WFMH: Mental Health in an Unequal World

Members of our WONCA Working Party on Mental Health joined World Mental Health Day with important collaborations to the document “Mental Health in an Unequal World: Together we can make a difference”, produced by the World Federation for Mental Health.

Below you will find the article "Realising the Astana Declaration and mental health in an unequal world - the role of family doctors", created in collaboration with some members of the WONCA Working Party on Mental Health.

Realising the Astana Declaration and mental health in an unequal world - the role of family doctors

MD, PhD, FRCGP(Hon), FWONCA, FESC. Professor of General Practice and Primary Health Care at the School of Medicine, University of Crete and Head of the Clinic of Social and Family Medicine at
the School of Medicine, University of Crete.

MD, MSc, PhD. Principal Investigator. Interdisciplinary Research Laboratory on Primary Care, Universidade do Estado do Rio de Janeiro, Rua São Francisco Xavier, 524, Maracanã, Rio de
Janeiro, RJ 20551-030, Brazil.

MD, PhD. Family Physician, Assistant Professor, Primary Health Care Department, Federal University of Rio de Janeiro, Brazil.

M.B.B.S, MMedFM instead of M.B.B.S, MMedFM. My address is 796 Providence East Bank Demerara, Guyana instead of 796 Providence EBD, Georgetown, Guyana.

ABFM, FFCM, MSc.Med Edu (Cardiff-UK), DTQM, MSc/Diploma PMHC (Nova-Lisbon). Consultant Family and Community Medicine, Director of the Primary MH Program-MOH Saudi Arabia.

MD, MPH, RN, FAAFP. Professor of Family Medicine, Psychiatry, and Public Health and the Health Professions. Department of Family Medicine, Jacobs School of Medicine & Biomedical Sciences.
UB Downtown Gateway Department of Family Medicine Primary Care Research Institute Buffalo, New York 

BA MSc MD FRCGP. Emeritus Professor, University of Liverpool UK; Chair, WONCA Working Party for Mental Health, UK


In October 2018 WHO convened a global conference on primary health care in Astana, Kasakhstan. The ensuing Declaration included the following statements:

• We strongly affirm our commitment to the fundamental right of every human being to the enjoyment of the highest attainable standard of health without distinction of any kind.

• We are convinced that strengthening primary health care (PHC) is the most inclusive, effective and efficient approach to enhance people’s physical and mental health, as well as social well-being.

• Remaining healthy is challenging for many people, particularly the poor and people in vulnerable situations. We find it ethically, politically, socially and economically unacceptable that inequity in health and disparities in health outcomes persist.

• Promotive, preventive, curative, rehabilitative services and palliative care must be accessible to all. We must save millions of people from poverty. [1]

As family doctors we fully endorse this commitment to the fundamental rights of people with mental health conditions. We support WHO in promoting a shift from stigmatizing long-stay mental hospitals, to more acceptable and dignified care in community-based settings.

Primary care, with its emphasis on the connections between mental and physical health, and its unique ability to tackle problems of co-morbidity and multimorbidity, is exceptionally well-placed to enhance mental health within universal health coverage systems. Family doctors are well placed to assess patients’ vulnerability, the impact of poverty and disadvantage, and their association with mental and psychological conditions. [2] We can intervene to reduce the mortality and morbidity of people with severe mental illness, who die prematurely, spiraling into homelessness, unemployment and poverty and with greatly increased risk of developing non-communicable diseases such
as diabetes. [3]

We agree with the need for mental health promotion, requiring multi-sectoral collaboration to build a healthy environment with the focus on those factors that reduce chronic stress, poverty and health inequalities. We include potential anti-stressors and supportive actions including social connectivity and (for many) spirituality and religiosity.

We now consider how these principles apply in four health care systems. 

Brazil: middle income country
The territorial basis of Brazilian Family Health Strategy (ESF), the cornerstone of Primary Care System in the National Health System, connects each of 40,000 Family Health Teams (FHT) of doctor, nurse, nurse technician and up to six community workers to a community of around 3,750 people.

These teams guarantee access for all Brazilians to health care; they also develop health promotion and preventive measures, including socioeconomic interventions, integrated with other sectors such as education, housing, culture and social assistance [4].

However, there are not enough family doctors and nurses to cover all these FHTs, bringing challenges when building a patient-centered approach and an integrated health system. The implementation of new Mental Health Care Internship is developing new models of undergraduate training in mental health. To translate the Astana Declaration into practice we need to expand psychosocial and secondary care teams working within a collaborative care model with PHC professionals. Getting these teams to work together through the Brazilian Collaborative Care model, the Matrix Support, will allow for an Integrated Care System to be implemented where each person can receive the best quality care needed in different levels of the health system [5].

The biggest challenge to actually apply the Astana declaration, in addition to structural inequalities in societies, is the lack of human resources to expand intersectoral actions between the PHC and other sectors [6]. Advocacy for mental health care in those territories could enhance community participation and intersectoral coordination, and reduce inequalities and inequities in relation to the integrated approach to a person with psychosocial suffering and their family members and caregivers.

Guyana: middle income country

Primary health care in Guyana has its challenges, especially as it relates to the management of mental health conditions. Referring all cases to the psychiatric department is overwhelming, given a population of over 700,000 and less than twenty public health psychiatrists. Family medicine was formally instituted in 2015 [7], and with mh-GAP training since 2016 has helped to reduce suicide rates.

There are unique challenges in Guyana in relation to sustainability and consistency in providing medications and human resources. There is a serious brain drain: 89% of university-educated Guyanese leave the country, the highest rate in the world. [8]. We have to continuously train doctors and nurses to fill these gaps, which puts a serious strain on our health care system. 

In PHC, staff such as psychologists and social workers need to be on board to provide comprehensive care. Mental health needs to be seen as equally important as any other organic illness, in order for there to be equity of care in Guyana. There is still a lot of stigma associated with these conditions. 

The Mental Health Unit and the Georgetown Public Hospital are the two main public entities in Guyana that provide mental health care. Working together, monitoring and surveillance are key to addressing the gaps, so that Ministry of Health knows what needs improving. More opportunities should be provided for Fellowship training in Psychiatry to enable our primary care physicians to be more confident and competent in their management of mental health conditions. Resources need to be provided to all ten administrative regions across Guyana.

To ensure comprehensive and holistic care we need more collaboration and advocacy with international bodies. 

Saudi Arabia: high income country

A situation analysis (1995-1999) identified that family doctors were unable to identify mental health problems in primary health care and showed that traditional training programs were ineffective (9). From 2002 to 2015 a long-term training program was implemented for primary health care workers and family doctors in primary health care centers, in collaboration with WHO, WONCA and other countries. Beginning in eleven primary health care centres in Eastern Province, this program has been extended across all provinces, with more than 436 training courses across all provinces.

In total 1435 family and PHC doctors, 931 nurses, 42 social workers, 31 psychologists have been trained; 253 PHC centres are now able to provides Primary MH care; more than 76,000 patients have been served in over 330,000 PHC visits; and each month more than 2000 patients show improvement in their conditions. One of the most important fruits of this experience was creating an innovative patients’ interview approach «5-Step Model» in line with the needs of PHC doctors in the Arab culture (10). This program is now being implemented in Egypt, Morocco and Sudan.

United States: high income country

The US remains without a solid system of national health care, though the Affordable Care Act has afforded access and coverage to millions of individuals and families. On the primary care front, value-based care is gaining momentum and with it stronger demands for reimbursement reform.

Events over the past year have forced a reckoning with the stark imbalance in health outcomes for people of color; inequities as a consequence of racism and other key social determinants of health. [11]
The COVID-19 pandemic has offered US primary care opportunity and challenge. Can we make mental health care more accessible, affordable and equitable? [12] Can we recognize how poverty, discrimination, prejudice, and many other traumas affect mental health – and act to eliminate these barriers?

A robust public health system in concert with primary care is key to addressing mental health and well–being. Community engagement can engage people in need, particularly those who are under-served, such as homeless individuals, those whose primary language is other than English, and individuals with serious mental illness. [13,14]

We must provide to those who seek refuge in the US due to violence or conflict in their home countries, utilizing a trauma informed approach – emphasizing resilience and approaching treatment through family, community and cultural contexts. [15] Totally integrated primary and behavioral health care is a recipe for successful care, decreased stigma, and better health outcomes. [16, 17]

With an already stretched primary care system, primary care doctors and their teams encountered enormous stressors, including increased risks of contracting the virus. We need support to improve medical well-being [18-20].


We have highlighted the challenges of translating the Astana Declaration into global action, and recommended what primary care doctors can do to make a difference in promoting equity and equality in mental health in differing health systems. To fully realize the Astana recommendations will take the power of governments as well as private sector foundations. We encourage family doctors to work collectively to turn these aspirations into achievements.

1. World Health Organisation, Declaration of Astana. 2018, page 5.
4. Menezes, Alice Lopes do Amaral et al. Parallels between research in mental health in Brazil and in the field of Global Mental Health: an integrative literature review. Cadernos de Saúde Pública [online]. 2018, v. 34, n. 11 [Accessed 11 June 2021] , e00158017
5. Onocko-Campos, Rosana Teresa. Mental health in Brazil: strides, setbacks, and challenges. Cadernos de Saúde Pública [online]. v. 35, n. 11 [Accessed 11 June 2021],e00156119. Available from: < 311X00156119>. ISSN 1678-4464
6. Giovanella, Lígia et al. De Alma-Ata a Astana. From Alma-Ata to Astana. Primary health care and universal health systems: an inseparable commitment and a fundamental human right. Cadernos de Saúde Pública [online]. 2019, v. 35, n. 3 [Acessado 11 Junho 2021]
9. Al-Khathami, A. Traditional mental health training’s effect on primary care physicians in Saudi Arabia. Mental Health Fam Med Journal, 2011; 8: 3–5.
10. AlKhathami A, et al. A primary mental health program in Eastern Province, Saudi Arabia, 2003-2013. Mental Health in Family Medicine; 10:203-210.
13. Westfall JM, Liaw W, Griswold KS, et al. Uniting Public Health and Primary Care for Healthy Communities in the COVID-19 Era and Beyond. JABFM doi: 10.3122/jabfm.2021.S1.200458M.
14. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. The Milbank Quarterly, 2005;83:457–502
15. Griswold KS, Loomis DM, Pastore PA. Mental Health and Illness. Prim Care Clin Office Pract. 2021;48:131-145.
16. Shim R, Rust G. Primary Care, Behavioral Health and Public Health: Partners in Reducing Mental Health Stigma. AJPH 2013. doi:10.2105/AJPH.2013.301214