International observatory on mental health systems: structure and operation
© Minas; licensee BioMed Central Ltd. 2009
Received: 16 March 2009
Accepted: 03 April 2009
Published: 03 April 2009
Sustained cooperative action is required to improve the mental health of populations, particularly in low and middle-income countries where meagre mental health investment and insufficient human and other resources result in poorly performing mental health systems.
The International Observatory on Mental Health Systems is a mental health systems research, education and development network that will contribute to the development of high quality mental health systems in low and middle-income countries. The work of the Observatory will be done by mental health systems research, education and development groups that are located in and managed by collaborating organisations. These groups will be supported by the IOMHS Secretariat, the International IOMHS Steering Group and a Technical Reference Group.
The International Observatory on Mental Health Systems is: 1) the mental health systems research, education and development groups; 2) the IOMHS Steering Group; 3) the IOMHS Technical Reference Group; and 4) the IOMHS Secretariat. The work of the Observatory will depend on free and open collaboration, sharing of knowledge and skills, and governance arrangements that are inclusive and that put the needs and interests of people with mental illness and their families at the centre of decision-making. We welcome contact from individuals and institutions that wish to contribute to achieving the goals of the Observatory.
Now is the time to make it happen where it matters, by turning scientific knowledge into effective action for people's health. (J.W. Lee, in his acceptance speech on his appointment as the Director-General of the World Health Organization) .
Sustained cooperative action is required to improve the mental health of populations everywhere . This is particularly so in low and middle-income countries where mental health system performance is poor as a result of meagre mental health investment [3, 4] and strikingly insufficient and inequitably distributed human and other resources [5, 6]. While many aspects of health and illness are universal, they are imbedded, and must be understood, in local socio-cultural, economic and political contexts. Such understandings can only be gained through high quality locally relevant research.
The particularities of local problems require the development of locally relevant and effective solutions. This requires strong local capacity in all relevant domains. One such domain, currently poorly developed, is mental health systems research. In most low and middle-income countries there is limited capacity to answer critical questions about the mental health status and needs of populations, how mental health is most effectively maintained and illness prevented, which treatments are effective, whether population health policy objectives are being met, and how health systems are most effectively organised. If the mental health of populations is to be improved such questions must be answered . They can only be meaningfully answered through local research that is high quality and is carried out by local researchers.
"The observatory will be an important source of information for governments who want to develop good mental health policies and best practices. Mental illness is common in all countries. Treatment and care is complex. Community attitudes and stigma surrounding mental illness take time to change. We are a developed country and we are still on a learning curve trying to get it right. Several countries in Asia and the Pacific are seeking to build up their capacity in mental health. The research you do will be critical in helping them improve their mental health services. I am a firm believer in the need for good evidence-based policy and programs. One of the key findings during consultations for the Development for All strategy , was the dearth of both quantitative and qualitative information about disability in our region. Governments and policy makers everywhere need good, sound information on which to make decisions. Your work will make a valuable contribution."
The goals of the Observatory are to:
foster the establishment, and support, a vibrant mental health systems research, education and development network, that will produce evidence for mental health policy and practice in low and middle-income countries, and build capacity for mental health system development;
produce new knowledge to inform the development of mental health systems that are effective, accessible, equitable, culturally appropriate, affordable and disability inclusive, and that protect the human rights of people with mental illness, and
monitor and evaluate progress in the development of mental health systems in low and middle-income countries.
The IOMHS Secretariat, located in the Centre for International Mental Health, will play a coordinating role and will support the International Steering Group, the Technical Reference Group, and collaborating groups.
An International IOMHS Steering Group has been established, with members from Australia, Cambodia, China, Egypt, Ghana, India, Indonesia, Japan, Malaysia, New Zealand, Pakistan, Philippines, South Africa, Sri Lanka, Switzerland, Thailand, UK, USA and Vietnam. The Steering Group will be expanded to ensure that all countries in which the Observatory has active programs are represented. The role of the Steering Group is to ensure that governance of the Observatory is representative, transparent and accountable.
The IOMHS Technical Reference Group will advise on technical aspects of research design, data collection, analysis and interpretation, research ethics, research governance and publication of research results. The membership of the Group will be researchers with high level technical skills who wish to contribute to building mental health systems research capacity in low and middle-income countries, particularly by supporting more junior research colleagues to develop their skills.
IOMHS collaborating organisations
"The work program of IOMHS will depend on the establishment of partnerships with governments, universities, international and local NGOs and other partner organisations that will collect, analyse and apply high quality information for mental health system reform and development. An outcome of such a collaborative work program will be the establishment of sustained and productive collaborations between mental health policy makers, academics, practitioners, NGOs, and civil society organisations, and improved capacity to analyse trends in health care reform. An explicit goal is to build the strengths of partner organisations and networks to provide evidence-based advice to national and sub-national policy makers, service planners and implementers." 
The major part of the work of the Observatory will be done by collaborating partners in participating countries. Collaborating organisations may be Ministries of Health, Universities, local and international NGOs, and civil society organisations – particularly consumer and carer groups. It is anticipated that, in any one country, a number of organisations of different kinds will enter into collaborative agreements to form and enlarge IOMHS. While all such collaborations will be welcomed by IOMHS a core strategy in building these collaborations will be the establishment of mental health systems research, education and development groups and, as resources and circumstances permit, some institutions may establish formal centres for mental health systems research, education and development. It is expected that these groups will:
be located in an appropriate academic department or other organisation;
have a close working relationship with the Ministry of Health and other relevant government ministries (e.g. Education, Social Affairs, Employment, etc.) and actively support the use of research findings for evidence-based mental health system development;
be committed to establishing and strengthening collaborative working relationships with mental health stakeholder groups in the country (e.g. national professional associations, other universities, public and private mental health service agencies, and NGOs – particularly associations of consumers and carers), and with groups with similar goals internationally;
be committed to education and training in mental health systems research and in policy and service development;
be committed to the ethical conduct of mental health systems research and, where they do not formally exist, the establishment of ethics review procedures for such research;
be disability inclusive;
promote and support capacity development in consumer and carer organisations and facilitate and support consumer-led and carer-led research;
be committed to open access publishing to ensure that the results of the work of the Observatory are freely available to all;
share what they learn through participation in the annual International Mental Health System Development Conference and other relevant national and international meetings.
The work agenda and priorities of such groups will, of course, be a matter for the groups themselves to determine, on the basis of local and national needs and priorities. With the support of IOMHS such groups will build the opportunities to participate in or to lead multi-country collaborative research projects on matters that are of regional and global as well as local significance.
Research capacity strengthening
What is to be strengthened? Research capacity is multidimensional. It includes the production, dissemination and use of knowledge. It includes the ability – the existence of the necessary skills and resources -and the motivation to produce, widely disseminate and appropriately use newly acquired knowledge. It includes also systems for allocating priority, or value, to different research objectives, to ensure that research contributes to national health goals.
Available resources can be concentrated in particular institutions, teams, and networks that can focus on national health priorities in order to enable an increased volume of high-quality and well-targeted research to be undertaken.
A central element of the Observatory strategy is resource concentration through the establishment of mental health systems research, education and development groups and, where possible, formal centres committed to such work. This will bring together and support researchers with an interest and expertise in mental health systems research and will continuously build such expertise.
Improving interaction between different parts of the research system so that available resources are used effectively and efficiently, with the additional benefit that interaction may produce a 'multiplier' effect. The networks should be across different institutions and teams, across different parts of the research system (e.g. research producer and user groups) and across different disciplines.
A key role of the collaborating organisations is to build such networks in the country in which they are located and to establish collaborations with centres in other countries in order to facilitate knowledge exchange.
Well-functioning communication infrastructure is essential.
The IOMHS Secretariat will develop effective means for communication within the IOMHS network, and between IOMHS and other organisations.
When it is intended that the research should influence policies and practice, it is essential that the users of the research results are engaged as early as possible in the research process. This will improve commitment by users to the research, will ensure that the research is relevant to the goals of the users, and will make it more likely that the research results are understood and used in an appropriate manner.
IOMHS collaborating groups should have established links with key research users, particularly Ministries of Health and other relevant government agencies, as well as other research user organisations. A particularly important responsibility of the collaborating oranisations in the IOMHS network is that research outcomes are turned into tools for advocacy, for use by consumer and carer organisations and by other civil society organisations, and into policy briefs, for use by policy makers and implementers.
This involves taking a systemic view of research capacity and creating mechanisms for formulating and implementing strategies for its development.
Within countries the IOMHS collaborating groups will take primary responsibility for strategic leadership. They will particularly have responsibility for shaping the national mental health systems research agenda. They will be supported in this role by the IOMHS Steering Group, in which all IOMHS collaborating groups will be represented, the Technical Reference Group, and the IOMHS Secretariat.
Training and skills development
Those who are engaged in research must have the necessary skills if they are to carry out research confidently and well, and if they are to maintain a commitment to research. There are many forms that such training can take, such as basic skills development, research higher degrees and training in leadership for research. Often neglected but very important is training in research governance and research ethics.
Research career development
Training is one component may form part of a wider attempt to open up career pathways which encourage talented individuals to become involved in research and then to develop their skills to the highest possible level.
The establishment of mental health systems research, education and development groups in key academic departments will open up career pathways that currently do not exist for mental health systems researchers. Increased expertise and the existence of groups with the benefits of scale will improve ability to compete for scarce research funds from national and international sources, further enhancing technical capacity and career opportunities. Professional development courses and formal university qualifications in international mental health will make a substantial contribution to building careers in mental health systems development and will support career advancement.
Ensuring political independence
Establish mechanisms for the management of research that enables activity to be directed by a concern for knowledge-building rather than by short-term political expediency. Whilst research should inform policy, political micro-management of research is likely to be damaging to capacity rather than otherwise.
The expectation that most IOMHS collaborating groups will be established in influential academic institutions, which everywhere jealously guard their independence, will contribute to ensuring political independence. However, political independence does not mean political isolation. Unless such research is respected and used by those who are directly engaged in the political process it is unlikely to have any influence on, or to contribute to, mental health system development. An important element in ensuring political independence is the strengthening of a culture of research (see below).
A key component of cultural change is the creation of a culture in which the production, dissemination and use of high-quality research is valued as an integral part of the health system.
Excellence: Ensure that research is of the highest quality
Curiosity: Encourage curiosity and support exploration
Free inquiry: Remove impediments to free inquiry
Attitudes to authority: Examine and question authority
Justice and equity: Ensure that research contributes to the public good
Research ethics: Protect and enhance the rights and interests of research participants by establishing processes that ensure ethical research practice
Increasing the resources available within the research system (which ultimately means increasing the funding dedicated to research) is the most obvious means of strengthening capacity. However, careful attention should also be paid to the coordinated and efficient use of existing resources.
"Funding for health systems research in developing countries and by developing country researchers is meagre. Evidence suggests that such funding is at most 0.02% of health expenditure, far too low to have an impact on health system development. Funding should be mobilized from within national health systems as well as from science and technology budgets and international sources. Priority problems for research need to be identified in relation to health system and development goals and in consensus with policy makers" . The establishment of mental health systems research groups within established academic environments that are closely linked to policy development and implementation will strengthen capacity to secure research funds from national and international sources. Support from the IOMHS Technical Reference Group, which will advise on technical aspects of research design, will improve the capacity of such groups to compete for scarce research funds, as will a growing record of publications in international peer-reviewed scientific journals.
Governance of health research determines the means by which stakeholders set, pursue and achieve agreed research goals – what kinds of research should be supported, by whom it should be done and for what ends [16, 17]. Among the criteria for governance are representativeness, transparency and accountability. Good research governance is essential to ensure that research is conducted ethically, that it is relevant to the population being researched, and that it is of high scientific quality.
In many low and middle-income countries there is not a formal system in place for review of the ethical dimensions of proposed research projects, whether the research is being conducted by local or international organisations. Where this is the situation the collaborating organisations in which the mental health systems research groups are located will promote and support the establishment of ethics review procedures that protect the rights of all concerned, and ensure the ethical conduct of research and of the use of research findings.
There is little interaction between research groups within and across low and middle-income countries . Most interaction is between research groups in low and middle-income countries and research groups or funding organizations in high-income countries . This is a situation that must be changed. Interaction between organisations within and across low and middle-income countries must be strengthened. Good research governance is particularly important in circumstances where collaborative research is being carried out, particularly collaboration between researchers in low and middle-income countries and high-income countries. The collaboration must be equal, with the interests and health needs of the population in the low and middle-income countries being of paramount importance.
The mental health systems research, education and development groups;
The IOMHS Steering Group;
The IOMHS Technical Reference Group; and
The IOMHS Secretariat.
The International Observatory on Mental Health Systems will strengthen capacity for mental health systems research, and the translation of that research into benefit for people with mental illness, in low and middle-income countries. Success will be dependent on free and open collaboration, sharing of knowledge and skills, and governance arrangements that are inclusive and that put the needs and interests of people with mental illness and their families at the centre of decision-making. It will also crucially depend on a collective capacity to mobilise resources that will support the work of the Observatory.
We welcome contact from individuals and organisations who wish to contribute to achieving the goals of the Observatory. We would particularly welcome contact from academic and other institutions that may wish to establish a mental health systems research, education and development group and to become active collaborators in the IOMHS network.
The author gratefully acknowledges the valuable comments of members of the IOMHS International Steering Group on a draft version of this paper.
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