ThriveNYC is part of a global awakening that not only is bringing mental health from the margins to the mainstream but is also pioneering pathways to secure the public’s health. The 6 principles and 54 evidence-guided initiatives that comprise ThriveNYC constitute a maverick effort to transform opportunities for mental health in New York City and in many other cities in the United States and beyond. Stimulated by Belkin and McCray’s (p. S156) article in this issue of AJPH, in this counterpoint I raise three issues related to societal demand for mental health care, cities as entry points, and how evaluation design might enhance the impact of ThriveNYC.
From an international perspective, far too often the wider public, policymakers, and especially finance ministers view health care expenditure as a drain on economic growth. This view leads to a lack of demand for investing in health care that is manifested by perilously low public expenditure on health care in many countries. Evidence, however, suggests that better health drives economic growth.1 Challenging this misperception, therefore, is critical and is the primary impetus for the World Bank’s Human Capital Project, which aims to cultivate and sustain demand among decision makers to invest in people’s health and education. This mobilization of demand is especially important for mental health where evidence of both the high economic costs of inaction and high returns on investment are critically important adjuncts to overcoming widespread residual stigma.2
Encouragingly, ThriveNYC embraces the demand side through its principles of changing the culture of partnering with community and directly engaging the wider public. Despite these principles, the project focuses on the mental health of the early years constituency; it thus overlooks other critical populations, such as working age adults, for whom mental illness exerts a disproportionate economic toll. Sustaining demand may benefit from engaging a life course approach and progressively realizing a universal entitlement to mental health services.
The city entry point of ThriveNYC corresponds well with the pervasive demographic shift toward urban dwelling globally. Despite longstanding recognition of the importance of cities for health, the structural fault lines of health systems that privilege federal or state programs and facility-based services continue to leave local and community programs on the frugal fringes. ThriveNYC appears well positioned to counter this systems bias by tapping latent local resources critical to effectively dealing with mental health challenges, including deep contextual knowledge, connection with communities, and critical multisectoral engagement.
Assuming ThriveNYC succeeds in establishing a nidus of transformation for mental health, it is not clear how it will avoid becoming yet another successful “pilot” that fails to “scale,”3 especially considering the density of resources found in New York City that are not a given elsewhere. In this regard, a clearer sense of how ThriveNYC links to broader mental health and health policy reforms at the level of state and federal governments will be important. For example, the mental health innovation lab might benefit from being part of a formal network of such labs guided by federally agreed on criteria to assess efficacy and the safety of digital innovations. Efforts to secure these sorts of strategic complements may help to support the spread and scale of ThriveNYC.
The design of ThriveNYC, with its multiple synergistic interventions, raises questions related to whether the program is achieving its intended impact, the contributions of its constituent parts, and the timeline for change. Clearer time-bound targets that are shared among programmers, policymakers, and the public might help to motivate action and transcend inertial forces toward a common goal—as has been seen, for example, in the Healthy People initiative in the United States4 and the United Nations Sustainable Development Goals, which include a mental health target.5 Similarly, rigorous prospective evaluation assessing the specific contributions of interventions may help to channel scarce resources into higher performing parts of the program, harness tacit knowledge for improvement, and deal more proactively with unintended consequences.6
CONFLICTS OF INTEREST
The author has no conflicts of interest to declare.
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