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Published in final edited form as: Transcult Psychiatry. 2023 Jul 25;60(3):602–609. doi: 10.1177/13634615231183928

Critical reflections on the concept and impact of ‘scaling up’ in Global Mental Health

C Bayetti 1,✉, P Bakhshi 2, B Davar 3, G C Khemka 1, P Kothari 4, M Kumar 5, W Kwon 6, K Mathias 7,8, C Mills 9, C R Montenegro 10,11, J F Trani 1, S Jain 12
PMCID: PMC7615199  EMSID: EMS189225  PMID: 37491885

Abstract

The field of Global Mental Health (GMH) aims to address the global burden of mental illness by focusing on closing the “treatment gap” faced by many low- and middle-income countries (LMICs). To increase access to services, GMH prioritizes ‘scaling up’ mental health services, primarily advocating for the export of Western centred and developed biomedical and psychosocial “evidence-based” approaches to the Global South. While this emphasis on scalability has resulted in the increased availability of mental health services in some LMICs, there have been few critical discussions of this strategy. This commentary critically appraises the scalability of GMH by questioning the validity and sustainability of its approach. We argue that the current approach emphasizes the development of mental health services and interventions in ‘silos’, focusing on the treatment of mental illnesses at the exclusion of a holistic and contextualised approach to people’s needs. We also question the opportunities that the current approach to GMH offers for the growth of mental health programmes of local NGOs and investigate the potential pitfalls that scalability may have on NGOs’ impact and ability to innovate. This commentary argues that any ‘scaling up’ of mental health services must place sustainability at the core of its mission by favouring the growth and development of local solutions and wider forms of support that prioritise social inclusion and long-lasting mental health recovery.

Keywords: Global Mental Health, Scaling up, India, Innovation, Sustainability

While there is significant diversity and contestation within Global Mental Health (GMH)1 and the Movement for Global Mental Health (MGMH)2, a key ‘condition of possibility’ (c.f. Foucault, 2002) shaped their emergence: the availability of data on the prevalence and burden of mental disorders worldwide, contrasted with the low number of available professionals and resources for mental health across countries (Saxena & Belkin, 2017). These metrics have been central in making visible and constructing the idea of a ‘treatment gap’3 — a core issue GMH seeks to address (Mills, 2018) — and in exposing the lack of available mental health care as a “hidden emergency” (Funk & Van Ommeren, 2010). GMH and MGMH frame the failure to address this emergency as a “failure of humanity” (Kleinman, 2009), which sets up a moral call for action founded on a quantified notion of the scale of the ‘problem’, with ‘scaling up’ poised to be a key solution.

Indeed, ‘scaling up’ access to mental health care has emerged as a core aim of GMH and is framed as a means to close the treatment gap, increase coverage and extend the reach of services (Lancet Global Mental Health Group, 2007; Patel et al., 2018). Scaling up in this context has been “defined multifariously as the process of increasing the number of people receiving services; increasing the range of services offered; ensuring these services are evidence-based, using models of service delivery that have been found to be effective in similar contexts; and sustaining these services through effective policy, implementation and financing” (Mills & White, 2017, p.188). In practical terms, it has become one of the main avenues for the globalization of the mental health response, exemplified in the development of key high-profile ventures like the WHO’s Mental Health Gap Action Programme (mhGAP)4 and its suite of increasingly digitised products. These tools build upon ideas of the universality of mental disorders and a logic of expansion in relation to mental health, and target (often female) non-specialist health workers who are trained in the use of such tools (Mills & Hilberg, 2019). This practice of task-sharing/shifting is a leading strategy for scaling up, with the Lancet GMH group (2007) explicitly prioritising the development of interventions ‘that can be delivered by people who are not mental health professionals’ across routine care settings (ibid, p.1241).

This emphasis on ‘scaling up’ mental health services within GMH also increasingly defines existing public mental health strategies in Lower- and Middle-Income Countries (LMICs) and the organization of their public mental health services (Thornicroft et al., 2011), including the nature and growth trajectories of local third-sector organisations5 providing mental health care (Funk et al., 2004). Critical reflections on the validity, impact and sustainability of this scaling up approach, however, remain sparse. This commentary builds on existing engagement with these considerations and the ideas of ‘scale’ that underpin GMH (Bemme & D’Souza, 2014, Cosgrove et al., 2019) and offers a critical discussion of positioning ‘scaling up’ access to mental health services as the ‘solution’.

GHM’s current approach to scale

GMH and the MGMH follow the perceived success of the global HIV/AIDS response, which reinforces the scalar and spatial mindset that mental health is a global problem with a universal solution. Under this view, mental health is “framed as a truly ‘global’ problem” demanding “an ethical case for the right to access to treatment” in LMICs (Howell et al., 2017). This approach provokes important questions: What is the nature of the content being scaled? How are processes — particularly regarding task-shifting/sharing — being scaled, and under what politics of scale?

GMH espouses and reproduces a view of mental health which, particularly in its early days, centres on individual pathology, often to the detriment of a wider view encompassing the well-being of individuals and communities (UNHCR, 2019)6. It defines mental disorders as universal phenomena, predicated on Western psychiatric models and nosology, with diagnoses matching distinct biomedical entities with clear biological aetiologies. This emphasis remains despite scholarly criticisms of its validity7. GMH has attempted to answer these criticisms by embracing a ‘staging model of mental disorders’; however, this reductive model remains focused on symptom-based management and fails to appropriately challenge GMH’s reliance on psychiatric diagnosis and classification as “indispensable for clinical practice” (Patel et al., 2018, p. 33).

Crucially, GMH’s conceptualisation of mental health and illness shapes how solutions are identified and developed for ‘scaling up’. Viewing mental illness as a universal and technical problem notably renders it amenable to biological and technological interventions and solvable by a change in format and content of service delivery (Appelbaum, 2015). GMH thus prioritises the scaling up of ‘evidence-based interventions’, justified as a strategy to spur governmental action and resourcing, despite critiques of the applicability and validity of Evidence-Based Medicine (EBM) to the treatment of mental ill health (Gupta, 2007). As a result, treatments whose efficacy is most easily demonstrated using EBM-favoured research methodologies (ibid, 2007) are largely selected for scaling up. These treatments, including pharmacological and manualised psychological therapies, are perceived to be more efficient, cost-effective, of better quality and with more predictable outcomes (Adams, 2013). Indeed, their propensity for algorithmic and manualised configurations and their ability to be implemented via ‘treatment algorithms’ and ‘prescription guidelines’ allows for deploying these treatments via mobile solutions, such as e-mhGAP (Mills & Hilberg, 2019). Such initiatives are hailed for extending service reach, in turn making the deployed interventions inherently appear more scalable8.

The nature of these interventions thus reifies the dominant spatial orientation of GMH’s view of mental health and scale, with knowledge and resultant practice being extended through a geographic plane. For example, an underlying assumption of the use of technology and task-sharing/shifting is that psychiatric knowledge can be disseminated to and subsequently deployed by local actors, such as community health workers (McInnis & Merajver, 2011). The result is that, where recognized, local and community knowledge is valued primarily for aiding implementation and acceptability of global solutions. Local actors are not empowered to question the motives, values and worldviews inscribed within global mental health projects, or to deepen existing community competencies (Campbell & Burgess, 2012) and local solutions of psychosocial care and support (White & Sashidharan, 2014). In that sense, GMH’s approach to ‘scaling up’ assumes the global and local as separate, hierarchical units of analysis where the global is often valued more than the local9,10. This is reflected in the underlying logic of expansion and prioritization governing GMH’s twin notions of the treatment gap (the ‘problem’) and scaling up (the ‘solution’). Under this value system, ‘scalability’ is prioritized, granting visibility and relevance to interventions that more effectively extend the reach of services while backgrounding the content of the services themselves, the assumptions upon which they are based and the effect of their interaction with local contexts (Cooper, 2015).

This lack of consideration for local values also undermines the sustainability of GMH’s approach. Crucially, GMH’s ‘scaling up’ of mental health services assumes a form of pre-existing ‘buy-in’ from the population, which in fact is often lacking. In reality, a large percentage of people with psychosocial disabilities (PPSD) don’t seek treatment from formal mental health services, necessitating a pluralistic approach to their care (Orr & Bindi, 2017). While stigma may partly explain this, so might the emphasis on the biomedical nature of mental illness and treatment often found in psychiatric services. Indeed, the latter often lacks cultural congruence and fails to address the complex nature of the suffering and needs faced by most PPSD (Bayetti et al., 2019), resulting in waning attendance, increased ‘revolving door’ patients, and poor treatment outcomes (Jain & Jadhav, 2009). A narrow biomedical understanding of mental suffering also jeopardizes the sustainability of GMH’s approach to scaling up by constricting the ability of mental health services to adapt and address the existential threats that populations are and will be facing, including social exclusion, poverty, conflict, unemployment, and climate change (UNHCR, 2019).

In this context, the notion of ‘value’ cannot be disentangled from GMH’s inherently neoliberal worldview (Cosgrove & Karter, 2018). Indeed, how valid is an approach premised on the idea of value as the “economic calculus for lost productivity” (ibid, p.172) in addressing the burden caused by mental disorders? Can the effectiveness of ‘scaling up’ an intervention be adequately understood from solely the incremental economic return it produces? This ‘value’ is further reified by the EBM paradigm clinicians must adhere to, which, “under the banner of evidence-based ‘efficient’ (i.e., cost effective) practice” (ibid, 2018), increasingly pushes them to work according to an ‘audit culture’ to the detriment of an ethic of care (Rizq, 2014). The market-driven values central to GMH’s approach thus fail to align with the philosophical and cultural values that might be important to PPSD, such as kindness, respect, independence, recovery, community acceptance, belonging, autonomy of decision-making and working in partnership. While some GMH advocates contend the economic constraints of LMICs and the ‘urgency’11 of the ‘treatment gap’ support market-driven ‘values’, we suggest that this position may be short-sighted. We argue that mental health services in LMICs should be evaluated on more than their effectiveness in reducing symptoms and returning individuals to economic productivity12.

Re-thinking ‘scaling up’ within GMH

The above discussion illustrates how the ‘scaling up’ advocated in certain circles of GMH is often more about ‘how can we treat people’ rather than ‘how can systems support people to live a meaningful and socially included life’. This is reflected in GMH’s focus on providing ‘services’ and ‘interventions’ as well as in the nature of these interventions — and a shift from the former perspective to the latter is necessary. This proposed reframing offers greater intersectionality in what shapes distress and how to address suffering, which invites a broader reconceptualization of mental health care as more than the absence of symptoms, but rather as dependent on complex systems involving wider social and structural determinants.

Such a shift necessitates a re-appraisal of the ‘values’ that are promoted by scaling up strategies. This requires recognising and addressing the power disparity between those who decide what counts as ‘global’ and ‘local’; and what is ‘scaled’, how, and for whom13. This must embody a greater recognition of the knowledge and experience of PPSD and communities, and greater acknowledgment of the value of their expertise in their own wellbeing and care. We must develop a new shared language between ‘professionals’ and the communities they serve. These altered power dynamics would challenge the traditional stigma associated with mental illness while promoting PPSD’s rights and furthering social inclusion, community cohesion and resilience. Such discussions on the politics of power within mental health care must be prioritised in curriculum development and within the training of mental health professionals (Bayetti, Jadhav & Deshpande, 2017).

Organizational structures must reflect this holistic and person-centred approach and challenge traditional notions of service and interventions. Bottom-up driven structures and those guided by principles of ‘learning organisations’, for example, ensure that solutions to be scaled up are primarily shaped by what is at stake for individuals and communities, furthering engagement and bolstering resilience. Indeed, such changes can support feedback mechanisms that allow solutions to evolve to meet the ever-changing and complex nature of people’s ‘ecologies of suffering’ (Jadhav et al., 2015), and, in turn, promoting their long-term sustainability.

Such a framework challenges the ‘siloed’ thinking that prevails in current service commissioning, in which each issue experienced by people is addressed via individual and poorly-connected services with their own pre-set outcomes — despite a sometimes-obvious overlap between the issues each service is designed to address. For example, complex array of specialized interventions and pathways are commissioned based on ‘individual’ needs such as housing, financial assistance, social welfare, mental health, with little to no acknowledgement of their intersectionality. This ‘service’ approach takes a focalized view of the ‘problem’, rather than see it as part of a broader whole and often results in unnecessary and costly duplication of services and stifles intersectoral collaboration. Challenging this ‘siloed’ thinking is a crucial step in recognising and addressing the complex systems of social and structural determinants of mental health and in re-thinking what we expect of mental health services and interventions. In this way, the above suggested reorientations deliver more ‘value’ than the biomedical orientation dominating GMH’s current approach to scale.

NGOs: innovation, scale and ‘paradigm shifts’

Over the last two decades, third-sector organisations have emerged as important mental health service providers in LMICs. They often deliver innovative interventions that exemplify the above advocated shifts and demonstrate positive outcomes including service quality, social inclusion and high rates of remission (Kohrt et al., 2018). Authors of this paper have recently reported on a study investigating how some mental health NGOs in India balance innovation, impact, sustainability, and scale (Srinavasan et al., 2023).

The NGOs studied appear dependent on idiosyncratic and heterogeneous assemblages of local actors and resource structures that emerged through trial-and-error rather than top-down14 planning. This make-up shapes their approaches to interventions, resulting in a more ‘holistic’ recovery that challenges the structural issues underlying people’s suffering. Engagement with service users’ immediate families and broader communities is integral to their approaches, with the success of interventions in part predicated on how mental wellness generates value for individuals, their families and the local community. This community embeddedness has enabled these NGOs to empower local actors and co-opt resource structures, including families and participants with mental ill health themselves, to become actors in the recovery process, a critical dimension for the success and sustainability of their operations. Unfortunately, there is sparse literature investigating these participatory processes in localised mental health interventions.

With an increasing emphasis on closing the ‘treatment gap’, NGOs have felt growing pressure (and commensurate funding) from governments, donors and other macro- and meso-level GMH actors to scale up the impact of successful social innovations. In the case of the previously identified NGOs, the complex set of local values at the core of their philosophies of care and the micro-dynamics central to their interventions and approach to patients’ care may be hard to replicate and scale up using current dissemination and implementation practices. Similarly, the inherent interconnectedness of local NGOs with their communities and wider ecologies raises concerns as to how effective their interventions would be if replicated in a different local context without critical reflection. Any impetus to scale up interventions developed in the third sector thus first requires developing an understanding of the nature and dynamics of these innovations and their local adaptations15. This provides insights into which aspects are generalisable, how they might be scalable or replicable, and what resources would be required to adapt them to new contexts. The pressure faced by mental health NGOs in the Global South to ‘scale up’ may tempt organisations to do so without the above understandings, thus jeopardising the efficacy and sustainability of their approaches.

Areas for future research

Further research is needed to best support community-centred approaches that alleviate the suffering of PPSD and promote social inclusion. As identified above, there is a need to identify the components that make mental health NGO innovations in the Global South successful. This might include establishing the relationship between processes followed and ‘theory of change’, and distinguishing the nature of the local adaptations at and whether they embed questions of participant ownership. These inquiries would clarify necessary precursors to the design and implementation of programmes to scale up social innovations and would determine the conditions under which scalability is feasible. Research is equally needed to determine the effects that increasing demand for evidence, scalability and impact have on the innovative practices of these organisations, particularly in terms of ownership by PPSD. Innovative approaches to mental health care promoting holistic and people-centred care often rely on specific ‘philosophies of care’ that demand particular soft skills to remain culturally grounded and to prioritise service users’ individual meanings, ownership and experiences. Research is needed to understand the tension between the need to identify these soft skills to scale up such interventions and the inherent risk of standardising them excessively in doing so, thus turning these soft skills into ‘technical’ ones that neglect the role played by individuals within their own journey to recovery. In that regard, while concepts such as ‘recovery’ and ‘wellbeing’ are useful in framing and promoting the previously advocated shift towards supporting PPSD to live a meaningful and socially inclusive life,16 more inquiry is needed into how these concepts and their meanings translate across cultures (Bayetti et al., 2016).

Lastly, any reconceptualization of what mental health work can and should achieve demands a novel understanding and approach towards what constitutes valid outcomes and how they should be measured. Revising what constitutes success and positive change within mental health work requires a deep paradigm shift to emphasize participatory processes and individual meaning for PPSD. This requires flexible processes that allow for adjustment and adaptation to the needs of each person, and account for individual free will, local resources and policies.

Shifting to this new perspective entails an in-depth discussion of how to redefine “success” not merely in terms of limited standardisable outcomes and outputs but through a concerted effort towards documenting processes that hold meaning for individuals and communities in LMICs. As such, the debate over how to determine an “outcome” metric for improving mental health requires us to move beyond a quantitative data approach (objective) to incorporate the agreed and negotiated processes between mental health professionals, patients and the drivers that influence human experience (subjective). Yet, the research methods that unpack these drivers (including ethnographies and other qualitative and participatory research methods) continue to hold less weight than quantifiable outcomes in the evidence-based context that dominates GMH policy making. Until a shift occurs in the philosophical underpinning of how GMH views, values and engages with care, the expressions of individuals with mental ill health in terms of their own needs and aspirations will remain largely ignored by the current GMH approach to scale, to the detriment of people and communities.

Footnotes

1

Global mental health (GMH) is a complex and developing field that resists simple definition. We conceptualise it as a global assemblage of diverse and sometimes contrasting ideas and practices, encompassing concepts such as constellations of care, research, and policy. GMH is a broad ‘church’ that includes many who partly subscribe or do not subscribe to the forms of GMH propagated via the Lancet Series.

2

GMH is closely associated with MGMH, which advocates for a scientific endeavour and policy agendas specifically grounded in the Lancet 2007 Series on GMH and related high-profile publications. MGMH describes itself as a social movement and a response by the international civil society to particular psycho-medical constructions of mental disorder as a global crisis.

3

Publications in the field acknowledge the limitations of this concept and have proposed replacing it with the more holistic ‘mental health care gap’ (Patel et al., 2018), which reflects not only the lack of biomedical treatments but also treatments of a psychosocial and physical nature.

4

This includes an operation manual, algorithmic diagnostic guides, an e-learning platform and a smartphone app.

5

The third sector is used here as an umbrella term to covers a range of different organisations with different structures and purposes, belonging neither to the public sector nor to the private sector and encompasses entities such as non-governmental organizations (NGOs), charities, think tank, social enterprises, and other non-profits.

6

Over the last five years, there has been greater acknowledgement in the field of the role of social determinants (Patel et al., 2018), as well as a growing number of approaches that attend to the cultural and social determinants that influence mental health conditions (Bemme & D’souza, 2014, Kirmayer & Pedersen, 2014a; Mills & White 2017)

7

These include, but are not limited to: the poor validity of psychiatric diagnostic categories; their assumed ‘universality’; the reductive nature of biomedical understanding of mental illness; and culture’s role in shaping the understanding, presentation and experience of mental ill health (Bayetti & Jain, 2018).

8

In this context scalability is primarily related to increasing the availability of services. The accessibility of services remains a challenge in the absence of local contextual grounding.

9

This can result in giving less priority to or wholly excluding contextualised ‘local’ interventions from consideration for scaling up, without consideration of effectiveness. Similar processes are documented by ethnographies of local and global tensions in HIV/AIDS (e.g. 2016 Critical Public Health special issue on global health indicators). Some exceptions to this global-over-local preference exist; for example, the Friendship Bench Approach, a contextualised ‘local’ intervention that has successfully been brought to scale (Chibanda et al., 2015).

10

It is worth highlighting that recent initiatives have challenged this hierarchy by calling for an increased “mutuality” within GMH, with the aim of producing knowledge more equitably across epistemic and power differences (Bemme et al., 2023). Global partnership seeking to valorise the (unpublished) experiential knowledge of people with lived experience, implementers and to co-produce the priorities and process of scale-ups with local communities have now emerged and provide interesting counter point to GMH’s inherent assumption about the separation existing between global and local. See for example: https://www.together2transform.org/

11

It is worth point out that the temporality inherent to these market driven values also stands in direct opposition with the temporality of some the philosophical and cultural values that might be important to PPSD and their personal recovery (Topor, Boe & Larsen, 2022).

12

The imposition of economic productivity is, in many cases, a cause or an aggravating factor of mental illness, particularly for the most vulnerable (Trani & Bakhshi, 2017).

13

For recent work interrogating this, see for example: https://www.together2transform.org/scaling

14

Top down is used here to make reference to a process where decision are made primarily by the leader(s) of an organization before being filtered down through a hierarchical structure.

15

The experience and failure of ‘scaling up’ in other sectors should give us pause and lead to critical reflection on the usefulness of scaling up innovative mental health NGO interventions.

16

Some PPSD have expressed concern how terms such as ‘recovery’ and ‘wellbeing’ are increasingly co-opted to pressure people to ‘recover’ according to pre-determined criteria often aligned with the neoliberal values permeating mental health services (McWade, 2016).

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