Mental Health, Primary Care and the Challenge of Universal Health Coverage

June 28, 2015


Thank you for the opportunity to join you here in Bucharest for this conference.   And congratulations to the World Psychiatric Association (WPA) for your great work in strengthening mental health care for the people of the world.  The World Organization of Family Doctors, WONCA, and the WPA have a strong history of working together to promote and support universal access to mental health care. I congratulate president Dinesh Bhugra on your leadership of the WPA, I congratulate my fellow Australian and longstanding colleague and friend, Helen Hermann on your recent appointment as president-elect, and I thank Eliott Sorel for making this event happen.  I look forward to the continuing work of our organisations.

One of my first acts when I became president of WONCA two years ago was to accept an invitation from the WPA, to travel to Armenia, to join the WPA and other world mental health associations in signing the Yerevan Declaration.  This declaration committed our organisations to work together to promote global awareness of mental health problems, access to affordable mental health services for all people, tackling stigma and discrimination, and continuing to strengthen education and research.

Accepting the invitation to join you today is part of this shared commitment.  This congress in Bucharest has a very welcome focus on primary care mental health with specific reference to Innovation and Transdisciplinarity.  I know what innovation is, but I had to look up on Google the term “transdisciplinarity”.  My favorite definition is a “strategy that crosses many disciplinary boundaries to create a holistic approach”, which I think is appropriate given the global focus on person-centredness in health care delivery.

We all recognize that mental health and mental well-being are fundamental to the quality of life of individuals, families, communities and nations. We have the capacity to successfully treat mental health disorders. Yet in many parts of the world only a small minority of people with mental health illnesses has access to effective treatment. 

In this presentation I will focus on the integration of mental health into primary care, and on the challenge of ensuring universal health coverage, and I will argue that integrating mental health into primary care is the most viable way to close the treatment gap and ensure that all people get access to the mental health care they need. I will draw in particular on some of the work that the World Health Organization, the WHO, and WONCA have been engaged in around the world over recent years.

I am sharing with you some images of family doctors who have allowed me to visit with them in their clinics in different parts of the world.  Yesterday I met with Dr Sandra Alexiu who is a family doctor working in the small community of Jilava, outside Bucharest.  Sandra has a list of 2,500 patients, many of them disadvantaged, and works in partnership with her practice nurse.

First, a little about WONCA.  WONCA was started 43 years ago by a small group of family medicine colleges and academies, which banded together to create a world body that shared an ideal of training and education for family medicine and high standards for clinical care in all nations of the world.

WONCA now has member organisations representing over 500,000 family doctors in 145 countries and territories around the world.  Each year, the 500,000 family doctors represented by WONCA have over 2 and a half billion consultations with our patients.  Two a half billion.  That’s the scope of our current work and our influence.

But we need to do more. We need to work to ensure that every family doctor, every GP, every primary care doctor, joins us in our commitment to deliver high quality primary care to our patients and communities. We need to expand our commitment to the education and training of family doctors, and quality care, and primary care research, to the 60 nations of the world where WONCA does not yet have a presence.  And we need to ensure that the care we provide includes mental health, as well as addressing physical health concerns.

So let’s talk about mental health and primary care at its basic level.  There are a number of ways that I know, as a family doctor, that I have had a good day working in my clinic.  Here is one of them:

“I haven’t had a good day as a family doctor unless at least one person has cried in my consulting room.”

This might sound mean, but you need to understand the context. 

In my practice, I see many people with chronic disease, especially with HIV/AIDS.  I know that many of my patients are at risk of depression as a comorbid condition.  I also know that, as a family doctor, I need to be vigilant in seeking to detect patients with undiagnosed depression.  I know that many people who commit suicide in my country have presented to a health care setting seeking help in the days before they kill themselves.  So detecting undiagnosed depression among my patients is a medical emergency. 

I also know, as you do, that many of my patients don’t come in saying “I’m depressed.”  They may come in with physical symptoms like headache or backache and stomach ache, or wanting to talk about trouble at home or at work or with their children, or complain of difficulty sleeping, or excessive worrying, or loss of weight, or poor concentration, or just not feeling right. It is only when I pick up on the cues, and ask the right questions, that the tears start to flow.  And I can work towards making a diagnosis.  And work towards assisting my patients on the pathway towards managing their depression. 

Family doctors, like psychiatrists, appreciate the link between the physical health and well being of our patients, and their mental health and well being.

One of the key features of family medicine, like psychiatry, is that we put our patient in the centre of care and have a focus on the whole person, rather than on individual diseases.

In the words of the late Canadian family medicine academic Ian McWhinney, one of the giants of our profession, “The family doctor is committed to the person rather than to a particular body of knowledge, group of diseases, or special technique.”  This is our generalist ideal.

Ian McWhinney also advised us that, “ideally, family doctors should share the same habitat as their patients.”  Living in the community that we serve allows us to best understand the social context of our patients’ lives.

Mental health problems constitute a substantial part of the burden of illness of patients in the community and they are a regular reason for contact with a family doctor. In fact, mental health problems are part of patients' and families' daily life experience, which is why it is vital that we address such problems in primary care.

You and I know that people are more than a collection of disconnected parts. The woman with a history of myocardial infarction may be depressed that she can no longer care for her aged mother – and her depression may put her at increased risk for another heart attack.

The man who uses alcohol to control his chronic anxiety symptoms and develops pancreatitis – may then worry obsessively that he will be doomed to a life of chronic pain, which further compounds his anxiety.

We are aware of the consequences of physical ill health on the mental health of many of our patients. Depression, in particular, is a common co-morbid condition for many people with chronic health conditions, such as cancer, heart disease, diabetes, HIV and tuberculosis. We are also aware of how mental ill health can impact on the physical well being of our patients. This especially affects our patients with intellectual disability and those with chronic mental health conditions.  And it affects the increasing number of older people in our communities, underscoring especially the importance of awareness of dementia and the potential for early diagnosis and intervention.  And we have the evidence about the importance of primary care in tackling the links between mental health, physical co-morbidity and deprivation.

Integrating mental health into primary care is an essential part of this work, and together WONCA and the World Health Organization have been working to strengthen the provision of mental healthcare through primary care. This led to our joint publication on Integrating Mental Health into Primary Care, and I thank the WPA members here in this audience who contributed to this publication. With this publication, the WHO made a powerful statement that mental healthcare is a core component of primary care.

Specific skills and competencies are required to effectively assess, diagnose, treat, support and refer people with mental disorders; it is essential that people working in primary care around the world are adequately prepared and supported in their mental health work.

All medical students need education about mental health; all trainees in family medicine need training in mental health; all qualified primary care doctors and nurses need continuing professional development on the prevention and management of mental health conditions. Access to appropriate therapies, medications, and referral services is essential. Research needs to continue on rates of mental health problems in communities and the diagnosis and management of mental health problems in primary care.

It was excellent to see the 2013 WHO World Health Report, which focused on the research needed for universal health coverage.  It has important messages for family medicine and psychiatry.

Dr Margaret Chan, Director-General of the World Health Organization has said that “Mental health is essential for achieving person-centred and holistic primary health care”.

Dr Chan is right.  We need to create awareness and change the public perception of mental health. We need to sensitize the public on the issues of mental health, and I am going to share with you some ways we can do this.

I am a director of an organization in Australia, called beyondblue, which is funded by the Australian Government to raise awareness among health professionals and the general public about mental health, tackling stigma and discrimination about mental health, and supporting the people of our nation to seek the support they need.  This is an example of one of our public education campaigns, launched on World Mental Health Day, with a series of online resources to increase people’s confidence and skills in talking about anxiety and depression. They provide suggestions for how to talk to someone you’re concerned about, or how to talk about how you’re feeling yourself.

In each country, we need to highlight the role of clinical leaders among primary and specialty care doctors who will advocate for the need to manage both the physical and mental health care needs of each of our patients.

We need to reinforce the need for active government and corporate support, including funding reform, to ensure that the care of mental health concerns is integrated with the care of physical health concerns for people attending both primary and specialty medical care settings. 

For too long, mental health disorders have been largely overlooked as part of strengthening primary care. Mental health is central to the values and principles of the Alma Ata Declaration; holistic care and universal health coverage will never be achieved until mental health is integrated fully into primary care.

Common misunderstandings about the nature of mental health disorders and their treatment have contributed to their neglect. For example, many people think that mental health disorders affect only a small subgroup of the population, but you and I know that large numbers of people attending primary care clinics may have a diagnosable mental disorder. Some think that mental health disorders cannot be treated, but you and I know that effective treatments exist and can be successfully delivered through primary care. Some believe that people with mental health disorders are violent or unstable, and therefore should be locked away, when we all know that the vast majority of affected individuals are non-violent and capable of living productively within their communities.

I visited Brazil recently to see in action the famous “Family Health Team” model of universal access to primary care.

At a family medicine clinic in one of the favelas, or shantytowns, of Rio de Janiero, I met young family doctor Euclides Colaço and his colleagues. Euclides works with a family medicine resident, two nurses and six community agents, or community health workers, providing comprehensive clinic-based and home-based care as a team to a defined population of 4,500 people.  They are expected to know about the health status of every single person living in that area.

The community health agents in Brazil have a key role to play; they go out into the community and visit everybody and bring those in need of assessment and assistance to the clinic, or the community health agents escort the doctor or one of the nurses on a home visit.  This is the “Family Health Team” model of Brazil in action.   It delivers true comprehensive primary care delivered to an entire community.  And there are over 33,000 such teams in operation across the entirety of Brazil.  It is a very impressive model

I was keen to hear how psychiatrists link in with their primary care colleagues in Brazil.  I was advised that one of the most important aspects in Brazil were the difficulties found to develop collaboration between psychiatrists and family doctors. I was advised that some psychiatrists were afraid that family doctors would take their place in caring for patients with mental health problems.  Yet what they perhaps don’t realise is that in Brazil up to 70% of mental health care is already provided by family doctors. I was also advised that some psychiatrists tend to see mental health problems only as those that present to a psychiatrist, mainly people with severe psychosis.

So our psychiatry colleagues in Brazil have developed "matrix support teams" that work with Brazilian Family Health Teams to integrate mental health professionals with the primary care professionals.  In Rio one psychiatrist and one psychologist is attached to 10 family health teams, covering a population of around 35,000 people, many of them extremely poor. They visit each Family Health Team at least once a month and the Family Health Team members feel better supported by this integration, knowing that if anything happens they can call their own mental health professionals. This has improved access to treatment for the members of these communities and has had a remarkable effect that on continuing education.

We need to build effective partnerships between primary care and psychiatry and the people who utilize our services. This requires willingness to work together and to negotiate professional and cultural understandings of mental health problems and how best to manage them.  

People need to be able to access mental health services close to their homes, keeping their families together and maintaining their daily activities. In addition, they avoid indirect costs associated with seeking specialist care in distant locations, indirect costs that can be catastrophic for low income people when a family member has a serious health problem.

Mental health services delivered in primary care have the potential to minimize stigma and discrimination, and remove the risk of human rights violations that sometimes occur in hospitals and institutions in some parts of the world. And integrating mental health services into primary care generates good health outcomes at reasonable costs. Nonetheless, primary care systems must be strengthened before mental health integration can be reasonably expected to flourish.

A particular challenge for some of the nations in this region of the world is rebuilding health services following emergency situations, including crises like the Ebola outbreak, or natural disasters like the recent earthquakes that affected our friends and colleagues in Nepal.

Emergency situations can also be due to armed conflicts and civil unrest as we have seen in some of the nearby nations of this region of the world.  Regardless of the cause of emergency situations, a cascade of human suffering is often the result including large scale displacement with refugees moving across borders, shortages of food and clean water and sanitation, disease outbreaks and the risk of terrible human rights abuses. 

I am particularly impressed with the work of the WHO on addressing the mental health consequences of the tragedies that accompany natural disasters and conflict situations and the excellent report on Building Back Better Sustainable Mental Health Care after Emergencies.  It documents work underway to support rebuilding of more sustainable mental health services in many developing countries.  It’s only failing is that it does not address the importance of also building back primary health care systems and ensuring the mental health and primary care services are integrated.

Our common humanity compels us to respect people’s universal aspiration for a better life, and to support their attainment of a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity. With integrated primary care, the substantial global burden of untreated mental disorders can be reduced, thereby improving the quality of life for potentially hundreds of millions of people and their families.  This is all part of universal health coverage.

2015 is a landmark year in global health as we come to the end of the Millennium Development Goals.  In 2000 the United Nations adopted the Millennium Development Goals, called the MDGs; eight aspirational goals, agreed by all the world’s countries, which aimed to halve extreme poverty rates by the end of 2015, provide primary school education to all children, empower women, reduce infant and maternal mortality, combat HIV, tuberculosis and malaria, and ensure the sustainability of our environment.

The MDGs have galvanized unprecedented efforts across the globe to meet the needs of the world’s poorest people, including in this region of the world.  And progress has been impressive with rates of extreme poverty halved, and significant reductions in infant and maternal mortality and HIV infection rates in many countries, with millions of lives saved through reductions in preventable deaths. 

It is clear that success in these areas has occurred only when there has been both national and local ownership to give the MDGs traction, and the importance of allowing the local adaptation of the MDGs to target local conditions.  And it is no surprise that this process has reinforced that developing countries want capacity, not charity – and that building self-reliance is critical; this is a key role for WONCA and WPA in our support through our member organisations for education and training for the members of the primary care workforce in every nation.

The MDGs have also come in for criticism because of what is missing. They didn’t have a specific focus on rural communities, where the poorest half of the world’s population is based, they didn’t tackle the need to strengthen the primary care basis of each country’s health system, they didn’t tackle chronic disease and certainly didn’t tackle mental health, or address the social determinants of health, and, by focusing on vertical programs, they did not focus on ensuring universal health care access for all people. 

Each nation needs a strong system of primary care.  We have the evidence of the benefits of primary care in lowering the cost of care, improving access to services, and reducing the inequities in a population’s health.  And we have seen the terrible consequences when a nation faces a serious health challenge without well-developed primary care and the capacity to respond swiftly to health threats. This is exactly what happened during the recent Ebola crisis in West Africa. Those nations without strong established primary health care systems experienced the greatest challenges and significant loss of life.

Strengthening primary care must continue to be addressed beyond 2015. WONCA and the WPA need to ensure our clear voice is heard on behalf of our patients and communities. ?We need to be clear about our role in working with our patients and communities to increase life expectancy and achieve equitable health outcomes. ?

We are now facing a new set of global challenges.  The United Nation has developed the Sustainable Development Goals and targets, or SDGs, which will guide the global development agenda post-2015.

In his inspiring address to the United Nations General Assembly last December, Secretary-General Ban-Ki Moon, discussed “The road to dignity by 2030: ending poverty, transforming all lives, and protecting the planet” and he made a call to action to transform our world beyond 2015.  In his words “we are at a historic crossroads...  With our globalized economy and sophisticated technology, we can decide to end the age-old ills of extreme poverty and hunger.  Or we can continue to degrade our planet and allow intolerable inequalities to sow bitterness and despair.  Our ambition is to achieve sustainable development for all.”

He went on to state that the 1.8 billion young people on the planet need to be “the torchbearers for the next sustainable development agenda through 2030.  We must ensure this transition, while protecting the planet, leaves no one behind.”

The United Nations has adopted 17 Sustainable Development Goals.  There is only one health specific goal, number 3: “Ensure healthy lives and promote well-being for all at all ages.”  But each of the 17 new goals has an impact on global health and the health of individuals.

The challenge now is to finalise the indicators that will be used to measure how each nation is progressing against the Sustainable Development Goals, and ensure that each government is kept accountable.

Primary care provides the answer to universal health coverage, and health systems founded on strong primary care are critical “to ensuring healthy lives and promoting well-being for all at all ages”.  We need an unambiguous commitment by the UN and other stakeholders to the measurement and development of high quality, comprehensive primary health care.  The greatest risk of the Sustainable Development Goals to primary health care, is the current lack of a specific focus in the draft UN indicators on primary health care.  This is surprising, as we know many countries want to strengthen primary health care, and countries want to get better data to better plan for better health service delivery.  The same applies to mental health 

There is a lot of current debate about the indicators that will underpin the SDGs.  As Margaret Chan has said, “What gets measured, gets done”, especially if there is funding attached.

There has been a recent seismic shift in the global focus on primary care with the establishment of the new Primary Health Care Performance Initiative (PHCPI), developed by the World Bank, the Bill and Melinda Gates Foundation and the WHO.  This initiative aims to encourage countries, especially low and middle income countries, to achieve the health-related Sustainable Development Goals and Universal Health Coverage, by catalysing improvements in primary health care systems, through better measurement, knowledge-sharing of best practices, and practical tools to manage and improve delivery of essential health services.

The initiative has the explicit support of Bill and Melinda Gates who now understand that strengthening primary health care is fundamental to achieving universal health coverage.  A list of draft "Vital Sign Indicators" has been developed for discussion.

WONCA has been asked to assist the World Bank and Gates Foundation on focusing this work.  To date attention appears to have been on “what can be measured, rather than on what should be measured”.  I see this as the fundamental challenge that will determine whether this initiative delivers real improvements in global primary health care.

Part of the challenge is that the PHCPI describes primary care as a  “Black Box”.  A “Black Box” is something that can be viewed in terms of its inputs and outputs without any knowledge of its internal workings.  I am troubled that our work in primary care is described as a “Black Box”.  The work we do may seem impenetrable to health care policy makers and statisticians who haven’t engaged closely with us.  But those of us working inside the “Black Box” see everyday the benefits of the work that we do with our patients and with our communities. 

Primary care is a complex system, just like hospital-based health care, and is no more a “Black Box” than hospital-based health care.  But what makes primary care more difficult to understand and measure are the added challenges of being distributed, rather than centralized, of being delivered by multiple types of health care providers, often with a mix of private and publicly-funded services, with patients often moving between providers, and with a lack of standardized ways to capture our data. 

I am pleased that the vital sign indicators of PHPCI do not just include vertical disease-focused measurements, but also include important health systems indicators that provide some indication of how well a nation’s primary health care system is working.  I applaud the inclusion of measures of primary health care expenditure as a proportion of total health expenditure but also note that this needs to be measure appropriate spending, especially on those activities that genuinely knit primary health care interventions together, such as the integration of mental health and primary care.

Whether we like individual indicators or not, the SDGs and the PHCPI will be an important part of global primary health care development over the years ahead and provide a real opportunity to work with other major global organisations to advance those things the WPA and WONCA feel most passionate about; universal health coverage, quality care, education and training, and research.

If we are going to succeed in delivering universal health coverage, and the integration of primary care and mental health, then we also need to focus some specific areas that require attention:

Child and adolescent mental health. Many children suffer from a mental health disorder. Disorders regularly seen within primary care include attention-deficit/hyperactivity disorder, conduct disorder, delirium, generalized anxiety disorder, depressive disorders, post traumatic stress disorder, and separation anxiety disorder. Adolescent depression often continues, unabated, into adulthood, and is a risk of youth suicide.

Mental health in older people. The population of the world is ageing rapidly. Older people are more likely of course to have chronic diseases and need health services. Their mental health is influenced by their access to health services, education, employment, housing, social services and justice, and by freedom from abuse and discrimination. It is pleasing to see a rise in interest in dementia, especially as this becomes an issue for the baby boomer generation.

The emerging problem of misuse or overuse of mental health treatments. On occasion, primary care workers recommend mental health treatments for those who do not need them. Though clearly not as frequent as underdetection and undertreatment, overuse wastes scarce resources and can be hazardous to patients. Overuse can be the result of poor diagnostic and treatment skills, often related to inadequate education and training. For example, in some countries primary health care workers increasingly are prescribing antidepressants and anxiolytics for people who are experiencing unhappiness but do not meet the threshold for a mental health disorder. Psychotropic medications are sometimes overused in place of other modes of evidence-based treatment such as psychotherapy.  And pharmaceutical industry promotion can be a double-edged sword – with increased awareness of conditions like depression, there may be a tendency to overdiagnose and overtreat.  I am especially concerned about the pharmaceutical industry getting control of the global dementia agenda and pushing expensive and unnecessary drugs onto our patients, when what they really need is care and support and love, things that don’t come packaged in a capsule.

The challenge of adherence to long-term treatment is also important. The average adherence rate for long-term medication use in primary care is just over 50% in high-income countries, and is thought be even lower in low- and middle- income countries. Patients are blamed when prescribed treatment is not followed, in spite of evidence that health workers and health systems can greatly influence patients’ adherence. In reality, adherence to long-term medication treatment is a multifaceted challenge that requires consideration and improvement of several factors, including a trusting health worker– patient relationship, a negotiated treatment plan, patient education on the consequences of good or poor adherence, recruitment of family and community support, simplification of the treatment regimen, gauging the patient’s ability to pay for treatment, and managing side-effects of the treatment regimen.

The impact of austerity.  Governments around the world are looking at ways to cut their health budgets.  This is especially pertinent in this part of the world where austerity measures are destroying social cohesion and damaging national health care systems.  While strengthening primary care can help alleviate the burden placed on the shoulders of poor families, and especially those with family members with mental disorders and disabilities, austerity is increasing a need for mental health services while reducing their supply, and especially access to care in specialist settings.  These are false economic measures.

Finally a word about our own mental health as doctors. One of the major life lessons we need to learn as doctors is to find balance in our lives.  Balance between caring for our patients and caring for ourselves. Being a doctor is stressful, and if we don’t look after ourselves, then we will not have the capacity and resilience to provide continuing high quality care to our patients and our communities.

We need to ensure that we stay as physically and mentally well as possible. In the words of Sir William Osler: “A physician who treats himself has a fool for a patient.”

Every doctor needs their own doctor, someone we can trust for our own medical care and advice. If we are going to prevent major physical and mental health problems in ourselves, we need to have our own trusted doctor.  As doctors we deserve to have access to the same high quality medical care that we provide to each of our own patients. And our families also deserve this standard of care. So please, and this applies to everyone in this room, if you don’t have your own family doctor, please find one and look after your own mental health.

We also need to look after each other.  In 2013 beyondblue conducted a national mental health survey of doctors and medical students in Australia and found that up to 21% of respondents reported a history of depression, and 6% had an existing diagnosis.  These figures should not be surprising.  We also know that doctors are most at risk of mental health problems at times of transition, especially when they move from being a medical student to being a young doctor.  In Australia we have had a recent cluster of suicides among young doctors, including among young trainees in psychiatry.  This is a tragedy for the families of these individuals and for our profession. 

The statement that there is “no health without mental health” applies to our patients, and it also applies to you and me.  We need to be more vigilant in looking after our younger colleagues and supporting them to deal with the stresses and challenges posed by our profession.  And we need to be vigilant in looking after and supporting each other as well.

It is by working together, and supporting each other, that we will be able to tackle the challenge of integrating mental health and primary care to achieve health coverage for all people.


Michael Kidd

President, World Organization of Family Doctors (WONCA)

Bucharest, June 24, 2015