Centre for Applied Research on Mental Health and Addictions, Simon Fraser University, Vancouver, BC, Canada; Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada; Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA.
Mental Health Unit, Pan American Health Organization, Washington, DC, USA.
Lancet Public Health. 2019 Feb;4(2):e89-e96. doi: 10.1016/S2468-2667(18)30203-2. Epub 2018 Nov 14.
Disorders affecting mental health are highly prevalent, can be disabling, and are associated with substantial premature mortality. Yet national health system responses are frequently under-resourced, inefficient, and ineffective, leading to an imbalance between disease burden and health expenditures. We estimated the disease burden in the Americas caused by disorders affecting mental health. This measure was adjusted to include mental, neurological, and behavioural disorders that are frequently not included in estimates of mental health burden. We propose a framework for assessing the imbalance between disease burden and health expenditures.
In this cross-sectional, ecological study, we extracted disaggregated disease burden data from the Global Health Data Exchange to produce country-level estimates for the proportion of total disease burden attributable to mental disorders, neurological disorders, substance use disorders, and self-harm (MNSS) in the Americas. We collated data from the WHO Assessment Instrument for Mental Health Systems and the WHO Mental Health Atlas on country-level mental health spending as a proportion of total government health expenditures, and of psychiatric hospital spending as a proportion of mental health expenditures. We used a metric capturing the imbalance between disease burden and mental health expenditures, and modelled the association between this imbalance and real (ie, adjusted for purchasing power parity) gross domestic product (GDP).
Data were collected from July 1, 2016, to March 1, 2017. MNSS comprised 19% of total disability-adjusted life-years in the Americas in 2015. Median spending on mental health was 2·4% (IQR 1·3-4·1) of government health spending, and median allocation to psychiatric hospitals was 80% (52-92). This spending represented an imbalance in the ratio between disease burden and efficiently allocated spending, ranging from 3:1 in Canada and the USA to 435:1 in Haiti, with a median of 32:1 (12-170). Mental health expenditure as a proportion of government health spending was positively associated with real GDP (β=0·68 [95% CI 0·24-1·13], p=0·0036), while the proportion allocated to psychiatric hospitals (β=-0·5 [-0·79 to -0·22], p=0·0012) and the imbalance in efficiently allocated spending (β=-1·38 [-1·97 to -0·78], p=0·0001) were both inversely associated with real GDP. All estimated coefficients were significantly different from zero at the 0·005 level.
A striking imbalance exists between government spending on mental health and the related disease burden in the Americas, which disproportionately affects low-income countries and is likely to result in undertreatment, increased avoidable disability and mortality, decreased national economic output, and increased household-level health spending.
Weatherhead Center for International Affairs, Harvard University.
影响心理健康的疾病发病率极高，可能导致残疾，并与大量过早死亡有关。然而，国家卫生系统的应对措施往往资源不足、效率低下且效果不佳，导致疾病负担与卫生支出之间失衡。我们评估了影响心理健康的疾病在美洲造成的疾病负担。该指标经过调整，纳入了经常未被纳入心理健康负担估计的精神、神经和行为障碍。我们提出了一个评估疾病负担与卫生支出之间失衡的框架。
在这项横断面、生态研究中，我们从全球卫生数据交换中提取了分类疾病负担数据，以生成美洲各国精神障碍、神经障碍、物质使用障碍和自残（MNSS）占总疾病负担的比例的国家层面估计数。我们整理了世界卫生组织心理健康系统评估工具和世界卫生组织心理健康地图集的数据，以获取各国精神卫生支出占政府卫生总支出的比例，以及精神病院支出占精神卫生支出的比例。我们使用了一个捕捉疾病负担与心理健康支出之间失衡的指标，并对该失衡与实际（即经购买力平价调整）国内生产总值（GDP）之间的关联进行建模。
数据收集于 2016 年 7 月 1 日至 2017 年 3 月 1 日。2015 年，MNSS 占美洲总伤残调整生命年的 19%。精神卫生支出中位数占政府卫生支出的 2.4%（IQR 1.3-4.1），精神科医院支出中位数占精神卫生支出的 80%（52-92）。这种支出代表了疾病负担与有效分配支出之间的比例失衡，从加拿大和美国的 3:1 到海地的 435:1 不等，中位数为 32:1（12-170）。精神卫生支出占政府卫生支出的比例与实际 GDP 呈正相关（β=0.68[95%CI 0.24-1.13]，p=0.0036），而分配给精神病院的比例（β=-0.5[-0.79 至-0.22]，p=0.0012）和有效分配支出的失衡（β=-1.38[-1.97 至-0.78]，p=0.0001）与实际 GDP 呈负相关。所有估计系数在 0.005 水平上均显著不同于零。
美洲的政府精神卫生支出与相关疾病负担之间存在显著失衡，这对低收入国家的影响不成比例，可能导致治疗不足、可避免残疾和死亡率增加、国家经济产出减少以及家庭层面卫生支出增加。
哈佛商学院怀尔德中心国际事务。
