuasively indicate that cost-effec-tive solutions are possible in all contexts. Manystrategies, approaches and interventions have beenidentified and are being used in numerous smallprojects around the world.These need to be evaluat-ed and the results disseminated widely to includethem in national mental health programmes.TheMinisters expressed their commitment to addressingthe pressing mental health needs of their populationsand called for international support and action.

The current social context ofmental health

Ministers expressed the importance of con-textualizing mental health since it is deter-mined by a variety of challenges faced by

their countries. Much of the world is facing rapideconomic reforms and social change, includingeconomic transitions that are linked to alarmingrates of unemployment, family breakdown, per-sonal insecurity and income inequality. Povertyremains a reality for much of the world, withwomen constituting a majority of those affected.Many countries experience political instability,social unrest and war.There are large populationsof traumatized refugees and internally displacedpersons who must be resettled, often in countrieswith limited resources to do so.The spread of HIVand AIDS has had a major social and economicimpact on many countries, leaving large numbersof survivors in need of care and support.Womenface great pressures with a range of gender-based

disadvantages and huge numbers experience physi-cal and sexual violence resulting in high rates ofdepression and anxiety disorders.Young people,particularly street children and those exposed toviolence, are at high risk for substance misuseincluding alcohol. Indigenous people and othergroups are undergoing social upheaval that isaccompanied by climbing suicide rates. In manyparts of the world, mental health systems are poor-ly funded and organized.

Taken together the above concerns cast a broadframework for discussing mental health problemssince they are squarely placed at the heart of thesocial changes of our era. Ministers also broughtup some of the more positive effects of changewhich include a steady increase in awareness,weakening of stigma, and the development of glob-al approaches to mental health problems and pre-vention.They referred to the enthusiastic engage-ment of governments and communities alike in thecelebrations of World Health Day 2001 dedicatedto mental health.

Overcoming stigma and humanrights violations

The ministers repeatedly made urgent callsfor action to further reduce stigma, discrimi-nation and the violations of rights of persons

with mental illness since these affect the wholecontinuum of care. It was noted that the discrimi-nation between coverage of mental and physical ill-ness by health insurance schemas is fed by stigma.There is need to address the institutionalizedstigmatization of persons with mental illness, aprocess exacerbated by the placement of psychi-atric hospitals in far out places away from publicscrutiny. Shifting mental health services to generalhospitals and community clinics has helped inmainstreaming mental health problems; this mustbe pursued. Efficiency can be gained by recyclingthe infrastructure of mental hospitals to serve gen-eral health care purposes. Enforcing minimumstandards in infrastructure, and in the provision ofhigh quality care, coupled by the support of updat-ed legislation, is a critical step in protecting therights of persons with mental illness. Most impor-tantly, addressing stigma amongst all health profes-sions, including mental health workers, was con-sidered necessary.

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Since much of the stigma related to people withmental illness results from lack of information onthe causes, the frequency and treatment possibili-ties, accurate information and education should beprovided to politicians, decision makers, serviceproviders, the general public and the media as aprimary means to reduce stigma.The media caneither reinforce or reduce stigma powerfully. Itneeds to be involved in campaigns designed toeradicate negative stereotypes and promote attitu-dinal change.The role of consumers, families andtheir organizations as well as visible role models instigma reduction efforts was considered pivotal.Educational campaigns must be accompanied bythe development and upgrading of services.

Sensitization on mental health issues, removingignorance, superstitions and false traditionalbeliefs, requires multisectoral approaches andshould include, among others, schools, criminaland judiciary systems, employment agencies, andhousing and welfare systems.

Improving mental health policies and services

Shifting to community-based care and integrating mental health within Primary Health Care

Ministers discussed strategies to advancemental health care beyond the recognitionthat there must be parity between care for

physical and mental disorders.There was agree-ment that mental health care should be intimatelyintegrated into the general health care system. Itwas repeatedly noted that Primary Health Care(PHC) has a significant role to play in mentalhealth services delivery, including in countries withhighly specialised care. Integration into PHC is inline with the global movement in which manynations are engaged in the provision of mentalhealth care shifting it from psychiatric hospitals tothe community. For this shift to occur, budgetsmust be maintained or even increased; mentalhealth teams, with multidisciplinary representa-tion, must be developed; the needs of especiallyvulnerable groups must be met through supervisedcare; communities must have access to crisis cen-tres for the management of acute conditions; andbroad public support for community care must be

secured. Shifting the location of care also facilitatescollaboration with non-governmental organiza-tions, social services, and other community agents,many of which are motivated to fill some of theservice gaps.

Treatment costs

Mental health treatments should be affordable forall those in need. Given that poverty is a risk factorfor mental disorders, the principle of equitabletreatment for the poor must be preserved.Concern was expressed that access to basic psy-chotropic drugs, especially in rural areas, was acrosscutting problem and that strategies to reducecosts should be considered by regions and bygroups of countries, amongst them the bulk pur-chase of essential psychotropic drugs.

Financing of care

Financing community-based mental health care is achallenge for all nations, especially the provision ofcomprehensive care to all those in need. Sincemental health problems have intersectoral ramifica-tions, it was suggested that financing of servicesshould be intersectoral as well; ways to overcomethe barriers in this regard ought to be devised.

Human resources

Many ministers noted that the human resourcebase for mental health care is limited partly due tothe brain drain.Therefore, attention has to begiven to sustainable training programmes in mentalhealth care at various levels of service provision.However, there are unsolved issues in this regardsuch as who should be trained and what should bethe content of that training. Identifying categoriesof health workers who can be trained in the deliv-ery of psychotropic drugs and psychosocial inter-ventions with reasonable quality of care standards,is critical. Protecting mental health professionalsworking under adverse conditions was consideredimportant to prevent the high rates of staffburnout. Special mention was made of the need tobuild capacity in research training in developingcountries.

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Traditional and faith healers

The reality in many countries is that traditional andfaith healers provide much of the mental healthcare in communities because of traditional beliefsand because these practitioners outnumber thosewithin formal health systems.There is a lack ofadequate information on the practices of faith andtraditional healers, and few programmes that artic-ulate collaborative linkages between traditional andmodern medicine systems. Research into theseaspects is urgently needed along with inquiry intothe effectiveness of traditional practices. In themeantime there is need to inform traditional heal-ers and co-ordinate them with the general healthcare system through some form of regulation forconsumer protection.

Consumer and family involvement

To help families in their role as primary caregivers, they must have full access to systems ofsupport including education and training.Consumers/users and their organizations can bemost valuable in providing patient education, peersupport and policy input.

Services for the special needs of women

All agreed that gender issues are pertinent in men-tal health care. Service provision has to take intoaccount women’s health and mental health needsresulting from widespread discrimination. In par-ticular, the mental health needs of victims ofdomestic and sexual violence requires specialinterventions.To properly address this problem,special training must be provided to health work-ers.The reduction of two frequent factors, alcoholand drugs, that facilitate violent behaviour amongmen, demands preventive interventions.

Country strategies

Ministers reported recent developments andapproaches in mental health care in their countries.These included:

Decentralization of mental health services:

■ Downsizing of mental hospitals and establish-ment of community mental health servicesincluding beds in general hospitals.

■ Establishing proper funding for community serv-ices.

Integration of mental health care in primaryhealth care:

■ Training health care professionals and paraprofes-sional workers.

■ Training traditional healers in mental health care.

Improvement of mental health services:

■ Incorporating a gender approach in mental healthpolicies.

■ Using mobile mental health units to serveremote and rural areas.

■ Integrating a mental health component in essen-tial packages of care.

■ Using telepsychiatry to train and consult withmental health workers in rural areas and wherepopulations are dispersed.

■ Monitoring quality of care and human rights vio-lations.

Legal provisions for mental health care:

■ Revising legal provisions for care of persons withmental illness.

■ Decreasing stigma around persons with mentalillness.

■ Involving the mass media.

■ Encouraging self-help, consumer/family groups,and NGOs in mental health advocacy.

■ Replacing stigma-generating labels with stigma-free denominations.

Implementation of multisectoral approaches for mental health:

■ Collaborating with education, employment,social welfare, and other sectors.

■ Building partnership with private enterprises andlabour unions.


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■ Creating employment opportunities for womento empower them economically and reduce stresslevels.

■ Integrating mental health programmes withviolence prevention initiatives.

Meeting the needs of specialgroups

The following population groups were espe-cially mentioned by many ministers sincethey require immediate mental health action

in their countries:

Rural, remote and dispersedpopulations

The unmet needs and difficulties in providing ade-quate health services to rural and dispersed popu-lations were noted.

Services for children and adolescents

A focus on the needs of children emerged.Attention to maternal nutrition, and the pre andpost natal multiple needs of mothers and theirinfants is vital for the normal health and mentalhealth development of children. School aged chil-dren constitute a group that is readily accessiblefor mental health services. School-based mentalhealth activities serve to promote mental health,channel preventive interventions, and educate onthe understanding of mental disorders and thoseaffected by them. Bringing health care workersinto schools also provides an opportunity for earlydetection and treatment of childhood and adoles-cent psychiatric disturbances that often remainundiagnosed. Additionally, children and adolescentsare at high risk for substance misuse and suicidalbehaviour for which sustained prevention and edu-cation are needed. Addressing the special needs ofstreet children and those orphaned by AIDS wasconsidered critical.

Refugees, displaced, indigenous anddisaster-stricken populations

Wars, disasters and displacement have left hugepopulation groups with serious mental healthproblems which countries are unable to addressbecause of limited resources and untrained staff.

Social and economic change is having destructiveimpact on the mental health of indigenous popula-tions which countries acknowledge but are unableto fully address.

Areas for WHO support andcollaboration

Ministers identified ways in which WHOcould provide technical support to countriesat global/regional and country levels.

At the global level, WHO should:

■ Continue global awareness-raising and advocacycampaigns.

■ Provide gender disaggregated estimates of inci-dence and prevalence rates, and on the burden ofmental disorders.

■ Carry out studies on the determinants of mentalhealth problems and the factors that influencemental health outcomes, including spiritual sup-port systems.

■ Promote and support programme evaluation.

■ Produce information (particularly for politiciansand decision makers) on the burden, determi-nants and solutions to mental health problems.

■ Document effectiveness of interventions withspecial reference to prevention, treatment andpatient satisfaction.

■ Update guidelines and materials for prevention,treatment and care of mental disorders.

■ Include more psychotropic drugs in the essentialdrug list and devise strategies to ensure the con-tinuous supply of these essential drugs at afford-able prices.

■ Establish regional and global networks.

■ Mobilize funding support for mental health pro-grammes.

At the national level, WHO should:

■ Support the development of national databaseson mental disorders that can inform policy andservice development.

■ Provide materials and guidelines for communityeducation, awareness raising, and anti-stigmacampaigns.

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■ Collaborate with countries in the implementa-tion of programmes to repair the psychologicaldamage of war and conflict.

■ Provide technical expertise for capacity buildingin research and evaluation.

■ Assist in the formulation of mental health policyand plans, and training of different cadres ofhealth professionals in mental health care.

■ Ensure supply of essential psychotropic drugs.

■ Assist in addressing harmful traditional practices.

■ Assist in mobilizing resources for national pro-grammes.


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A new beginning

Senator the Hon. Phillip C. Goddard

Minister of HealthBarbados

Speech to the plenary

Mr. President, Director-General, colleagueMinisters, ladies and gentlemen, I have thehonour and pleasure to share with you the

salient points of the Ministerial Round Tables onMental Health that were held on Tuesday, May15th.

First let me say that Ministers spoke with greatunanimity on the importance of mental health tohealth and human development and the relativeunder investment in this area of health services. Inthe words of one of our peers, “for too long we hidthis subject”. Another said “our concern for infec-tious diseases should not deter us from dealingwith mental health problems”.Yet another stated,“we must find a share for mental health out of ourlimited budgets”.

Given this response, it is not surprising that allMinisters expressed appreciation to the WorldHealth Organization for placing this subject on theworld health agenda.The overriding theme thatemerged from the discussions was that mentalhealth affected all spheres of human endeavour andthat there is no health without mental health.

Ministers agreed that raising the level of awarenesswas the first priority. Policy makers in governmentand civil society need to be sensitized about thehuge and complex nature of the economic burdenof mental illness and the need for more resourcesto treat mental illness.To quote another Minister,we must “dispel the unjustified pessimism aboutthe treatment of mental disorders”. Indeed, it wasrecognized that new technologies were availablethat are based on scientific evidence. Many of theseare within the affordable range of most countriestoday.

We must also recognize the reinforcing loopbetween poverty and mental disorders.Whilepoverty is often a powerful determinant of mentaldisorders, it is equally true that mental disorderscould deepen poverty. Many families without sup-port could fall into the abyss of poverty fromwhich it would be difficult or impossible to extri-cate themselves.

Ministers agreed that the stigma associated withmental illness was a severe stumbling blockbecause, among many other reasons, it preventedpeople from seeking help. Health professionals arenot immune from the impact of stigma, which they

need to overcome to effectively manage the care oftheir patients. Stigma can also have an insidiouseffect on health policy, such as health insurersdenying parity for the care of mental disorders. Anunderstanding of mental health has to start early inlife, and one Minister commented on the need formental health to be placed in the schools’ curriculato help change attitudes.

Ministers discussed the need to move mentalhealth care from outdated centralized institutionsto community-based alternatives. “For too long,mental health institutions were placed in remotelocations, out of site and out of mind” said oneMinister, “they need to be brought back into popu-lation centres”. Furthermore, he noted “serviceslocated in general hospitals and clinics do not bearthe stigma of the old mental hospitals”.

Of course this transference of care into the com-munity requires new structures and the appropri-ate training of mental health care providers. It wasrecognized that evidence-based interventions in thecommunity require proper knowledge and newskills.This massive effort, that entails the engage-ment of primary health workers to deliver mentalhealth care, poses a challenge for which Ministerswould like to have the support of the World HealthOrganization, particularly in training rural healthcare providers.

There was general agreement that the steady sup-ply of psychotropic drugs was of fundamentalimportance if proper care is to be provided. Manyideas were floated in this regard; one of them wasjoint purchase of drugs by regional entities toreduce the cost to individual countries. It was alsorecognized that in many countries, faith and tradi-tional healers outnumbered mental health workers,and treated large segments of the population. Notmuch was known about their effectiveness, howev-er, and particularly so where traditional and mod-ern methods of treatment coexist.The WorldHealth Organization was asked to devise method-ologies to study these phenomena and to assist inconducting the necessary research. Another areamentioned in this context were studies to providenational epidemiological data and evaluation ofservices including customer satisfaction.

Ministers from war torn countries and regionsraised the need to involve the World HealthOrganization in restoring the mental health of


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traumatized populations. Strategies and techniquesto deal with large numbers of displaced victims ofviolence are needed along with the assistance toimplement the appropriate remedial actions.

Sadly, violence afflicts those countries at peace aswell. It was recognized that there was an alarmingincrease in violence against women in many coun-tries. Ministers often mentioned that domestic vio-lence should be considered an epidemic that oughtto be eradicated. In addition to the physical dam-age and injury caused by domestic violence, therewas also a significant impact on mental health thatwas often more damaging and long-lasting than thephysical injuries.This was evident in the high rateof depression and anxiety disorders amongwomen. Ministers wanted to better understand thegender-based mental health issues.They were allagreed that there was a need for short-term andlong-term strategies to curtail violence againstwomen, their families, the fabric of the communi-ties and ultimately their nations.

The Round Table discussions were at times livelyand informative.They generated much interest. Acomplete report of the issues highlighted duringthe course of the discussions is contained in thereport which I invite you to take back with you.

Finally, I conclude by saying that Ministers sharethe universal concern of listening to people, andcommit to strengthening the pivotal role thepatients and families play in the treatment of men-tal illness. I would further remind you of the pow-erful presentation in the opening Plenary sessionmade by a mother who related her real life experi-ence of living with her son as she struggled to copewith the effects of his schizophrenia.We walkedwith her as she described his trauma and his slowrecovery.We rejoiced with her as together theybegan the process of recovery and the joy of hisfirst job.

Madame, I am sure that I can now say on behalf ofus, your message has been heard.

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Renewing commitment to mental health

Regionalstatements

Regional Office for Africa

Dr Ebrahim M. Samba

Regional Director

Dr Custodia Mandlhate

Regional Adviser for Mental Health

The mental health situation in Africa is a veryserious one indeed. It is recognized thatpoverty, civil strife, armed conflict, alcohol

and drug abuse, among others, stand out as themain causes of mental problems which are a majorconcern of a number of countries in our Region.Needless to say, the HIV/AIDS pandemic is wors-ening the situation, adding considerably to thealready existing psychosocial problems and creat-ing unprecedented need for support, counsellingand care for those affected.

In Africa, political turmoil deserves special men-tion as a causative factor of mental problems. Aswe observe World Health Day today, more than 20of the 46 countries in our Region are experiencingone form of civil disturbance or other.This hascreated at least 10 million refugees and more than30 million internally displaced persons. All thesepeople, especially women, children and the elderlyamong them, are invariably severely stressed physi-cally, psychologically and emotionally.

Also in Africa, as elsewhere, mental problemsremain a hidden burden. Consider some of theeconomic and social costs: lost production frompremature deaths (e.g. suicide); lost productivity ofthe mentally ill who are unemployed, underem-ployed or unemployable; lost productivity of fami-ly members providing care; the cost of accidents bypeople who are psychologically disturbed; directand indirect costs for families caring for the men-tally ill. If we add to these the incalculable emo-tional burden and the diminished quality of life forfamily members of people with mental illness, themagnitude of the problem becomes easier toappreciate.

In most countries of the African Region, mentalhealth programmes are limited to curative healthcare of poor quality, usually provided in decrepithospitals located far away from residential areas.These conditions create a serious problem ofaccess to and acceptability of the treatment.

Hence, dropout rates are very high, and follow-uptreatment as an outpatient is seriously hampered.In those countries where some services are provid-ed, these are mainly for adults with major psychi-atric disorders, the needs of children not beingcatered for.

Also, the pervasive effect of social exclusion result-ing from stigma and discrimination prevents peoplefrom acknowledging their mental health problems,disclosing them to others and seeking treatment.

This situation is not helped by weak or totalabsence of policies, programmes and legislation todeal with the problem in many of our countries.

For example, a recent survey in the 46 countries ofour Region indicates that only half of them havemental health and substance abuse policies.

Although 74% and 71% respectively of the coun-tries have mental health programmes and legisla-tions, these were developed relatively recently –only in the last five years. Some of the most dis-tressing statistics emerging from the survey relateto financing: 84% of the countries spend less that1% of their total health budget (usually 10% orless of the national budget) on mental health.

However, on the positive side, the report indicatesthe existence of drug policies and updated lists ofessential drugs in 93 % of the countries; 64% ofthe countries also have included drugs for thetreatment of conditions like epilepsy, depressionand major disorders like psychosis. Unfortunately,most people who need these drugs cannot affordthem because the costs are prohibitive.The situa-tion is particularly serious in rural Africa whereantidepressants, anticonvulsants and antipsychoticdrugs are rarely available. In relation to the issue ofaccess, it is pertinent for countries to make overalltreatment for mental illness available to the generalpopulation.Therefore, mental health needs to beintegrated into general health, especially primaryhealth care.

All these show very clearly that our countries needto rank mental health higher on their scale ofhealth priorities by providing the necessary fundingas well as appropriate policy and legal frameworksto deal with the problem.

We therefore appeal to individuals, families, com-munities and Governments to use this year to


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rededicate themselves to raising the profile ofmental health, and to creating a solid basis forchanging the present scenario regarding mentalhealth in our Region.

A real beginning was made in Windhoek in 1999when our Health Ministers adopted the RegionalStrategy for Mental Health.

This Strategy serves as a tool to be used byMember States to identify priorities and developand implement programmes at various levels of thehealth system, with particular emphasis on actionat the district and community levels.

The aim of the strategy for mental health and theprevention and control of substance abuse is tohelp prevent and control mental, neurological andpsychosocial disorders, thus contributing to theimprovement of the quality of life of the popula-tions.This can be achieved through the formulationand strengthening of national mental health poli-cies and the development and implementation ofprogrammes in all the Member States in theAfrican Region.

While adopting and implementing the regionalstrategy, all Member States should integrate mentalhealth and the prevention of substance abuse intotheir national health services.This will lead to:

■ a reduction in the incidence and prevalence ofspecific mental and neurological disorders(epilepsy, depression, mental retardation andpsychosocial disorders due to man-made disas-ters) and other prevalent conditions;

■ equitable access to cost-effective mental, neuro-logical and psychosocial care;

■ progress in the adoption of healthy lifestyles; and

■ improvement in the quality of life.

Today, thanks to advances in science and medicine,mental disorders can be correctly diagnosed andtreated with medications or short-term therapy ora combination of approaches.

It is therefore the collective responsibility of all,particularly Governments, to take appropriatemeasures to increase access to care; to improvepublic awareness of effective treatments; to popu-larize the use of effective community-based servic-es; to ensure the existence of conducive socioeco-nomic environments for our people to live in, and

to factor mental health into general health pro-grammes.

We, at WHO, pledge to continue to respond tothese challenges by assisting Member States todevelop evidence-based policies and effectivestrategies that will help our populations achievethe highest possible state of health.

Stop exclusion. Dare to care.

This is the ultimate challenge!

Regional Office for the Americas

Dr George Alleyne

Regional Director

Dr Caldas de Almeida

Coordinator, Program on Mental Health

The Pan American Health Organization,WHO’s Regional Office for the Americas(PAHO/WHO) and the countries of the

Americas have been working together for decadesto promote mental health and improve mentalhealth care in the Region.

These efforts have led to significant advances, par-ticularly following the 1990 Caracas Declaration.These advances include the establishment ofnational mental health policies, plans, and legisla-tion in several countries; the development of inno-vative experiences of community mental healthservices; and the promotion of specific programsfor the treatment of the most prevalent disorders.

Although these advances represent important mile-stones, we recognize that much more must bedone in order for mental health to recover fromthe historical neglect to which it has been subject-ed worldwide, and to meet the mental healthneeds of all populations in the Americas. Manyproblems remain.

For example, in the last few years spectacularprogress has been made toward understandingmental health problems, as well as toward thedevelopment of new and more effective treat-ments.Yet, despite the availability of effectivetreatments for most mental disorders, millions ofpeople suffering from depression, schizophrenia,epilepsy, and other disorders with devastating con-

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sequences still do not have access to these treat-ments.

Similarly, although comprehensive communityservices have proven more cost effective than theolder centralized models, and are preferred bypatients and families, in most places mental healthcare continues to be centered in old institutionsseparated from the general health system and thecommunity.

The recognition of these realities, together withrecent data showing the true magnitude of theimpact of mental disorders, has led to an increasedawareness of the need to mobilize all of civil socie-ty, including policy makers, professionals, users,families, and NGOs, to change the situation.

WHO initiatives and events dedicated to mentalhealth in 2001 have begun this urgently neededprocess of mobilization at the global level and havealready elevated mental health on the global politi-cal agenda.

PAHO/WHO, and the countries of the Americas,have collaborated enthusiastically in these initia-tives and, taking advantage of the unique opportu-nity created in 2001 by the World Health Day, theWorld Health Assembly, and the World HealthReport, are strongly committed to reinforcingtechnical cooperation in mental health.

Based on an evaluation of the current situation, thefollowing objectives have been defined for priorityattention in the Region:

■ implementing national mental health policies andplans ensuring: (a) the restructuring of mentalhealth services, leading to the development ofcomprehensive community-based services andintegrating all necessary facilities and programsto meet the different needs of the populations;(b) the provision of essential treatments for themost prevalent mental disorders, in particulardepression; c) the development of preventive andhealth promotion interventions;

■ creating/revising mental health legislation inte-grating the key elements of mental health policy,and providing basic guidance to protect therights of people with mental health problems;

■ raising awareness and fighting stigma related tomental disorders;

■ reducing inequity and addressing issues of parityto ensure that: (a) disadvantaged populations,refugees, and victims of disasters have access toservices that meet their specific needs; b) parityof mental health services with other types ofservices is achieved;

■ promoting mental health training for health pro-fessionals;

■ improving monitoring and evaluation of theimplementation of mental health plans; and

■ increasing the participation of users and familiesin mental health care.

To attain these objectives, the following actions arespecifically being emphasized in technical coopera-tion with countries:

■ collection and dissemination of information onmental health;

■ development of country capacities to plan, man-age and evaluate mental health services; and,

■ dissemination of guidelines on cost-effectiveinterventions and development of innovativeexperiences.

The establishment of partnerships in the areas oftraining, research and policy development is also akey element of the defined strategy.The confer-ence “Mental Health in the Americas: Partneringfor Progress”, planned for November 2001, willseek to promote these partnerships, taking advan-tage of the momentum created by WHO initia-tives.


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Regional Office for the Eastern Mediterranean

Dr Hussein A. Gezairy

Regional Director

Dr Ahmad Mohit


The selection of mental health as the themeof the year 2001 is a reflection and recogni-tion of the increasing importance of the role

mental health plays in the everyday life of humanbeings.We would like to take this opportunity todispel a common misconception that mental healthis restricted to the treatment of mentally ill per-sons. Mental health is concerned with all aspects ofour daily life, be they emotional, intellectual orbehavioural.The quality of relationships we devel-op and maintain with fellow human beings, ourfamilial bonds, the nurturing milieu we provide forour children to develop their potential, societieswhere individual members are respected and caredfor, civil societies tolerant of dissent, are alldependent on mental health. Mental health thusencompasses, and interacts with, cultural life, tra-ditions, religious aspirations and spiritual life of apopulation.

The countries of the Eastern MediterraneanRegion of WHO are blessed with the existence ofstrong family ties, cohesive social institutions andthe presence of spiritual and religious beliefs hav-ing the potential to positively affect the mentalhealth of the population. However, the Region alsofaces a number of issues which can adversely affectmental health. Our population is very young and isfaced with uncertainties about its future.Youngpeople receive many conflicting cultural messagesrequiring reconciliation of traditions with the newtrends, causing insurmountable stress in manyinstances.Waves of migration and unplannedurbanization, bringing in their wake poverty andloss of social capital, are placing heavy stress notonly on the infrastructure but on the coping abili-ties of individuals as well. A number of countriesof the Region face war, occupation, sanctions andinternal conflicts, and millions of refugees in dif-ferent parts of the Region are straining the socialfabric of the societies they live in as well as facingthe burden of nonassimilation in an alien culture.

There are also existing and emerging issues of theelderly, women and children, who are “doubly vul-nerable” to develop mental health problems.

As far as diseases are concerned, the Region is par-ticularly faced with issues of depression, epilepsy,management of the chronically ill and suicide, theincidence of which is on the rise in many parts ofthe Region. Substance abuse is a major mentalhealth and development problem in the Regionwith grave public health consequences such asincreasing the risk of HIV and other blood-borneinfections.

In the past 15 years, the countries of the EasternMediterranean Region have adopted national pro-grammes of mental health as a method of meetingthe needs of the population.The main strategicapproach of all these programmes is integration ofmental health within the existing health systems,including primary health care. Accordingly, theobjective of the almost all of the national pro-grammes of mental health that are developed incollaboration between WHO and Member States isto develop proper systems for the realization ofsuch integration. Such programmes that havespecifically been put to experience in the countriesof the Eastern Mediterranean Region of WHOduring the last decade have been blessed by a num-ber of opportunities and struggled with a numberof constraints.Thus, the future success and/or fail-ure of such programmes would depend on the cor-rect understanding of these opportunities and con-straints and on finding ways to deal with them.

In some countries, such as Bahrain, Cyprus,Islamic Republic of Iran, Pakistan, Saudi Arabia andTunisia, mental health needs are addressed throughintegration of mental health into existing generalhealth systems in more than one area of the coun-try or on a nationwide basis. Other countries, suchas Egypt, Jordan and the Republic of Yemen, havewell sustained projects of integration of mentalhealth in some areas.There are good examples ofschool mental health programmes in Egypt, IslamicRepublic of Iran, Pakistan and Tunisia. Pakistan andTunisia have also modernized their legislation.Sudan has worked on both modernizing the mentalhealth programme and utilizing the traditionalhealers. Cyprus, Lebanon and Morocco are exam-ples of effective use of NGOs. In Afghanistan athree-month diploma course was coordinated by


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WHO/EMRO in collaboration with the twoneighbouring countries of Islamic Republic of Iranand Pakistan.This model has been recently used totrain a new group, this time using the trainerstrained, in a move towards self sufficiency.Theexperience of Afghanistan can be utilized for coun-tries with similar conditions.

At the regional level, the Region held a majoradvocacy event for mental health connected withthe Region’s ministers of health or their represen-tatives, and signed a declaration in support of men-tal health during the Regional Committee of 1997in Teheran, Islamic Republic of Iran. As a follow-upto this event, a 10-item programme for develop-ment of mental health was proposed and MemberStates asked to choose from among a number ofactivities and start implementation in their respec-tive countries.

As we enter the new millennium, developingcountries face a number of burning issues and chal-lenges that affect all aspects of health, includingmental health. Population explosion, unplannedurbanization, scarcity of human resources, reliabledata and systematic approach to health deliveryand referral and a number of cultural issues areamong these. On the other hand, it is fair to saythat since the middle of this century the generalattitude towards mental health has been changingin both developing and developed countries.Reasons for this change include the coincidence ofmany factors like scientific and technologicaladvancements and socioeconomic changes.Theintroduction of a more accurate and holistic defini-tion of mental health, new scientific discoveriesregarding the etiology and treatment of mental ill-nesses and their treatment, and the possibility ofreturning a considerable number of patients totheir homes and the community are among thesefactors. One of the major by-products of thesedevelopments is the introduction of much bettercoordination between the general and mentalhealth services. Integration of mental health withinprimary health care systems is a major product ofthis coordination.

Let us conclude by pledging to continue to developmental health in the Region and collaborate withMember States to provide the minimum necessarymental health care for all. Let us also note that atthis stage of the development we need to realisti-

cally assess our programmes and determine whatchallenges we face, what assets and opportunitieswe have and what constraints are ahead of us. Onlythrough such a comprehensive approach and trueunderstanding of the real needs and specificationsof each country and community can we developthe capacity to provide an acceptable level of men-tal health for our people.

Regional Office for Europe

Dr Marc Danzon

Regional Director

Dr Wolfgang Rutz


A case for action

Depression and depression-related morbidityand mortality are an important focus of theMental Health Programme of the European

office of the World Health Organization.The dis-tribution of these conditions is not homogeneousthroughout the region. Some countries haverecorded decreasing suicide and depression preva-lence rates while others show increasing depres-sion rates but stable or decreasing suicides. In yetothers, both depression and suicide rates are on theincrease. Among the reasons accounting for thisunevenness are differences in access to mentalhealth services as well as differences in quality ofservices for diagnosis, treatment and monitoring ofdepressive disorders.

In a number of countries affected by rapid socialtransitions, mortality rates are on the increase.These rates can be related to social stress, helpless-ness and loss of identity brought about by sudden,disruptive and severe changes in income, employ-ment, living conditions and belief systems of largenumbers of people who are powerless to resistthem. Such changes can pose overwhelming threatsto mental health through increases in alcoholabuse, depression, suicide, violence, accidents aswell as cardio- and cerebrovascular diseases. Familyviolence is a widespread problem in countriesundergoing rapid transition and armed conflict.

And so is sexual violence which affects women andgirls disproportionately.


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Studies have shown that in Western Europe one infour persons needs psychiatric treatment duringtheir life-time, in some countries, this figure is onein three. Among adolescents, about 15-20% havemental problems. However, mental problems arenot necessarily accurately reflected in the numberof health service contacts since most of thoserequiring mental health care do not use the services.

As in other WHO regions, many European coun-tries spend less than 3% of their health budgets onmental health care, although mental ill health caneasily amount to one third to a half of all healthcare costs.

Mental health services development and obstacles for implementation

More than 50% of all patients in some EasternEuropean countries continue to be treated in largemental hospitals. Stigma and discrimination withregard to mental illness makes early interventionextremely difficult, especially in rural areas.However, there is consensus among most MemberStates on the need to shift from psychiatric hospi-tals to community-based services and on theinvolvement of personnel in mental health care.

Obstacles in Europe are often found in outdatedlegislation concerning the rights of doctors andpatients and in the lack of or limited insurancecoverage for outpatient care. Also, the transfer ofinpatient services to outpatient settings has provedto be complex especially from the stand point offinancing.

Sizable minorities in European countries are affect-ed by poverty and deprivation creating large num-bers of people with increased vulnerabilities tomental and behavioural disorders. Since it is notonly the degree of poverty but the increasing gapbetween the richest and poorest in society whichact as powerful determinants, many people are atrisk of mental problems in the unequal societies inEurope. Overcoming poverty might contribute toimprove mental health but it will not be enough; amore equitable distribution of wealth remains achallenge for all countries.

Stigmatization and human rights violations

In some countries positive changes have been madeover the years to reduce stigmatization and humanrights’ violations of people with mental illnessincluding legislative reforms. Such reforms takeinto account the right to freedom and autonomy aswell as the right to health and treatment.Theseefforts have been potentiated by the extensive cele-brations of World Health Day 2001 throughoutEurope. Mass media initiatives aimed at raisingawareness and improving the quality and quantityof information on mental health issues have inten-sified everywhere and it is expected that themomentum generated will be sustained over thenext years.

WHO/EURO response

In order to address the finding that about 40% ofEuropean Member States have no government-sanctioned national mental health plan,WHO/EURO is assisting many of its MemberStates to establish or strengthen their nationalmental health plans.The regional office is activelypursuing technical collaboration activities withmember states to reduce premature mortality incountries undergoing rapid transitions and thosefacing conflicts, address and eradicate stigma andhuman rights violations, control the rise in depres-sion and suicides, and, buffer the effect of genderdisparities in mental health. An area of specialfocus is to assist countries in pursuing psychiatricreforms through the establishment of community-based mental health services and the utilization ofthe primary care system with the active involve-ment of consumers and families.

Mechanisms for collecting reliable country infor-mation, promoting and carrying out research andestablishing programmatic guidelines on variousaspects of mental health have included the settingup specific Task Forces such as the ones onPremature Mortality, National Assessments andMental Health Audits and Destigmatization.Thework of these Task Forces will help to assess thesituation in countries, identify the key determi-nants of mental problems in various populationgroups and asses their impact, analyse the obstaclesto service improvement, design appropriate inter-ventions and strategies and monitor the implemen-


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tation and follow-up of national programmes onmental health. Another objective of the Task Forcesis to evaluate different models of interventions forpromotion, prevention and care and to disseminateevidence-based information on successful strategiesand approaches to Member States.

An example is provided by the heavy toll of mentalhealth problems associated with violence, alcoholaddiction and suicide in men.WHO/EURO isdocumenting this trend and designing appropriateintervention strategies based on different models.Also being investigated are the factors that protectfemales in times of change and transition andwhich lead to better coping by women.The abilityof women to engage in social networking to keep asense of control of their lives and to ask for help intime of need may provide a useful resource modelfor men.

Similarly, research generated in Western Europeancountries is being used to assist East Europeancountries to understand the complex socio-psycho-logical processes currently being experienced bytheir populations. Promoting the practices of main-taining strong family ties, cohesive networks offamilies and friends, and spiritual and religiousbeliefs will hopefully protect some of the sociallydistressed societies from major mental health prob-lems. EURO will continue to promote bilateraland multilateral collaboration including exchangeof experience between Eastern and WesternEuropean countries in a mutually respectful way.

A European Ministerial meeting will be convenedin the near future to provide further direction andguidance to EURO’s mental health programme andto reach consensus on its broad strategic direc-tions.

Regional Office for South-East Asia

Dr Uton Muchtar Rafei

Regional Director

Dr Vijay Chandra


Populations of Member Countries of theWorld Health Organization’s South-East AsiaRegion have suffered for ages from many

communicable diseases. Some have been successful-ly controlled, while others continue to be seriouspublic health problems. However, it is now increas-ingly clear that noncommunicable diseases, includ-ing mental and neurological disorders, also causeuntold suffering and death in the Region.Worldwide, an estimated 450 million people sufferfrom mental and neurological disorders or frompsychosocial problems related to alcohol and drugabuse. Our Region accounts for a substantial pro-portion of such people.Thus, the Region faces thedouble burden of disease – both communicable andnoncommunicable. Moreover, with the populationincreasing in number and age, Member Countrieswill be burdened with an ever-growing number ofpatients with mental and neurological disorders. Asstated by Dr Gro Harlem Brundtland, the Director-General of WHO, “Many of them suffer silently, andbeyond the suffering and beyond the absence ofcare lie the frontiers of stigma, shame, exclusionand, more often than we care to know, death.”

In SEAR Member Countries, mental health pro-grammes have generally concentrated on hospital-based psychiatry. However, there is increasingawareness in these countries of the need to shiftthe emphasis to community-based mental healthprogrammes.The WHO Regional Office forSouth-East Asia is concentrating on supportingMember Countries to develop community-basedmental health programmes and also programmesfor prevention of harm from alcohol and sub-stances of abuse.The programmes will be gender-appropriate and culture-sensitive and reach out toall segments of the population, including marginal-ized groups.

There are many barriers to the implementation ofcommunity mental health projects and pro-


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grammes.While some countries have developedmental health policies, there has not been adequateimplementation. Governments urgently need to besensitized on the importance of mental health andon clearly defining the goals and objectives forcommunity-based mental health programmes.Mental health services should be integrated intothe overall primary health care system. At the sametime, innovative community-based programmesneed to be developed and research into relevantissues and traditional practices promoted.Communities have to be educated and informedabout mental and neurological illnesses to removethe numerous myths and misconceptions aboutthese conditions. But most important, the stigmaand discrimination associated with mental illnessmust be removed.

The Regional Office is developing strategies forcommunity-based programmes based on five “A”s:Availability, Acceptability, Accessibility, Affordablemedications and Assessment.

Availability

Services to address at least the minimum needs ofpopulations in mental and neurological disordersshould be available to everyone regardless of wherethey live.The key questions are: what are the mini-mum services needed and who will deliver them?

Acceptability

Large segments of populations in the countriescontinue to perpetuate superstitions and falsebeliefs about mental and neurological illnesses.Many believe that these illnesses are due to “evilspirits”.Thus, even if appropriate medical servicesare made available, they would rather go to sorcer-ers and faith-healers. Populations need to beinformed and educated about the nature of neu-ropsychiatric illnesses.

Accessibility

Services should be available to the community, andat a time convenient to them. If a worker has togive up his daily wages, and travel a substantial dis-tance to see a medical professional who is onlyavailable for a few hours a day, he/she is unlikelyto seek these services.

Affordable medications

Frequently, medications are beyond the reach ofthe poor. Every effort should be made to ensure anuninterrupted provision of essential medications,at a reasonable cost.Thus, government policies interms of pricing and the role of the pharmaceuticalindustry in distribution and pricing become criti-cal.

Assessment

Being new, these programmes need to be continu-ously assessed to ensure appropriateness and cost-effectiveness. Changes in the ongoing programmesbased on impartial evaluations are essential.

Mental health care, unlike many other areas ofhealth, does not generally demand costly technolo-gy. Rather, it requires the sensitive deployment ofpersonnel who have been properly trained in theidentification of illnesses, use of relatively inexpen-sive drugs and psychological support skills on anoutpatient basis.What is needed, above all, is foreveryone concerned to work closely together toaddress the multifaceted challenges of mentalhealth.


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Regional Office for the Western Pacific

Dr Shigeru Omi

Regional Director

Dr Helen Hermann

Regional Adviser (a.i.) for Mental Health

Mental health is the foundation of all health.Scientific evidence and research today underscorethe inseparable links between mental and physicalhealth. But while physical health has improved inthe Western Pacific Region, mental health hasdeclined over the last 50 years.

Social and economic factors have had a significantnegative effect on the level of mental health. Mentaland neurological disorders include common disor-ders such as depression, anxiety, and substanceabuse and dependence; less common but disablingconditions such as schizophrenia; epilepsy anddementia; and intellectual disability. Suicide is animportant problem closely linked to mental health.

According to some estimates, the burden of mentaldisorders is higher in the Western Pacific Regionthan in some other parts of the world. In the rela-tively affluent countries of the Region, mental disor-ders accounted for 27% of the disease burden in1999, and in the other countries the figure was 15%.

The obstacles to improving mental health rangefrom poverty, family disruption, uncontrolledurbanization, disasters and armed conflict, andproblems resulting from the situation of refugeesand displaced persons, to community attitudes andknowledge, insufficient attention to healthy poli-cies, low priority for services, and outmoded andinadequate service provision aggravated by weaklinks to community resources.

In the Western Pacific Region, two key strategicdirections are proposed to improve mental health.First, the application of the public health approach tomental health promotion and the prevention and treatmentof illness. This includes intersectoral approaches tomental health promotion (including legislation, poli-cy and workforce training), gathering and dissemi-nating the evidence of the effect on mental health ofdecisions in these areas, more specifically, preven-tion of disorders among groups at high risk (such asthose with harmful use of alcohol and new mothers

with a history of depression), and organization ofacceptable, accessible and effective health services.

Second, the integration of mental health services intogeneral health services and the wider community.Integrated services of a good standard will providefor (a) early recognition and treatment of mentalhealth problems and mental disorders, and (b) con-tinuity of care close to home, family and employ-ment for those with persisting disabilities.Providing quality service will require improvingcommunity awareness and reducing the stigma anddiscrimination affecting those with mental disor-ders and their families; easy and quick access totreatment and care; improved provision and organ-ization of mental health services; appropriate legalprotection; workforce training in mental healthskills; service standards and accreditation; inclusionof support for consumers and families, self-helpand advocacy associations in treatment and plan-ning; a culture of service and programme researchand evaluation; and attention to the psychosocialaspects of health care.

It is recognized that to improve mental health andaddress the challenges posed by mental disorders,WHO/WPRO and its partners will need to takeconcerted action. Action is needed at several levels– awareness, policy and intervention – and indeveloped and developing countries alike.WPROwill, therefore, work with countries and otherpartners to:

■ analyse the situation and develop policies andprogrammes that reflect emerging perspectivesin mental health;

■ develop the technology needed for prevention,treatment and rehabilitation programmes;

■ integrate mental health care into general healthcare;

■ reorient services from hospital-based to commu-nity mental health care;

■ develop a culture of research and evaluation; and

■ include mental health in health promotion pro-grammes.

WHO/WPRO is committed to using the frame-work of an agreed mental health strategy to workwith Member States and other partners to translatethese elements into action.


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WHO’s response to theMinisters call for action

Benedetto Saraceno

DirectorDepartment of Mental Health and Substance DependenceWorld Health OrganizationGeneva

Epilogue

It is with a deep sense of satisfaction that weare witnessing the emergence of a phenome-nal movement for improving mental health at

international and national levels.This movement isthe result of a series of events that unfolded pro-gressively throughout 2001 in WHO and countriesaround the world. Never before did Mental Healthreceive such central focus during a single year, norwas there ever before a stronger sense of solidarityand mobilization of people around this criticalhealth concern. Non-governmental organizations,private sector entities, academics, professionalgroups, and the media have expressed eagerness toteam up with governments and civil society toincrease access and means of addressing the mentalhealth needs of all people.

Key amongst the recent events that have led to thisglobal response for mental health is undoubtedlythe consensus reached by more than one hundredMinisters of Health on the need to prioritize themental health needs of their populations since thiswas threatening the wellbeing of large segments oftheir populations and compromising the socioeco-nomic development of their nations.They madeclear their beliefs by stating that the round tableson the theme of mental health were “long over due”and “historic” because “for too long we hid the subject”,and that “our concern for infectious diseases should notdeter us from dealing with mental healthproblems…...we must find a share for mental health outof our limited budgets”.This new political commit-ment provides an important platform for scalingup action in mental health.

The reasons that have propelled WHO to bringmental health into the limelight are multiple andwell described in the different sections of thisbook. On the one hand there is the alarming epi-demiological burden and projected increases inincidence and prevalence of mental, neurologicaland behavioural disorders, the vast treatment gapand, the epidemic stigmatization and human rightsviolations of people with mental problems. On theother hand, there is the solid scientific evidencethat provides us with strong basis for action.Psychotropic drugs with less adverse side effectsare now available to treat different crippling disor-ders, such as schizophrenia and depression.Themechanisms of their action are better known andindications for their proper use have been system-atized and made available for specialized and non

specialized medical personnel. Psychological inter-ventions for depression have been researched andtheir success rates documented.The effect of mod-ifying the family environment to reduce negativeoutcomes in some disorders such as schizophrenia,have been carefully tested.We have also made hugeadvances in identifying the best channels for deliv-ering these treatments to people in the context ofthe primary health care and as close as possible tocommunities where people live.

Indeed, evidence is replacing ideology or traditionand all this new information is persuading manythat the practice of mental health care can nowhave a scientific anchor. But progress in actuallymaking the shift from knowledge to action is slowand uneven in countries. Recent surveys carriedout by WHO Department of Mental Health showthat no more than one third of persons with schiz-ophrenia receive any treatment. It is likely thetreatment gap is much higher since the basis forthe calculations world-wide were studies carriedout in countries where mental health care wasmore readily available.The case of epilepsy alsoillustrates well the treatment gap. Between 60 to90% of treatable patients with epilepsy receive nocare, 5% or less of people who have depressive dis-orders have access to treatment in resource poorcountries. Moreover, even when treatments areaccessible, people do not seek care for long peri-ods of time because of the fear of being stigmatizedby health workers, community and society at large.And, the prevalence rate of mental disorders can-not be reduced without reduction in the treatmentlag.

These facts beg an appropriate response by govern-ments.The reorientation of services, the use ofavailable technologies and the promotion ofhealthy public policies can make a difference. Itwas time therefore for WHO to stimulate andcatalyse a collective response for mental healthaction by taking the evidence to the internationalcommunity, governments and the public.This iswhat we tried to achieve through the messages oftheWorld Health Day (7th April) which reached allsectors of society.

This is also what we tried to achieve through theMinisterial Round Tables in the World HealthAssembly this year by arousing the interest and moti-vation of health ministers to place mental health


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squarely on the health and development agendas oftheir countries.The results of the Assembly RoundTables have been very encouraging. 132 Ministersof Health from all parts of the world came togeth-er and collectively expressed their political com-mitment for addressing people’s needs in this area.They highlighted their strengths as well as theirshortfalls in so doing during their discussions.Theyalso made a strong call for international supportspecifying WHO’s intensified technical support inpriority areas. Based on these requests, we are pro-posing a global mental health strategy to ensurethat WHO at headquarters, regional and countrylevels can assist countries effectively in achievingtheir national mental health goals.

The strategy consists of the four following pillars:

■ generating information and disseminating itwidely;

■ supporting countries in developing their policies;programmes and services;

■ promoting research and building nationalresearch capacity;

■ strengthening advocacy and protection of humanrights.

The first pillar addresses two essential elements:one which aims at increasing significantly the quan-tity and quality of information available to policy-makers and service providers on the science andprogramme experience related to mental healthcare, promotion and prevention.We believe thateven if a small fraction of what is known can bemade available to those who plan and provide serv-ices, it will have a large impact.The second armaddresses the existence of tremendous gaps inknowledge about the state of mental health incountries as well as lack of information on coun-tries’ capacity to address the factors affecting men-tal health. Intensified support to countries willneed to be provided for building national informa-tion systems for the collection of reliable datarelating to mental health systems and their moni-toring, the evaluation of service delivery, and thecollection of basic epidemiological information.Particular attention will be given to ensure theseefforts are compatible with and linked to broaderhealth sector information systems.

The second pillar of the strategy will redress thecurrent situation in which more than 40% of coun-

tries have no mental health policy and over 30%have no mental health programme. Even countriesthat do have mental health policies often disap-pointingly neglect some of the more vulnerablepopulations. For example, over 90% of countrieshave no mental health policy that includes childrenand adolescents. Providing a comprehensive pack-age of support to countries to develop capacity forpolicy and service development in prevention,treatment and surveillance of mental disorders istherefore a much-needed activity.The developmentof the package would be accompanied by technicalassistance to countries, upon their request, forplanning and financing of comprehensive mentalhealth systems. Essential elements will include leg-islation, service planning especially the integrationof mental health into the larger public health sys-tem, human resource development, services forespecially vulnerable populations such as women,children, elders, refugees, adolescents and thosewith chronic physical illnesses and/or disabilities,and quality of care.

The third pillar of the strategy addresses researchand country support for building research capacity.The impetus for considering research one of thefour pillars of our strategy is driven by the under-standing that there is currently very limitedresearch capacity in most countries and a seriouslack of trained researchers, especially in low andmiddle income countries.Yet this is a critical andessential element of health system development.Most current research on mental health is conduct-ed in a few wealthy countries and we know thatthe relevance and transferability of findings fromwealthy countries to poorer countries remainsquestionable.This is a serious contributing factorto the lack of locally relevant and evidence basedmental health policies and practices based on oper-ational research findings. Encouraging and sup-porting countries to build the necessary infrastruc-ture to sustain research capability, in particularapplied research, is essential for improved efficien-cy and effectiveness of services as well as forextending knowledge about the causes, preventivemeasures, and the possibilities of treatments.

The fourth pillar, pertains to the critical role of sus-taining advocacy for mental health at the interna-tional, regional and national levels.Through the useof partnership relationships with governments,NGOs and community groups, countries will be

E P I L O G U E

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supported in developing their important advocacysector in order to position mental health on the pub-lic agenda, to promote a greater understanding andacceptance of those affected by mental illness, topromote legislation for the protection of the humanrights of people with mental illness, to reduce thepervasive effects of social exclusion resulting fromstigma and discrimination and the out-dated natureof many mental institutions. Less exclusion, less dis-crimination will help those afflicted and their fami-lies to lead better and more productive lives andencourage those in need to seek treatment.

The systematic process of awareness raising andadvocacy launched through the World Health Daycampaign “Stop exclusion. Dare to care”, will con-tinue to provide the platform for generating enthu-siasm, inspiring people to represent the needs offamilies and consumers in policy, legislation andservice delivery; and ensuring that the response ofthe mental health system matches the real needs ofpeople with mental illness.

While beneficial results of this strategy are alreadyevident, we expect much more substantial impactwithin the next three to five years. In order to bet-ter assess the impact of these activities, a systemat-ic and in-built mechanism of evaluation is beingput in place.We believe that we can optimally tar-get our limited resources only through a continu-ous evaluation of the results of what we do,whether the area is research,policy/programme/service development or advo-cacy.The same applies for countries.

In conclusion,WHO wishes to pay tribute to theMinisters of Health who iterated a strong call formental health action during the World HealthAssembly of 2001. In aligning our strategic direc-tions with their expressed concerns and priorities,we want to ensure that our vision and goals arecollective and that they follow pathways that arerealistic as well as achievable.We appeal to all whoshare this vision to join us in improving access andquality of mental health care for all those who havewaited far too long.


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List of participants of the round tables

Annex

ROUND TABLE – Room VI I

Chair Mr Phillip Goddard (Barbados)

Facilitators Professor Jill Astbury (Australia)Professor Arthur Kleinman (United States of America)

Belgium Mrs Magda Aelvoet

Burkina Faso Mr Pierre Tapsoba

Cameroon Mr U. Olanguena Awono

Chile Dr Carmen López

Denmark Mr Arne Rolighed

Dominica Dr John Toussaint

Ecuador Dr Patricio Jandriska

Ethiopia Dr Menilik Desta

Fiji Mr Pita K. Nacuva

Germany Mrs U. Schmidt

Hungary Mr Gyula Pulay

Lesotho Mr T. Mabote

Mexico Dr Julio Frenk Mora

Mongolia Professor P. Nymadawa

Morocco Mr Thami El Khyari

Namibia Dr Libertina Amathila

Nepal Mr Ram Krishna Tamrakar

Oman Dr Ali Bin Mohammed Bin Moosa

Pakistan Dr A.M. Kasi

Paraguay Dr Martin Chiola

Poland Professor Grzegorz Opala

Qatar Dr H.A.H. Al-Bin-ali

Republic of Korea Dr Kyeong Ho Lee

Saint Kitts and Nevis Mr Earl Martin

San Marino Mr Romeo Morri

Senegal Mr Abdoul Aziz Diop

Singapore Professor Ee Heok Kua

Slovenia Mr Dorjan Marusic

South Africa Dr M.E.Tshabalala-Msimang

Turkey Professor Orhan Canbolat

Zambia Dr L. Mumba


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^ ^

ROUND TABLE – Room XI I

Chair Mr Lyonpo Sangay Ngedup (Bhutan)

Facilitators Dr J. López-Ibor (Spain)Dr Sylvia Kaaya (United Republic of Tanzania)

Angola Dr Albertina Hamukwaya

Belarus Dr Igor Zelenkevich

Bosnia and Herzegovina Dr Zeljko Misanovic

Botswana Ms Joy Phumaphi

Brazil Dr João Yunes

Brunei Darussalam Mr Ahmad Matnor

Democratic Republic of the Congo Professor Mashako Mamba

Gabon Mr Faustin Boukoubi

Greece Professor Christina Spyraki

Grenada Dr Clarice Modeste-Curwen

Guatemala Mr Mario Bolaños Duarte

Haiti Dr Henri-Claude Voltaire

Israel Dr A. Leventhal

Jordan Dr S. Kharabseh

Lao People’s Democratic Republic Dr Boungnong Boupha

Liberia Dr Peter S. Coleman

Madagascar Professor Henriette Ratsimbazafimahefa

Maldives Mr Ahmed Abdullah

Nicaragua Dra Mariángeles Argüello

Norway Mr Tore Tønne

Peru Sr Dr Eduardo Pretell Zárate

Rwanda Dr Ezéchias Rwabuhihi

Samoa Mr M. Siafausa Vui

Sierra Leone Dr I.I.Tejan Jalloh

Slovakia Mr Svätopluk Hlavacka

Sri Lanka Mr W.D.J. Seneviratne

Switzerland Ms Ruth Dreifuss

Uganda Dr C. Kiyonga

United Arab Emirates Mr Hamad Abdul Rahman Al-Madfaa

United States of America Mr Tommy Thompson

Yemen Dr Abdul Nasser Ali Al-Munibari

A N N E X

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ROUND TABLE – Room XVI I

Chair Mrs Annette King (New Zealand)

Facilitators Professor Julian Leff (United Kingdom of Great Britain and Northern Ireland) Dr Lourdes Ignacio (Philippines)

Algeria Dr M. Abdelmoumène

Bahamas Dr Ronald Knowles

Bangladesh Mr Sheikh Fazlul Karim Selim

Canada Mr A. Rock

China Dr Peng Yu

Côte d’Ivoire Professor Raymond Abouo N’Dori

Cuba Dr Carlos Dotres Martínez

Cyprus Mr Frixos Savvides

Egypt Professor Ismail Sallam

France Dr Bernard Kouchner

Gambia Mr Y. Kassama

Georgia Dr A. Gamkrelidze

India Dr C.P.Thakur

Iran (Islamic Republic of) Dr Mohammad Farhadi

Japan Mr Jungoro Kondo

Mali Dr Fatoumata Traoré Nafo

Mozambique Dr Francisco Ferreira Songane

Myanmar Mr Ket Sein

Netherlands Dr E. Borst-Eilers

Niger Mr Assoumane Adamou

Nigeria Professor A.B.C. Nwosu

Panama Dr Fernando Gracia García

Papua New Guinea Mr Ludger Mond

Portugal Mr José Manuel Boquinhas

Russian Federation Professor V.N. Krasnov

Saudi Arabia Dr Mohamed Abdullah Al Shawoosh

The former Yugoslav Republic of Macedonia Dr Muarem Nedzipi

Tunisia Dr H. Abdessalem

United Kingdom of Great Britain and Northern Ireland Ms Jane Hutt

Uruguay Dr E.Touyá

Viet Nam Professor Pham Manh Hung

Zimbabwe Dr Timothy J. Stamps


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ROUND TABLE – Room XVI I I

Chair Professor M. Eyad Chatty (Syrian Arab Republic)

Facilitators Dr Vikram Patel (India)Ms Paula Mogne (Mozambique)

Argentina Dr Hector Lombardo

Australia Professor John Mathews

Austria Professor Reinhart Waneck

Bahrain Dr Faisal Radhi Al-Mousawi

Benin Professor G. Ahyi

Bolivia Dr Guillermo Cuentas-Yáñez

Chad Mme Fatimé Kimto

Colombia Sra Sara Ordoñez Noriega

Croatia Dr A. Gilic

Czech Republic Professor Bohumil Fise

Democratic People’s Republic of Korea Mr Ri Si Hong

Dominican Republic Sra Angela Caba

Finland Dr Jarkko Eskola

Ghana Dr Richard W. Anane

Guinea Dr Mamadou Saliou Diallo

Guinea-Bissau Dr Francisco Dias

Honduras Dr Plutarco Castellanos

Iceland Mr David Gunnarsson

Indonesia Dr Achmad Sujudi

Iraq Dr Omid Midhat Mubarak

Italy Dr F. Oleari

Jamaica Mr John Junor

Malaysia Mr Chua Jui Meng

Mauritius Mr Ashok Kumar Jugnauth

Romania Dr Daniela Bartos

Saint Lucia Mrs Sarah Flood Beaubrun

Sudan Dr Ahmed Bilal Osman

Sweden Mr Lars Engqvist

Thailand Dr Winai Wiriyakitjar

Tonga Dr V.T.Tangi

Trinidad and Tobago Dr Rampersad Parasram

United Republic of Tanzania Ms Anna M. Abdallah

Venezuela Dra María Lourdes Urbaneja Durant

Yugoslavia Dr M. Kovac

A N N E X

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Mental health is the capacity

of the individual, the group and the environment

to interact with one another in ways that

promote subjective well-being,

the optimal development and use of mental abilities,

the achievement of individual and collective goals

consistent with justice and

the attainment and preservation

of conditions of fundamental equality.

World Health OrganizationDepartment of Mental Health and Substance Dependence

Avenue Appia 201211 Geneva 27

SwitzerlandTel:+41 22 791 21 11Fax:+41 22 791 41 60E-mail: [email protected]

Website: www.who.int/mental_health WH

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