Moving away from the scarcity fallacy: three strategies to reduce the mental health treatment gap in LMICs

Abstract

Moving away from the scarcity fallacy: three strategies to reduce the mental health treatment gap in LMICsThe mental health treatment gap -defined as the difference between the number of people who have mental disorders and those who can access appropriate treatment -is estimated to be as high as 85% in low and middleincome countries (LMICs), compared to only 40% in highincome countries (HICs) 1 .This high treatment gap in LMICs is unacceptable and represents an urgent global health priority.Here, we argue that possible solu tions to reduce this gap do exist within many LMICs.Conventionally, we often blame resource scarcity for the high er mental health treatment gap in LMICs.This includes: a) human resource scarcity (shortage of specialized personnel), b) financial scarcity (income shortage at individual, family and national lev els), and c) structural scarcity (e.g., concerning infrastructure, health systems, and policies) 1 .From our experience, we believe that this resource scarcity mindset is a fallacy.It is time to move away from this mindset if we are to minimize the mental health treatment gap in LMICs.Of course, it is true that, when compared to HICs, LMICs have a scarcity of mental health experts.But such an argument is based on the idea that the HIC model -where care is provided by "expert" caregivers such as psychiatrists and psychologists -is the goldstandard approach that LMICs must first attain to re duce the treatment gap.This Western/HIC model, however, does not often translate into accessible and effective care in LMICs 2 .Rather than focusing mostly on expert caregivers, LMICs should find answers to two important questions: a) what kind of human resources do we have in our hands, and b) how can we innova tively use these resources alongside the rather more expensive and relatively unavailable specialists?Indeed, there is a huge pool of utilizable human resources that can be trained to recognize symptoms of mental disorders, of fer first aid psychosocial support, and refer upwards and accept referrals downwards for continued support.These include: a) families, that are traditionally the primary caregivers; b) individu als with lived experience, who can be supportive of people with mental disorders; c) an inexhaustible pool of clergy and tradition al healers, who are often the first contacts for care even when spe cialists are available; d) community health volunteers, who are the backbone of community health services and the link between families, communities and community facilities; e) school teach ers and counselors available in every school; f) peer counselors in schools, colleges and universities, who are trusted within their circles more than others outside those circles, including special ists; g) the nurses and clinical officers at community health ser vice centers; h) general physicians working in communities.We have found that these different human resources can be expertly engaged to provide evidencebased interventions using the World Health Organization (WHO)'s mhGAP Intervention Guide (mhGAPIG) 3 , and that peers -as young as 18 to 22 yearscan provide evidencebased intervention in schools 4 .We, there fore, aver that in a way LMICs are not human resource poor, but