The challenge to public health and sustainable development

A primary reason for holding this and previous high-level meetings on NCDs is to bring attention to the enormous contribution they make to the global disease burden and the threat that that poses not only to health systems and universal health coverage goals but also to human capital development and economic prosperity more broadly. For example, in 2021 NCDs such as cardiovascular diseases, cancers, chronic respiratory diseases and diabetes accounted for 63% of all deaths and make up even of the world’s top ten causes of death. ⁵ The risk of dying prematurely from an NCD is notably increased by tobacco use, physical inactivity, the harmful use of alcohol, unhealthy diets and air pollution.

The explicit and full integration of mental health in the upcoming high-level meeting similarly reflects growing international concern about the public health and socioeconomic impact of mental health conditions. This increased attention ratcheted up in recent years due to the COVID-19 pandemic, which led to a rapid rise in rates of depression and anxiety, revealed in stark terms the weakness and vulnerability of most countries’ mental health services and left in its wake a marked loss of mental well-being, especially among younger people. Although mental health represents an intrinsic and indispensable part of overall health and well-being, only a fraction of the one billion people worldwide with a mental health condition receive treatment and care; a recent analysis estimated that only 9.1% of the 234 million people living with major depressive disorder globally get minimally adequate treatment, corresponding to a gap of 90%. ^{Reference Santomauro, Vos, Whiteford, Chisholm, Saxena and Ferrari6} Due to their high levels of prevalence and unmet needs, these conditions account for 1 in 6 years lived with disability globally; furthermore, more than 700 000 lives are lost per year due to suicide, the majority of which occur in low- and middle-income countries. ⁷

Current lifestyles and projected shifts in the size and structure of populations indicate that these numbers are only going to rise even further in the future. For example, mental health conditions affect around 8% of children aged 5 to 9 years and 14% of young people aged 10 to 19 years worldwide. ⁷ That not only poses a threat to our collective health and well-being, and for the health services tasked with taking care of these conditions, but also to societies and economies as a whole because of the huge expected losses in human capital and capacities. Millions of households are already impoverished each year by lost earning opportunities and out-of-pocket spending on health services and products, while trillions of dollars of global economic output are foregone each year as a result of lost productivity. ^{Reference Chisholm, Sweeny, Sheehan, Rasmussen, Smit and Cuijpers8}

The case for investment

The health and economic consequences of NCDs and mental health conditions are huge and increasing, but what is the case for investing societal resources into their prevention and management? Economic analysis carried out by the World Health Organization indicates that investing in cost-effective NCD interventions in poorer countries can generate US$230 billion in economic benefits and save close to 7 million lives by 2030, representing a return of US$7 per person for every dollar invested. ⁹ The economic case for investment in mental health is also clear: for every US$1 invested in scaled-up treatment for depression and anxiety, there is a US$4 return in better health and productivity. ^{Reference Chisholm, Sweeny, Sheehan, Rasmussen, Smit and Cuijpers8} Several national-level investment cases provide further evidence of the health and economic benefits that arise from scaled-up implementation of effective policies and interventions. ^{Reference Chisholm, Lee, Baral, Bhagwat, Dombrovskiy and Grafton10} On the equity side, households affected by NCDs and mental health conditions – especially the poorer ones – stand to greatly benefit from stronger fiscal policies including health taxes and from better financial protection when they need care.

Financing the response

Despite the grave socioeconomic implications and an articulated case for action and investment, funding for mental health and NCD services continues to represent a small fraction of health budgets in low- and middle-income countries, and accounts for less than 3% of development assistance for health. ¹¹ In the context of already squeezed health budgets and a very challenging macro-fiscal environment in which many countries are highly or increasingly indebted, what can be done to turn the tide and change the status quo?

Critical insights and conclusions arising from the international dialogue on sustainable financing for NCDs and mental health ⁴  – which included representatives from ministries of health and ministries of finance from over 34 countries, United Nations agencies, multilateral and bilateral development organisations, civil society, the private sector and academia, as well as individuals with experience of living with a NCD or mental health condition – included the following:

• Domestic resource mobilisation: To be genuinely sustainable, financing for mental health and NCDs needs to be driven by domestic investment. To increase national revenue and resource levels, it is essential to look not just at greater prioritisation of these conditions within the health sector alone but also to consider the broader public financing situation and opportunities, including fiscal policies relating to health-harming products and industries; such ‘health taxes’ continue to represent a win–win arrangement – good for population health, good for the public purse. A recent report points out that should all low- and middle-income countries increase their excise taxes to raise prices of tobacco, alcohol and sugary beverages by 50%, it would generate US$2.1 trillion in additional revenue over 5 years. ¹² Beyond fiscal policy, there is also major scope to strengthen public financial management and budget execution, including by consolidating and streamlining funding flows to reduce fragmentation, and by shifting from an input perspective to an output perspective that is targeted on defined priorities and tangible impacts at the population level.

• External assistance: Development assistance cannot replace a country’s own function to plan, mobilise and allocate the resources needed to promote and protect the health of its population, as this is inherently unsustainable. There is also currently a broader questioning around the role of official development assistance and global health initiatives. ^{Reference Ahmed, Calleja and Jacquet13} Yet, as demonstrated for several communicable diseases and public health priorities over recent decades, external financing can be transformative, especially in low-income and emergency settings. Much needed development assistance for mental health and NCDs can be most appropriately targeted on supporting and catalysing nationally determined and time-bound efforts to introduce and scale-up the implementation of essential and cost-effective interventions and services (such as the integration of mental health care into primary care or the development of community-based service networks). There is also an increasing consensus on the value to be realised through investment of development assistance in global or regional ‘health goods’ that benefit multiple countries simultaneously, such as new approaches to disease management and surveillance, or strategies to counter marketing, distribution and cross-border trade of unhealthy products such as alcoholic beverages.

• Health financing for service delivery reform: The health systems of most countries are not well designed to provide preventive services, high-quality longitudinal care or financial protection for persons with mental health conditions or other chronic diseases. To enhance continuity of care and avoid fragmented service delivery or financing, there is a need to leverage and align national health financing reforms, including targeted incentives and provider payment data systems, towards integrating and prioritising prevention and management of mental health conditions, NCDs and other chronic diseases. Existing advancements in digital technologies have the potential to offer significant benefits to support these reforms, for example, through increasing access to care in remote areas, improving affordability, reducing stigma, expanding reach to underserved populations and enabling a shift toward person-centred interventions. ^{Reference World14} For NCDs and mental health, particularly for common mental health conditions like depression and anxiety, the integration of digital health into service delivery can be a game changer for scaling services through diverse platforms that meet people where they are. ^{Reference Fu, Burger, Arjadi and Bockting15} At the heart of these issues is equity. Financial protection mechanisms such as national health insurance schemes need to be adapted to ensure that those with enduring needs are protected against the otherwise recurring and potentially impoverishing out-of-pocket expenditures on medicines, tests and visits incurred over a prolonged period of time.

In conclusion, the sheer extent or magnitude of the public health burden of mental health conditions and NCDs, and their multifaceted impacts on individuals, communities, societies and economies, calls for a resolute technical and political response in – and beyond – the health sector. A meeting at the level of heads of state can help accelerate actions and investments to be taken up across different arms of government and society to urgently mitigate against the enormous health and economic losses associated with these conditions. Acting on mental health and NCDs not only enhances population health but also promotes social equity and inclusion and protects the economy.

The stakes are high, because despite there being clear strategies for the prevention, care and financing of NCDs and mental health conditions to ‘turn the tide’, these are at risk of remaining underfunded because of misaligned or competing national priorities and subject to the countervailing influence of commercial, non-state actors such as the tobacco and alcohol industries. ^{Reference Suzuki, Webb and Small16} Together with tight macro-fiscal realities and a fast changing external financing environment, there is a large onus on national leaders to show resolve, commit themselves to measurable actions and collaborate in the effective implementation of robust fiscal policies, public financial management reforms and health financing strategies that, between them, can rapidly increase levels of available resources for the health sector in general and for the enhanced prevention and management of mental health conditions and NCDs specifically. Such commitments and actions can be monitored over time to enhance accountability, and this extends to the assessment of financing policies, strategies and their impacts.