Alliance Principles

U.S. Global Mental Health Alliance Statement of Principles for Global Mental Health Programming

Preamble

This document is a statement of practice principles by U.S.-based organizations seeking to enhance mental health and psychosocial well-being in foreign assistance programming. 

Mental health is a neglected human rights issue. It is common for persons with mental health problems to have their rights restricted by discriminatory laws and societal practices, including inappropriate involuntary institutionalization for long periods. It is also common for mental health needs to go unaddressed because accessible mental health services are rare or non-existent compared with physical health services. Persons with mental health conditions constitute a marginalized group that warrants the same attention and consideration as other marginalized groups. Other commonly marginalized groups—including persons that identify as LGBTQIA+, youth, persons with disabilities, and Indigenous populations—tend to have higher rates of mental health problems due to their experiences of discrimination, racism, power inequities, and oppression. These needs are exacerbated in fragile contexts. 

There are currently no widely accepted principles or guidelines for global mental health programming in the development and post-conflict environments adhered to by implementing organizations or funders. The most commonly used resources and guidelines on mental health programming in foreign assistance are those generated by the Inter-Agency Standing Committee and UNICEF’s Minimum Services Package2, which likewise focuses on humanitarian assistance. WHO and UNICEF have also produced global mental health resources encompassing both humanitarian response and development, focused on governments 3 which are the start of a growing body of work that specifically addresses the need for guidance on MHPSS in development settings. However, uptake by governments and aid organizations, while encouraging, has been slow and patchy. 

Programs continue to be funded and implemented that are of poor quality and do not meet the needs of persons with moderate to severe mental health issues. This is despite the large footprint of poor mental health in terms of prevalence, severity, and cross-cutting impact. A cycle has emerged whereby cheap, poor-quality mental health programming has emerged as acceptable, creating an expectation among funders, governments, and implementers that mental health is a secondary consideration that requires few resources, which, in turn, results in poor-quality services. 

This statement is intended to help break this cycle by declaring principles for quality effective programs that meet the needs of persons and communities with significant mental health issues. The statement draws on both the existing resources, including those of WHO and UNICEF cited above, and the collective experience of the staff of the organizations constituting the US GMH Alliance, with input from other organizations and individuals with GMH experience. The organizations listed at the end of this document declare their support for these principles as a basis for improved global programming standards.
 

Principles

  1. Programs need to treat mental health as a human rights issue by addressing the universal structural and social stigma and the discrimination experienced by persons with mental health problems. This stigma and discrimination are the core of the underlying lack of support for quality mental health services. Approaches to addressing stigma and discrimination can include:
    • Working with governments to withdraw discriminatory legislation (such as legislation that criminalizes suicide) and introduce laws that support persons with mental health conditions.
    • Education of communities to counter common myths about mental health that underlie stigma and discrimination.
    • Engagement of persons with lived experience of mental health issues to take prominent roles in program design and implementation. Programs should emphasize social contact as the best-supported, evidence-based approach to reducing stigma and discrimination.
    • Working with service providers, including those in health care. This includes health providers practicing person-centered care in which care recipients and their families are treated with respect and have agency in the decisions affecting them.
       
  2. Programs should include the necessary capacity and outreach to engage and serve everyone in the population in need. This requires active outreach to marginalized groups. This includes persons experiencing significant mental illness evident to others, because of the associated stigma and discrimination. It also refers to groups who are marginalized for other reasons and tend to have elevated rates of mental health problems as well as less access to care. This commonly includes persons who identify as LGBTQIA+, children and youth, persons with disabilities, victims of interpersonal (including domestic) violence, torture and other forms of violence, refugees, migrants and internally displaced populations, rural populations, lower socio-economic households, Indigenous populations, sex workers, individuals without homes, and prisoners.
     
  3. Interventions should be based on scientific evidence of impact. This refers to studies of effectiveness when comparing program interventions to either a control group or another intervention, conducted among the same or similar population to the program population and for similar problems. In the absence of such evidence, promising interventions can be implemented, meaning interventions that are locally informed, locally driven, and draw on local and/or expert opinions of what is likely to be effective. But these promising interventions need to undergo similar comparisons or evaluations to assess their impact before receiving long-term support and implementation.
     
  4. Programs should be contextually and culturally adapted. This means design, implementation, and assessment that is conducted in full partnership with local clients, local communities, and local organizations. Considerations should include appropriateness and acceptability. Local persons with lived experience should be engaged in all aspects of design, implementation, and service provision to the extent that they are comfortable being involved. This must go beyond ‘window-dressing’ and represent real openness to alternative views and approaches.
     
  5. Program implementation should include an assessment of uptake, appropriateness, acceptability, compliance, cost, and effectiveness for local priority problems. Programs should assess how well they engage and serve everyone in the population in need, including marginalized groups. Ongoing assessment and evaluation of providers is necessary to maintain quality.
     
  6. Mental health and psychosocial support services should be part of universal health care. This requires integration into primary health care and additional training of primary care providers in mental health diagnosis and medication treatment. It also requires employment and training of (and connection to) community-based psychotherapy and social service providers to work with primary health care providers as a system of care.4 These additional workers are needed to provide the first line, but time-consuming counseling elements of mental health care, so as to not burden existing primary care workers who are often fully occupied. Integration is also needed into those focused programs for which there is ample evidence of the adverse impact of poor mental health on program outcomes. This includes but is not limited to programs for education, early childhood development, maternal health, violence protection, prevention and treatment, nutrition, infectious diseases including HIV, TB, and malaria, chronic and non-communicable diseases, child and youth services, and public health emergencies such as Covid and Ebola. Integration will make these programs more effective.
     
  7. Programs should not limit service to a single subgroup, such as children, youth, or women, even when such a subgroup is the primary concern. Instead, programs should recognize that all persons are affected by the mental health of others close to them, particularly within families. Programs will have an enhanced effect on the mental health of subgroups when they are family-based. This means addressing the major mental health problems of all family members, including caretakers.
     
  8. Programs should be comprehensive. This includes the prevention of mental health conditions, promotion of good mental health and well-being, addressing the environmental factors that cause and sustain mental health problems, and treatment for those who already have mental health conditions. It also requires the inclusion of substance abuse and addictions as core mental health issues.
     
  9. To be comprehensive, program implementation should build permanent systems of care rather than one or a few single interventions. These systems should consist of community services linked to professional and institutional advice for support and referrals as needed. Permanent means building programs that the government or other key institutions commit to maintaining structurally and financially after any outside funding ends. This also requires building permanent local provider capacities to develop the mental health workforce across sectors, with capacity across the life course, and support after the initial training through frequent and regular supervision. This supervision includes monitoring and addressing stress and mental health issues among providers. Building local training capacity is also needed to replace staff turnover. 
     
  10. Support workplace mental health and psychosocial wellbeing. This is a fundamental component of capacity building and maintenance of an effective workforce. It should be a priority for critical workers who are subject to high levels of stress and dealing directly with people under duress. This includes teachers, workers who offer social services, and health care providers. Attention includes improving the work environment to counter stress and providing mental health treatment and psychosocial support service access.

References

  1. IASC Reference Group on Mental Health and Psychosocial Support in Emergency Settings. The Inter-Agency Standing Committee. https://interagencystandingcommittee.org/mental-health-and-psychosocial-support-emergency-settings

  2. The Mental Health and Psychosocial Support Minimum Service Package for an effective MHPSS emergency response. UNICEF and World Health Organization. https://www.mhpssmsp.org/en.

  3. Global Multisectoral Operational Framework GLOBAL for Mental Health and Psychosocial Support of Children, Adolescents and Caregivers Across Settings. UNICEF. https://www.unicef.org/media/109086/file/Global%20multisectorial%20operational%20framework.pdf.

  4. QualityRights materials for training, guidance and transformation. World Health Organization. https://www.who.int/publications/i/item/who-qualityrights-guidance-and-training-tools. 

  5. Expanding mental health services in low- and middle-income countries: A task-shifting framework for delivery of comprehensive, collaborative, and community-based care. Bolton P, West J, Whitney C, Jordans MJD, Bass J, Thornicroft G, Murray L, Snider L, Eaton J, Collins PY, Ventevogel P, Smith S, Stein DJ, Petersen I, Silove D, Ugo V, Mahoney J, el Chammay R, Contreras C, Eustache E, Koyiet P, Wondimu EH, Upadhaya N, Raviola G (2023). Cambridge Prisms: Global Mental Health, 10, e16, 1–14 https://doi.org/10.1017/gmh.2023.5