By Mary E. Wiktorowicz, Professor of Global Health Governance and Policy, Dahdaleh Institute for Global Health Research, York University, Canada
These deaths justify a deeper look at the societal response to those with episodic mental health and substance use issues.
Canadian and Ontario chiefs of police argue insufficient investment in community mental health care has made police “psychiatrists in blue.” More than 30 per cent of people with serious mental illness who were turned away from emergency departments as they tried to access care experienced police encounters, according to a study by the Canadian Mental Health Association (CMHA).
But while police budgets increase annually, research I helped conduct has found that investments in mental health declined from 2000 to 2014 compared to other health-care areas. Savings from psychiatric hospital closures were shifted to other sectors, even though funding community supports could avert mental-health crises. This holdover of what’s known as “structural stigma” enables systemic neglect.
Mental health system in distress
From an international perspective, Canada lags in addressing mental health. Only one in five children receive the care they require, enduring wait-lists of a year or more, according to the CMHA. Although mental illness and substance use account for 23 per cent of disease burden — more than 1.5 times that of all cancers combined — they represent only seven per cent of health-care spending.
The World Health Organization denotes a care gap of 35 to 50 per cent in developed countries, resulting in delayed care and treatment failures. Ensuring access to co-ordinated community care, psychotherapy, substance-use rehabilitation, court diversion and housing would prevent hospitalization, employment disability, homelessness, imprisonment and police encounters.
While societal savings from psychotherapy for depression are double their cost, they are uninsured unless offered by physicians whose supply is limited, constraining access.
The United Kingdom and Australia publicly insure psychotherapy, while B.C. and Ontario are expanding access. Early intervention for youth with psychosis can prevent disability and improve recovery, yet youth at risk are often turned away from emergency departments, waiting months for assessment, only to increase the likelihood of committal.
Most psychiatric hospitalizations are indeed involuntary. Would delays that increase the risk of youth death and disability be accepted for an illness like diabetes?
Enhanced funding for community supports — crisis teams and supportive housing — would reduce the direct and indirect costs of mental illness that represent 4.4 per cent of GDP; investment of $85 per capita pales in comparison to the $7,068 in health-care expenditures per Canadian.
Mobilizing greater commitment, however, entails immense political will.
Why health is a political issue
Mental health policy is politicized by the federal and provincial governments and contested among professionals and advocates.
Although jurisdiction for health care lies with provinces, Ottawa used its spending power to encourage the provinces to launch medicare. Of the five conditions provinces must meet to secure federal health transfers, comprehensive care was defined as medically necessary hospital and physician services.
The Canada Health Act followed the path of the 1957 Hospital Insurance and Diagnostic Services Act that excluded psychiatric hospitals, non-physician community care and limited psychiatric general hospital beds to 10 per cent, foreshadowing our current dilemma.
While provinces that fail to insure hospital and physician services risk forfeiting federal transfers, they can exclude community care with impunity. Mental health care has therefore focused on clinical, hospital-based services instead of helping people regain their health by insuring community supports that would reduce institutional system costs.
Federal and provincial government relations and their accommodation of the medical profession further guide health policy. Given competing demands on provincial budgets, political and professional concerns may overshadow patient needs. Physician strikes that occurred when medicare and the Canada Health Act were enacted reflect the contentious nature of policy negotiations.
Exclusion of community-based mental health care from the terms of the Canada Health Act, and the absence of targeted federal funds to address the omission, resulted in fragmented accountability, revealing misaligned strategy as politics ascended policy.
Addressing structural discrimination
Canada’s federal structure and intergovernmental dynamics profoundly shaped health policy. The Canada Health Act set the terms for federal health transfers, establishing financial incentives for provincial governments, which have reinforced regressive patterns of medical care.
Although the 2017 federal health accords targeted funds for mental health, they fell short of the $3.1 billion annual investment required to meet health spending targets recommended by the Mental Health Commission of Canada.
The 2002 Romanow Commission on the Future of Health Care emphasized federal and provincial co-operation and recommended funding follow patients rather than be tied to institutions.
Enhanced mental health supports would reduce public expenditures and employer productivity loss by $255 billion over 30 years. Failure of governments to adequately fund mental health will only raise societal costs and increase the 30,000 mental health crisis calls that Toronto police alone receive annually, and so the time for action is upon us. Were it not for federal incentives, after all, Canadians might not have universal health care today.
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