Table 1 Proposed allocations to mental health and the rationale

i) A mental health-in-all-policies approach must be adopted

• Social determinants of mental health are very important to achieving population mental health and hence policies adopted in sectors outside of health must consider their impacts on mental health. For example education, housing and labour can adjust their policies and programmes in ways that improve mental health outcomes without significantly adding to their output costs. Mental health must be included in structures currently existing or that are being set up in countries to deal with the social determinants of non-communicable diseases, such as National Health Commissions [43] or Health Promotion Foundations [44]

ii) There should be no more than a 20% gap in the humane and human rights oriented care, treatment and rehabilitation of people with severe mental order

• Ideally every person with severe mental disorder should have access to comprehensive mental health care, treatment and rehabilitation. However, given current large treatment gaps in LMICs [45] there should be a minimum initial target of 80%

• Quality of care and the human rights of users should be determined at internationally acceptable norms and standards

• This target should not include people who experience psychotic symptoms that are part of cultural expression or are non-psychotic hallucinations or delusions

• The vast majority of users, if not all, should live in communities

• Users must be treated for both their physical and mental health care needs

• Specialist personnel such as psychiatrists and psychologists should be available to support less specialized personnel through task sharing and task shifting while also taking referrals of more complex cases

iii) A minimum additional amount of 10% of the amount spent on severe mental disorder should be allocated to treating people with common mental disorder

• This percentage appears highly asymmetrical and unfair especially as this group would usually constitute 5–10 times more in actual numbers than people with severe mental order and usually includes highly vulnerable people such as victims of violence. However, this proposal is based on the cost of care itself (i.e. significantly higher for severe mental disorder); on the implications of not treating a person with severe mental disorder; and on the fact that for treatment of common mental disorder most LMIC countries will be starting from a very low base

• Cost benefit will be high

• These services need to be built up and further resourced over time

• Task shifting and task sharing must form an important part of the care and treatment for people with common mental illness

iv) Given the high co morbidity between mental and physical health and the reasons for this [46], screening for mental disabilities should take place within all chronic care services

• Screening for mental health should be included in services for both communicable diseases such as HIV and TB and Non-communicable diseases such as hypertension and diabetes. Treatment should then be offered/provided to those that are screened positive [47]. This would allow for a rational and logical process to increase the numbers receiving care especially for common mental disorder

v) A minimum of 3% of the budget spent on severe mental disorder should be spent on promotion and prevention programmes

• As with common mental disorder, it is expected that the economic return on investment through prevention and promotion will be far higher than expenditure on severe mental disorder, and indeed more desirable [48], however this proposal acknowledges that mental health resources will in all likelihood be in short supply and taking away from treatment of severe mental disorder, even if it is for prevention, will have medical, social, economic and even political implications

• Prevention and promotion will also be starting from a very low base in most LMIC and hence even 3% of the treatment amount may initially be difficult to absorb into effective prevention programmes. While financial returns on such investment is often difficult to measure, available research does indicates good value for money [49, 50] while also approaching mental health from the most humane way possible [38]

• Stigma reduction programmes must form part of this resource

vi) An additional 1% of the allocation for serious mental disorder should be provided for driving the mental health programme

• This allocation will for resourcing leadership, stewardship and assistance from policy development through to programme implementation as well as monitoring and evaluation. Without this, mental health interventions will fail