Background

The United Nations (UN) is negotiating the Post-2015 Sustainable Development Goals (SDGs), the predecessors of the Millennium Development Goals (MDGs). There is now an opportunity to include one of the disease categories with the greatest impact on the global burden of disease (GBD), namely mental illness.

This letter presents the case for the inclusion of mental health within the SDGs, drawn from lessons for global mental health from HIV/AIDS and malaria. The MDG health goal has stimulated the overall volume of health aid, and resulted in considerable gains in investment and actions for diseases such as malaria and HIV/AIDS. The MDGs have proven to be a powerful tool to strengthen health systems in low- and middle-income countries, and lessons can be taken for the Post-2015 SDGs and inclusion of mental health.

The examples of HIV/AIDS and malaria and the MDGs give indication what can be achieved for mental health if included in the Post-2015 SDGs. Mental illness has great impact on the GBD, and the impact is continuously rising. The mental health agenda is directly aligned with the UN development agenda, with many of the goals having strong interdependencies to mental health. It is time for the UN to include a mental health target in the SDGs.

What can the mental health sector learn from the MDGs?

In the past 15 years, we have witnessed how global development goals have increased investment and action for health system strengthening. Substantially increased investment and more coherent actions aimed at achieving MDG 6 (‘Combat HIV/AIDS, malaria and other diseases’) have resulted in substantial gains. Prior to the finalisation of the Post-2015 development agenda, we now have clear information about the massive global burden of mental illness (23% of total GBD), with an estimated 600 million people affected), and with most people with mental disorders (85%) living in low- and middle-income countries. Worldwide fewer than 20% of people with mental disorders receive any care, even though cost-effective treatments are available (World Health Organization, 2010). Stigma and human rights’ violations are the rule rather than the exception for most people with mental illness (Lasalvia et al. Reference Lasalvia, Zoppei, Van Bortel, Bonetto, Cristofalo, Wahlbeck, Bacle, Van Audenhove, van Weeghel, Reneses, Germanavicius, Economou, Lanfredi, Ando, Sartorius, Lopez-Ibor, Thornicroft and Grp2013).

Strengthening mental health in the UN SDGs will contribute to reduce the burden of disease attributable to mental disorders, especially if linked to poverty reduction and the productivity losses that are attributable to mental disorders. What can the mental health sector learn from the MDGs, from which they were fully excluded?

The UN development agenda

The MDGs stimulated accelerated growth in the total volume of global health aid, from $10.7 billion in 2000 to $28.2 billion in 2010. The proportion of total development aid spent on health has increased from 8% in 2000 to 12% in 2010 (Ooms, Reference Ooms and Samarasinghe2013). In low-income countries external development aid as a proportion of total health expenditure has risen from 14.4% in 2000 to 26.3% in 2010, while remaining unchanged at 2.5% in lower-middle-income countries (Institute for Health Metrics and Evaluation, 2011). This remarkable growth in funding for HIV/AIDS, malaria and tuberculosis (TB) has resulted in substantially reduced mortality in malaria and TB and in HIV new infection rates. Investment for other diseases has grown more slowly or not at all (United Nations, 2014a ).

HIV/AIDS

A notable example of what can be achieved by country partnerships and major development aid donors can be seen in the impact of the MDGs on HIV infection and AIDS mortality. Between 2001 and 2012, new HIV infections have declined by 33% and co-morbidity with TB has also fallen (World Health Organisation, 2014). In 2010, 30.5% of the development assistance aid determined for a specific health issue went to HIV/AIDS (Institute for Health Metrics and Evaluation, 2011). 9.5 million people in low- and middle-income countries (30% of people living with HIV) received antiretroviral treatment in 2012 (United Nations, 2014a ). The UN estimates that 6.6 million lives have been saved since 1995 (United Nations, 2014a ).

A central element of this success has been the information infrastructure that has been created to allow progress to be measured. MDG monitoring is a driver of development policy decision-making and has generated international support and funding. The MDGs have also acted as multiplier for additional HIV programmes, which have tripled in the last decade. WHO states that we now have the technical knowledge and the tools to end HIV as a major public health concern.

Malaria

Globally, between 2000 and 2012, malaria mortality has decreased by 26% and by 33% in the African region between 2000 and 2010 (World Health Organisation, 2013). The decrease in mortality has been achieved mainly by scaling up services (World Health Organisation, 2013), including preventive measures, early diagnosis and effective treatment (United Nations, 2014a ). According to WHO, 3.3 million deaths have been averted (United Nations, 2014a ) in a disease where 90% of cases are children. These co-ordinated malaria programmes demonstrate that concerted global investment, targeted to high-burden countries, can mobilise commitment of internal resources in order to achieve remarkable gains in terms of lives saved and economic return (United Nations, 2014a ). McKinsey found a $40 return in productivity from every $1 dollar invested in malaria interventions, arising from healthier, better educated more productive working people (Chambers, Reference Chambers2013).

Lessons for global mental health

The MDGs have proven to be a powerful tool to strengthen health systems in low- and middle-income countries, and have substantially contributed to measureable health gains. Reducing the problems of HIV/AIDS and malaria was successful because the problem was clearly defined, treatments were standardised, and the strategy based on experience and research, as well as growing awareness of the increasing impact and loss produced by the diseases. In the MDGs, mental health was absent, but since their formulation, the mental health sector has defined targets for action, formulated clear strategies and developed effective and standardised treatments. The mental health community is ready to act, and if included as a target in the SDGs, the outcomes for mental health are very likely to parallel those experienced for HIV/AIDS and malaria.

There is now an opportunity to include one of the disease categories with the greatest impact on the global burden of disease, namely mental illness, within the SDGs (Eaton et al. Reference Eaton, DeSilva, Regan, Lamichhane and Thornicroft2014; Thornicroft & Patel, Reference Thornicroft and Patel2014). The mental health agenda is directly aligned with the UN development agenda, with many of the goals having strong interdependencies to mental health (Thornicroft & Patel, Reference Thornicroft and Patel2014). The FundaMentalSDG initiative (www.FundaMentalSDG.org and #FundaMentalSDG) is now advocating to strengthen mental health in the Post-2015 agenda.

Mental health has been neglected in global development for too long. This has been stressed by Kofi Annan in November 2014, with a call to make mental health a global priority in the post-2015 agenda (Kingsland, Reference Kingsland2014). The current draft of the UN SDGs only briefly mentions ‘mental health and wellbeing’ in the overall Health Goal 3 ‘Ensure healthy lives and promote well-being for all at all ages’. In his report on this experts draft, ‘The Road to Dignity 2030’, UN Secretary General Ban Ki-Moon has stressed that the Post-2015 agenda must ‘reduce the burden of non-communicable diseases, including mental illness’ (United Nations, 2014b ).

A stronger emphasis on mental health, and integration of attention to mental health in all relevant development programs, will strengthen the general development effort as well as ensuring, for the first time, sustained attention to and investment in the major global contributor to GBD and lost productivity. As the burden of disease from infectious and maternal child health issues declines, the burden of non-communicable diseases and mental health is now rising in importance. The time is now for us to set a path for bringing needed attention to these common and disabling conditions.