**2. Primary health care**

The above issues have gained increasing importance against a background of increasing international recognition about what should constitute the ideal of health for individuals and communities. The Declaration of Alma-Ata (1978) defined health as "a state of complete physical, mental and social wellbeing and not merely as the absence of disease and infirmity" as a fundamental human right. The Declaration further called on all governments to formulate national policies, strategies and plans of action to launch and sustain primary health care as part of a comprehensive national health system and in co-ordination with other sectors". The Ottawa Charter for Health Promotion (1986) built on the initial foundations of the Declaration of Alma-Ata. The Charter reported that health "is therefore seen as a resource for everyday life, not the objective for living" and "as a positive concept emphasizing social and personal resources as well as physical capacities". The Charter goes on to define the prerequisites for health as: "peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice and equity".

The Declaration of Alma-Ata was produced in the context of a new "global approach" to health developed initially through the creation of the World Health Organisation (WHO) as a key agency of the United Nations and then the broad visionary strategy of the drive to "Health for All by the year 2000" by the then WHO director, Hafldan Mahler. This coincided with the increasing involvement of the World Bank as the major external funder for health sector development in developing countries and it has been noted that the Bank has "positioned itself operationally and intellectually at the fulcrum of international health development" (Walt 2006).

In the context of the above initiatives mental health is currently defined by the World Health Organisation as "a state of well being in which the individual recognises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully and is able to make a contribution to his or her community" (Herrman et al 2005)

#### **3. Amartya Sen and the concept of human agency**

216 Health Management – Different Approaches and Solutions

*"God went out of me As if the sea dried up like sandpaper, As if the sun became a latrine God went out of my fingers, They became stone My body became a side of mutton And despair roamed the slaughter house…"*(Porter 1991)

*"I am many things, in many places Fool that I may be, mad that I may be. I am, in all my precarious guises The creation of a cruel mind"*  People suffering from severe mental illness currently face significant levels of poor health (Symonds & Parker 2007), high levels of unemployment (Dunne E et al 2008), homelessness (Browne & Hemsley 2010), alienation from family members (Druss et al 2009) and services (Luhrmann 2008). The economic cost of these issues to society generally is significant with people affected by schizophrenia estimated to have provided a direct cost to the United

The above issues have gained increasing importance against a background of increasing international recognition about what should constitute the ideal of health for individuals and communities. The Declaration of Alma-Ata (1978) defined health as "a state of complete physical, mental and social wellbeing and not merely as the absence of disease and infirmity" as a fundamental human right. The Declaration further called on all governments to formulate national policies, strategies and plans of action to launch and sustain primary health care as part of a comprehensive national health system and in co-ordination with other sectors". The Ottawa Charter for Health Promotion (1986) built on the initial foundations of the Declaration of Alma-Ata. The Charter reported that health "is therefore seen as a resource for everyday life, not the objective for living" and "as a positive concept emphasizing social and personal resources as well as physical capacities". The Charter goes on to define the prerequisites for health as: "peace, shelter, education, food, income, a stable

The Declaration of Alma-Ata was produced in the context of a new "global approach" to health developed initially through the creation of the World Health Organisation (WHO) as a key agency of the United Nations and then the broad visionary strategy of the drive to "Health for All by the year 2000" by the then WHO director, Hafldan Mahler. This coincided with the increasing involvement of the World Bank as the major external funder for health sector development in developing countries and it has been noted that the Bank has "positioned itself operationally and intellectually at the fulcrum of international health

In the context of the above initiatives mental health is currently defined by the World Health Organisation as "a state of well being in which the individual recognises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully and

is able to make a contribution to his or her community" (Herrman et al 2005)

The recent poem by Sandy Jeffs (2009) describes her life affected by schizophrenia.

States economy of \$62.7 billion in 2002 (Wu et al 2005)

eco-system, sustainable resources, social justice and equity".

**2. Primary health care** 

development" (Walt 2006).

Apart from health, there has also been an appreciation of economic opportunities associated with the empowerment of human agency, ideas further developed by Amartya Sen, who was awarded the Nobel Prize for Economic Science in 1998. Sen (1999) defines "agency" as "someone who acts and brings about change and whose achievements can be judged in terms of their own values and objectives, whether or not we assess them in terms of some external criteria as well". Sen then goes on to discuss the way that *instrumental effectiveness* of freedom may enhance this potential for agency. "This instrumental role of freedom concerns the way different kinds of rights, opportunities and entitlements contribute to the expansion of human freedom in general and thus to promoting development". Sen then defines his instrumental freedoms as (1) political freedoms (civil rights), (2) economic freedoms (the opportunities to utilize economic resources for the purposes of consumption, production and exchange), (3) social opportunities (arrangements for education, health care etc), (4) transparency guarantees (transparency and trust in personal interaction) and (5) protective security (unemployment benefits, famine relief etc). These instrumental issues then underpin *substantive freedoms* for humanity such as political and civil liberty, social inclusion, literacy and economic security. The work of Sen is having as significant impact on individuals concerned with enhancing the agency of deprived groups such as those people affected by severe mental illness and this will be further discussed later in the chapter. Henry (2007) further defines the issues that Sen promotes "Sen also notes that a second subset of other relevant capabilities of considerable interest to the classical economists — such as the capability to live without shame, the capability to participate in the activities of the community, and the capability of enjoying selfrespect — provides a basis for relative poverty comparisons….policy makers should be concerned with opportunities. Specifically, they should be concerned to ensure that individuals are endowed with capabilities that allow them the *freedom* to choose to live their lives in ways that have real meaning and real value….".

The concepts that Sen defines have been usefully applied to Indigenous disadvantage in Canada and Australia (as described below). They may have also particular importance in supporting strategic policy initiatives to develop a mental health Recovery framework.

#### **4. Effective funding models for primary health care: The indigenous paradigm in Canada and Australia**

The broad spectrum of disadvantage experienced by those afflicted by severe mental illness is to a degree, similar to the current predicament of the Indigenous populations of Australia and Canada. Recent innovative government policies to redress this disadvantage have been based on the definitions of Primary Care previously described in addition to policies based on the desire to enhance substantive freedoms as promoted

In Canada in 2002, First Nations tribes constituted 976,305 people or about 3 percent of the population (Indian and Northern Affairs Canada Communications Branch 2004) Kirmayer et al (2000) note that First Nations Tribes have had contact with European culture since the sixteenth century. They comment " the history of European colonisation of North America is a harrowing tale of the indigenous peoples' decimation by infectious disease, warfare and active suppression of culture and identity that was tantamount to genocide (ibid). Kirmayer et al note that it is likely that 90% of an original population of 7 million Canadian First Nations people died as a direct and indirect result of European contact (ibid). The authors

A New Economic and Social Paradigm for Funding Mental Health in the Twenty First Century 219

"pillars" of health at equal value. The "pillars" were: Health, Lifelong Learning, Safe and Sustainable Communities, Housing, Economic Opportunity, Lands and resources and Governance and Relationships. Each of the "pillars" of the Framework was then be divided into "sub pillars". As an example, Safe and Sustainable communities were divided into: Community Infrastructure, Social Support and Community Well-being and Community Safety and Justice. Unfortunately, the policy appears to have been wound back following the election of the Conservative Government in Canada in 2006. However, the policy remains an important example of the way that a government can enact policy to remedy the broad range of disadvantage with financial "strategic pillars" attached to the relevant issues

In Australia, Archaeological evidence suggests that Aboriginal people have been present for the last 45000-50,000 years. The ethnographic evidence from early contact suggests that Aboriginal people who survived infancy were relatively fit and disease free (Flood 2006). Further, Australia's native foods supported a nutritious, balanced diet of protein and vegetables with adequate vitamins and minerals with little salt sugar and fat. Life on the

In terms of "mental health", traditional Aboriginal culture had a number of strong reinforcing factors that have been well defined by Professor(s) Helen and Jill Milroy (Milroy et al 2003). Aboriginal sense of self was seen in a collective sense, intimately connected to all aspects of life, community, spirituality, culture and country. The culture also provided for everyone through sharing rules and relationships and kinship were of prime importance, defining social roles. Aboriginal people were also given a sense of meaning and understanding of life experience through their connection to country and their Dreaming. Spiritual beliefs offered guidance and comfort and offered a sense of connectivity and belonging despite distress, death and loss. Lore, the body of knowledge that defined the culture and the tribal elders who contained and interpreted the Lore were highly valued. Customary law defined rules and consequences. Over 200 traditional languages and other methods of communication allowed a rich expression of interaction in the above social context and formal ceremony allowed a method of dealing with life's transitions thought birth, initiation and death. Men and women had defined economic and cultural roles within the tribe. Children were well protected within the group with a range of "aunties" and older

Franklin and White (1991) describe the elements of destruction of this optimum physical and mental good health of the Aboriginal people following the British colonization of Australia in 1788. These elements were the introduction of new diseases, the removal of ancestral land which led to psychological distress and spiritual despair and the herding of Aboriginal people into reserves and settlements, destroying lifestyle and leading to marginalisation and poverty. Other specific policies such as the Stolen Generations from the 1930s to the 1960s where Aboriginal children were forcibly removed from their parents and raised in Mission settlements reinforced government social Darwinist ideology and led to the destruction of

family life with resulting emotional desolation for many individual Aboriginal people.

The current significant disadvantage of Aboriginal health and social determinants is well recognized. Hospitalization rates for cardiovascular disease in Aboriginal and Torres Strait Islander was 80% higher than for other Australians in the North West of Australia in 2002 to 2004. (AHMAC 2006) Rheumatic heart disease was nine times more common for Aboriginal and Torres Strait Islanders than other Australians (ibid). Diabetes and renal failure also figure prominently in Aboriginal health issues. In 2004-2005, three times as many Aboriginal

siblings able to take over the child care role if the mother was stressed.

of "Primary Health" as outlined in the Ottawa Charter.

move kept people physically fit (ibid).

comment that First Nations people were removed to settlements that were chosen by government or mercantile interests rather than by the Indigenous Canadians themselves. This often resulted in major social dislocation for the community structures. In addition, from 1879 to 1973, there was a Government policy of removing First Nation children from their homes to church run boarding schools where their heritage was denigrated and suppressed. In addition, these children were subject to physical, emotional and sexual abuse (ibid).

Indigenous First Nations Canadians have high unemployment rates (25%) compared to the general Canadian population (10%) with particularly high rates on reservations (31%) (MacMillan et al 1996). First Nations people generally live in poor housing and only a limited number of communities have adequate water and waste disposal (ibid). They have high infant mortality rates of 13.8 per 1000 live births for all Canadian Indian infants compared to 7.3 for all Canadian infants. Age standardised mortality ratios for Canadian First Nation women is almost double that for Canadian women generally whilst the aged standardised mortality rates for First Nation men is about 50% above that for Canadian men generally with higher death rates for men on reserves. The leading cause of death for Canadian First Nation people between 1986 and 1988 was injury and poisoning that accounted for 31% of all deaths in this population compared to 7.5% of all Canadians (ibid).

Suicide rates for Indigenous Canadians are two to three times higher than Canadians generally. There is a particularly high suicide rate for the Inuit people with the suicide rate in Inuit youth being up to 5 times the rate of Canadian youth generally (ibid). Canadian First Nation communities also report high rates of alcohol abuse, other substance abuse and family violence (ibid) that are probably relevant is respect to the high suicide rates. Solvent abuse, including petrol, glue and cleaning products in isolated First Nation communities (ibid, p1576). Kirmayer et al (2000) also report that there are generally high rates of mental illness in many Indigenous Canadian communities. They note "the high rates of suicide, alcoholism and violence and the pervasive demoralisation seen in Aboriginal communities can be readily understood as the direct consequences of a history of dislocations and the disruption of traditional subsistence patterns and connection to the land". However, conversely, the First Nation communities with more "cultural control" factors such as employment of First Nations people in key positions in the community (such as the police) and with increased community governance appear to have less suicide (Chandler & Lalonde 1998).

A response to the significant disadvantage of Canada's First Nations Peoples, very much developed in the spirit of primary health as outlined in the Ottawa Declaration was the Canadian Aboriginal Horizontal Framework (Canada's Performance 2005). This government policy was co-ordinated between the Canadian Federal government and Provincial governments to address the disadvantage in Canadian First Nation social determinants across a "wide front". Leadership from the top was a key initial factor in the development of the Framework with the then Canadian prime minister Paul Martin committing to a round table discussion with all levels of Canadian government and First Nation leaders. A policy retreat with members of the Canadian Committee on Aboriginal Affairs and First Nations leaders followed. There was also a commitment to the development of an Aboriginal report card to track progress with the Canadian health strategy.

The Canadian Aboriginal Horizontal Framework was then developed as a strategic guide to funding priorities and co-operation between the various levels of government as well as allowing the establishment of performance indicators. The Framework appears to place the

comment that First Nations people were removed to settlements that were chosen by government or mercantile interests rather than by the Indigenous Canadians themselves. This often resulted in major social dislocation for the community structures. In addition, from 1879 to 1973, there was a Government policy of removing First Nation children from their homes to church run boarding schools where their heritage was denigrated and suppressed. In addition, these children were subject to physical, emotional and sexual abuse

Indigenous First Nations Canadians have high unemployment rates (25%) compared to the general Canadian population (10%) with particularly high rates on reservations (31%) (MacMillan et al 1996). First Nations people generally live in poor housing and only a limited number of communities have adequate water and waste disposal (ibid). They have high infant mortality rates of 13.8 per 1000 live births for all Canadian Indian infants compared to 7.3 for all Canadian infants. Age standardised mortality ratios for Canadian First Nation women is almost double that for Canadian women generally whilst the aged standardised mortality rates for First Nation men is about 50% above that for Canadian men generally with higher death rates for men on reserves. The leading cause of death for Canadian First Nation people between 1986 and 1988 was injury and poisoning that accounted for 31% of all deaths in this population compared to 7.5% of all Canadians (ibid). Suicide rates for Indigenous Canadians are two to three times higher than Canadians generally. There is a particularly high suicide rate for the Inuit people with the suicide rate in Inuit youth being up to 5 times the rate of Canadian youth generally (ibid). Canadian First Nation communities also report high rates of alcohol abuse, other substance abuse and family violence (ibid) that are probably relevant is respect to the high suicide rates. Solvent abuse, including petrol, glue and cleaning products in isolated First Nation communities (ibid, p1576). Kirmayer et al (2000) also report that there are generally high rates of mental illness in many Indigenous Canadian communities. They note "the high rates of suicide, alcoholism and violence and the pervasive demoralisation seen in Aboriginal communities can be readily understood as the direct consequences of a history of dislocations and the disruption of traditional subsistence patterns and connection to the land". However, conversely, the First Nation communities with more "cultural control" factors such as employment of First Nations people in key positions in the community (such as the police) and with increased community

governance appear to have less suicide (Chandler & Lalonde 1998).

track progress with the Canadian health strategy.

A response to the significant disadvantage of Canada's First Nations Peoples, very much developed in the spirit of primary health as outlined in the Ottawa Declaration was the Canadian Aboriginal Horizontal Framework (Canada's Performance 2005). This government policy was co-ordinated between the Canadian Federal government and Provincial governments to address the disadvantage in Canadian First Nation social determinants across a "wide front". Leadership from the top was a key initial factor in the development of the Framework with the then Canadian prime minister Paul Martin committing to a round table discussion with all levels of Canadian government and First Nation leaders. A policy retreat with members of the Canadian Committee on Aboriginal Affairs and First Nations leaders followed. There was also a commitment to the development of an Aboriginal report card to

The Canadian Aboriginal Horizontal Framework was then developed as a strategic guide to funding priorities and co-operation between the various levels of government as well as allowing the establishment of performance indicators. The Framework appears to place the

(ibid).

"pillars" of health at equal value. The "pillars" were: Health, Lifelong Learning, Safe and Sustainable Communities, Housing, Economic Opportunity, Lands and resources and Governance and Relationships. Each of the "pillars" of the Framework was then be divided into "sub pillars". As an example, Safe and Sustainable communities were divided into: Community Infrastructure, Social Support and Community Well-being and Community Safety and Justice. Unfortunately, the policy appears to have been wound back following the election of the Conservative Government in Canada in 2006. However, the policy remains an important example of the way that a government can enact policy to remedy the broad range of disadvantage with financial "strategic pillars" attached to the relevant issues of "Primary Health" as outlined in the Ottawa Charter.

In Australia, Archaeological evidence suggests that Aboriginal people have been present for the last 45000-50,000 years. The ethnographic evidence from early contact suggests that Aboriginal people who survived infancy were relatively fit and disease free (Flood 2006). Further, Australia's native foods supported a nutritious, balanced diet of protein and vegetables with adequate vitamins and minerals with little salt sugar and fat. Life on the move kept people physically fit (ibid).

In terms of "mental health", traditional Aboriginal culture had a number of strong reinforcing factors that have been well defined by Professor(s) Helen and Jill Milroy (Milroy et al 2003). Aboriginal sense of self was seen in a collective sense, intimately connected to all aspects of life, community, spirituality, culture and country. The culture also provided for everyone through sharing rules and relationships and kinship were of prime importance, defining social roles. Aboriginal people were also given a sense of meaning and understanding of life experience through their connection to country and their Dreaming. Spiritual beliefs offered guidance and comfort and offered a sense of connectivity and belonging despite distress, death and loss. Lore, the body of knowledge that defined the culture and the tribal elders who contained and interpreted the Lore were highly valued. Customary law defined rules and consequences. Over 200 traditional languages and other methods of communication allowed a rich expression of interaction in the above social context and formal ceremony allowed a method of dealing with life's transitions thought birth, initiation and death. Men and women had defined economic and cultural roles within the tribe. Children were well protected within the group with a range of "aunties" and older siblings able to take over the child care role if the mother was stressed.

Franklin and White (1991) describe the elements of destruction of this optimum physical and mental good health of the Aboriginal people following the British colonization of Australia in 1788. These elements were the introduction of new diseases, the removal of ancestral land which led to psychological distress and spiritual despair and the herding of Aboriginal people into reserves and settlements, destroying lifestyle and leading to marginalisation and poverty. Other specific policies such as the Stolen Generations from the 1930s to the 1960s where Aboriginal children were forcibly removed from their parents and raised in Mission settlements reinforced government social Darwinist ideology and led to the destruction of family life with resulting emotional desolation for many individual Aboriginal people.

The current significant disadvantage of Aboriginal health and social determinants is well recognized. Hospitalization rates for cardiovascular disease in Aboriginal and Torres Strait Islander was 80% higher than for other Australians in the North West of Australia in 2002 to 2004. (AHMAC 2006) Rheumatic heart disease was nine times more common for Aboriginal and Torres Strait Islanders than other Australians (ibid). Diabetes and renal failure also figure prominently in Aboriginal health issues. In 2004-2005, three times as many Aboriginal

A New Economic and Social Paradigm for Funding Mental Health in the Twenty First Century 221

interdependent foundations to current Aboriginal and Torres Strait Islander disadvantage in Australia. Poor economic and social incentives, the underdevelopment of human capital and an absence of the effective engagement of Aboriginal and Torres Strait Islander Australians in the design of policy frameworks that might improve these incentives and capabilities. Henry commented that he and other Secretaries in the Australian Government Secretaries Group on Aboriginal and Torres Strait Islander Affairs had identified seven platforms that need to be prioritized within a framework of Aboriginal and Torres Strait Islander capability development. These included: basic protective security for women and children, early childhood development, a safe and healthy home environment, an accessible primary care health service, ensuring that incentives in the welfare system do not work against promotion of investment in human capital, real job prospects as a result of education and governance systems that support political freedom and social opportunities of local Indigenous people

The proposal by Henry resulted in the formation of the Council of Australian Governments National Indigenous Reform Agreement in 2008. The building blocks of the strategic financial agreement between the Australian Federal and State Governments were based on the primary care principles outlined in the Ottawa Charter. The Building Blocks outlined by the Agreement are: Early Childhood (early learning, development and socialization opportunities), Schooling (infrastructure, workforce, curriculum, student literacy and numeracy achievement. and opportunities for parental engagement and school/community partnerships), Health (access to effective, comprehensive primary and preventative health care), Economic Participation ( real jobs, business opportunities, economic independence and wealth creation), Healthy Homes (adequate water and sewerage systems, waste collection electricity and housing infrastructure), Safe Communities (improved, accessible law and justice responses, effective policing. "safe houses", child protection and alcohol policy) and Governance and Leadership (capacity building so that Indigenous Australians can play a greater role in exercising their rights and responsibilities as citizens) (COAG 2008). The Agreement also has specific funding of \$ 4.6 Billion overall for the "Building Blocks" to allow their progression by the Australian Commonwealth and State governments. COAG continues to monitor the progress and

The above discussion of government programs for the Indigenous peoples of Canada and Australia shows that government is able to construct realistic funded policy initiatives based

The Recovery Movement in mental health has gained increasing momentum in recent years. Leff & Warner (2006) note that " the model refers both to the subjective experiences of hope, healing, empowerment and interpersonal support experienced by people with mental illness, their carers and service providers and to the creation of recovery-oriented services that engender a positive culture of healing and a support for human rights". The authors add that, as a result of the Recovery Movement, there is renewed interest in fighting the stigma that leads people with mental illness to lose their sense of self, to provide access to the services and education that give consumers the knowledge and skills to manage their illness, empowering consumers to share responsibility with providers in the healing process and providing access to peer support that validates the possibility of recovery (ibid). Recent discussion about the Recovery Movement has also focused on the "capabilities" approach of

on the accepted international principles defining primary health.

**5. The Recovery Movement in mental health** 

to be engaged in policy development.

outcomes of the funding strategy.

and Torres Strait Islanders were reported to have diabetes compared to other Australians (ibid). Hospitalization rates for Aboriginal and Torres Strait Islander people with diabetes are six times higher than for other Australians (ibid). End Stage Renal Disease, often the consequence of poorly controlled diabetes was eight times higher for Aboriginal and Torres Strait Islander peoples than other Australians (ibid). Given these alarming health statistics, it is not surprising that life expectancy for Aboriginal and Torres Strait Islander people is 17 years less than for other Australians (ibid), an issue now well recognized in the "CLOSETHEGAP" (HREOC 2008) agenda.

Aboriginal and Torres Strait Islander disadvantage is also apparent in other social indices. The 2002 National Aboriginal and Torres Strait Islander Social Survey estimated that 26% of the Aboriginal and Torres Strait Islander population over 15 were living in overcrowded housing. The overcrowding becomes more apparent in remote areas where it is estimated that 62% of Aboriginal and Torres Strait Islanders live in overcrowded housing (AHMAC 2006). In respect to education, the National Schools Statistics Collection reported that the retention rate of Aboriginal and Torres Strait Islander students in Year 7/8 to Year 10 was 88.3% compared to 98.6% for other students. Unfortunately, the retention rate for Aboriginal and Torres Strait Islander students from Year7/8 to year 12 of high school was only 39.5% compared to 76.6% for other students (ibid). Given this trend in education, the accompanying statistics of significant Aboriginal and Torres Strait Islander disadvantage in employment and income to the rest of Australia are no surprise along with data from the prisons that shows that Aboriginal and Torres Strait Islander people are twelve times more likely to be in prison compared to the remainder of the Australian population (ibid).

Poverty and racism also provide a framework for the above statistics. Walter & Saggers (2007) point to the significant association between poverty and adverse health outcomes. They note that a significant proportion of Australia's Indigenous population live in a situation of "absolute poverty" as defined by the United Nations where they have severe deprivation of basic human needs including food, safe drinking water, sanitation facilities, health, shelter education and information. Some diseases such as scabies and diarrhea are directly related to inadequate sanitation and living conditions (ibid). The issues of Indigenous poverty appear particularly marked in rural areas. In addition, the failure of a recent plethora of policies to advance Aboriginal health has been attributed to a pervasive culture of "welfare colonialism", an aspect of continuing poverty. "Welfare Colonialism" (Anderson 1997) affects Aboriginal communities where most Aboriginal populations rely heavily on the provision of public sector resources. Over time, the mechanisms to deliver these overlie the traditional methods of Aboriginal governance, reducing the capacity of the communities to develop leadership in the solutions to their problems. In addition, the continuing experience of widespread racism against Aboriginal people generally within the Australian community appears to have a continuing negative effect, particularly on the mental health of Aboriginal people (Paradis 2007).

The Australian government policy environment has also recently produced a number of innovative solutions in respect of government approaches to the above Aboriginal and Torres Strait Islander disadvantage leading to the formal Council of Australian Governments financial funding strategy, the National Indigenous Reform Agreement. The Agreement in 2008 was prefaced by a paper written by Ken Henry, Secretary of the Australian Treasury. Henry (2007) suggested a broad based approach across Australian Government Departments to address Aboriginal and Torres Strait Islander health disadvantage, similar in some ways to the Canadian Framework. Henry described three key

and Torres Strait Islanders were reported to have diabetes compared to other Australians (ibid). Hospitalization rates for Aboriginal and Torres Strait Islander people with diabetes are six times higher than for other Australians (ibid). End Stage Renal Disease, often the consequence of poorly controlled diabetes was eight times higher for Aboriginal and Torres Strait Islander peoples than other Australians (ibid). Given these alarming health statistics, it is not surprising that life expectancy for Aboriginal and Torres Strait Islander people is 17 years less than for other Australians (ibid), an issue now well recognized in the

Aboriginal and Torres Strait Islander disadvantage is also apparent in other social indices. The 2002 National Aboriginal and Torres Strait Islander Social Survey estimated that 26% of the Aboriginal and Torres Strait Islander population over 15 were living in overcrowded housing. The overcrowding becomes more apparent in remote areas where it is estimated that 62% of Aboriginal and Torres Strait Islanders live in overcrowded housing (AHMAC 2006). In respect to education, the National Schools Statistics Collection reported that the retention rate of Aboriginal and Torres Strait Islander students in Year 7/8 to Year 10 was 88.3% compared to 98.6% for other students. Unfortunately, the retention rate for Aboriginal and Torres Strait Islander students from Year7/8 to year 12 of high school was only 39.5% compared to 76.6% for other students (ibid). Given this trend in education, the accompanying statistics of significant Aboriginal and Torres Strait Islander disadvantage in employment and income to the rest of Australia are no surprise along with data from the prisons that shows that Aboriginal and Torres Strait Islander people are twelve times more

likely to be in prison compared to the remainder of the Australian population (ibid).

Poverty and racism also provide a framework for the above statistics. Walter & Saggers (2007) point to the significant association between poverty and adverse health outcomes. They note that a significant proportion of Australia's Indigenous population live in a situation of "absolute poverty" as defined by the United Nations where they have severe deprivation of basic human needs including food, safe drinking water, sanitation facilities, health, shelter education and information. Some diseases such as scabies and diarrhea are directly related to inadequate sanitation and living conditions (ibid). The issues of Indigenous poverty appear particularly marked in rural areas. In addition, the failure of a recent plethora of policies to advance Aboriginal health has been attributed to a pervasive culture of "welfare colonialism", an aspect of continuing poverty. "Welfare Colonialism" (Anderson 1997) affects Aboriginal communities where most Aboriginal populations rely heavily on the provision of public sector resources. Over time, the mechanisms to deliver these overlie the traditional methods of Aboriginal governance, reducing the capacity of the communities to develop leadership in the solutions to their problems. In addition, the continuing experience of widespread racism against Aboriginal people generally within the Australian community appears to have a continuing negative effect, particularly on the

The Australian government policy environment has also recently produced a number of innovative solutions in respect of government approaches to the above Aboriginal and Torres Strait Islander disadvantage leading to the formal Council of Australian Governments financial funding strategy, the National Indigenous Reform Agreement. The Agreement in 2008 was prefaced by a paper written by Ken Henry, Secretary of the Australian Treasury. Henry (2007) suggested a broad based approach across Australian Government Departments to address Aboriginal and Torres Strait Islander health disadvantage, similar in some ways to the Canadian Framework. Henry described three key

"CLOSETHEGAP" (HREOC 2008) agenda.

mental health of Aboriginal people (Paradis 2007).

interdependent foundations to current Aboriginal and Torres Strait Islander disadvantage in Australia. Poor economic and social incentives, the underdevelopment of human capital and an absence of the effective engagement of Aboriginal and Torres Strait Islander Australians in the design of policy frameworks that might improve these incentives and capabilities. Henry commented that he and other Secretaries in the Australian Government Secretaries Group on Aboriginal and Torres Strait Islander Affairs had identified seven platforms that need to be prioritized within a framework of Aboriginal and Torres Strait Islander capability development. These included: basic protective security for women and children, early childhood development, a safe and healthy home environment, an accessible primary care health service, ensuring that incentives in the welfare system do not work against promotion of investment in human capital, real job prospects as a result of education and governance systems that support political freedom and social opportunities of local Indigenous people to be engaged in policy development.

The proposal by Henry resulted in the formation of the Council of Australian Governments National Indigenous Reform Agreement in 2008. The building blocks of the strategic financial agreement between the Australian Federal and State Governments were based on the primary care principles outlined in the Ottawa Charter. The Building Blocks outlined by the Agreement are: Early Childhood (early learning, development and socialization opportunities), Schooling (infrastructure, workforce, curriculum, student literacy and numeracy achievement. and opportunities for parental engagement and school/community partnerships), Health (access to effective, comprehensive primary and preventative health care), Economic Participation ( real jobs, business opportunities, economic independence and wealth creation), Healthy Homes (adequate water and sewerage systems, waste collection electricity and housing infrastructure), Safe Communities (improved, accessible law and justice responses, effective policing. "safe houses", child protection and alcohol policy) and Governance and Leadership (capacity building so that Indigenous Australians can play a greater role in exercising their rights and responsibilities as citizens) (COAG 2008). The Agreement also has specific funding of \$ 4.6 Billion overall for the "Building Blocks" to allow their progression by the Australian Commonwealth and State governments. COAG continues to monitor the progress and outcomes of the funding strategy.

The above discussion of government programs for the Indigenous peoples of Canada and Australia shows that government is able to construct realistic funded policy initiatives based on the accepted international principles defining primary health.

### **5. The Recovery Movement in mental health**

The Recovery Movement in mental health has gained increasing momentum in recent years. Leff & Warner (2006) note that " the model refers both to the subjective experiences of hope, healing, empowerment and interpersonal support experienced by people with mental illness, their carers and service providers and to the creation of recovery-oriented services that engender a positive culture of healing and a support for human rights". The authors add that, as a result of the Recovery Movement, there is renewed interest in fighting the stigma that leads people with mental illness to lose their sense of self, to provide access to the services and education that give consumers the knowledge and skills to manage their illness, empowering consumers to share responsibility with providers in the healing process and providing access to peer support that validates the possibility of recovery (ibid). Recent discussion about the Recovery Movement has also focused on the "capabilities" approach of

A New Economic and Social Paradigm for Funding Mental Health in the Twenty First Century 223

Since the early 1990's, the Federal, in co-ordination with the State and Territory Governments of Australia have developed four successive mental health plans through the Australian Council of Health Ministers. The most recent plan of 2009-2014 has the following

The authors of the plan note that "the plan is ambitious in its approach and for the first time includes a robust accountability framework. Each year, governments will report progress on implementation of the plan to the Council of Australian Governments. The plan includes indicators for monitoring change in the way the mental health system is working for people living with mental illness as well as their families and carers. Health ministers have agreed to develop targets and data sources for each of the indicators in the first twelve months of the plan." (ibid). Although the plan stresses "A Whole of Government Approach", it is unlikely that it will develop the appropriate sustained funding strategy to support outcomes similar to that initiated by the Council of Australian Governments National Action Plan on Mental Health 2006-2011 (COAG 2006), a government response to substantial deficiencies in public mental health provision outlined in the "Not For Service" Report (MHCA 2005). This contrasts with the normal rather disorganised system of mental health funding in Australia where one recent review (AHHA et al 2008) commented "there is still no single agency, organization or level of government with the remit and responsibility for the setting of strategic mental health policy or for the oversight, monitoring or operationalisation of mental health care. Funding methodologies and funding amounts vary between jurisdictions and have traditionally not been based on population need. This and the range of agencies and providers involved in the provision of mental health care has lead to

The Canadian Government established the Mental Health Commission for Canada in 2007. After extensive consultation with a range of stakeholders in Canada, the Commission published it's strategy document in 2009 (MHCC 2009). The strategy has seven goals: the engagement of people suffering from mental illness in the process of recovery, mental health promotion and mental illness prevention, a responsive mental health system, recognition of the role of families, equitable and timely access to effective treatments and support, actions informed by best evidence with measurable outcomes and support for research and social inclusiveness (ibid). The Commission was allocated \$130 million by the Canadian Federal Government for 10 years in 2008 with the money being targeted towards the three key initiatives of the Commission which were to conduct a 10-year anti-stigma campaign, build a pan-Canadian Knowledge Exchange Centre, and elaborate a national mental health strategy for Canada (Government of Canada 2008). However, there does not appear to be any overall funding strategy for mental health in Canada apart from this with services being provided through it's Medicare system and mental health services bundled in with other general health services through the Regional Funding Authorities within each Province (Block et al 2008) It has been estimated that funding of mental health for Canada in 2003- 2004 was 5% of total health spending which was lower than most developed countries (Jacobs et al 2008). Other authors have argued that the funding models of Medicare in Canada have led to the restriction of community services and other professional services

five priority areas for government action in mental health:

3. Service access, coordination and continuity of care

inequities in access, service provision and health outcomes".

5. Accountability - measuring and reporting progress. (DOHA 2009)

4. Quality improvement and innovation and

1. Social inclusion and recovery 2. Prevention and early intervention

Amartya Sen. Davidson et al (2010) note "the capabilities approach diverts our attention away from the possession of resources to the exercise of freedoms. This shift is not meant to deny the crucial role that resources play in social and political life but rather places emphasis on the fact that the usefulness of wealth lies in the things that it allows us to dothe substantive freedoms it helps us to achieve". The authors go on to argue that Sen's concepts of active agency and freedoms should apply to the "here and now" in respect to people's choices on a daily basis rather than some theoretical ideal future. In addition, the pursuit of agency generates diversity as each individual will pursue such agency according to individual need and a supporting system needs to accommodate such diversity (ibid). The end result should be to "increase the access of people with serious mental illness to opportunities and supports that allow them to live a decent and self determined quality of life" (ibid). Sen's economic concepts are also closely aligned to emerging discussions of social capital that are discussed later in the chapter.

Piat et al (2010) review a range of government initiatives to develop the recovery model. The US President's New Freedom Commission identified a fragmented health system and gaps in care as obstacles to recovery and this led to all 50 US States adopting recovery mission statements and implementing at least one evidence-based service. In New Zealand, discrimination and stigma were identified as most problematic and this led to a significantly enhanced role for psychiatric patients (consumers) within the system with good consumerprovider being identified as a key indicator for recovery orientated services (ibid).

Unfortunately, the economic basis of supporting effective recovery does not appear to have matched the theoretical process of empowerment and particularly so in the developed world. The observation that people suffering from schizophrenia often have a better outcome from disease in the third world (Warner 1986) may be related to the situation where economic opportunity (such as having meaningful work on a family farm or in a family kitchen) along with a place to sleep and adequate diet may be much easier to provide within the economic restraints and social supports of third world countries. Warner (ibid) has also commented on the nature of work in less developed countries that may be protective for someone suffering from severe mental illness. He notes that the person's family is less likely to emotionally smother the individual and the tasks allocated to the individual are likely to be geared to the level of performance that the person can actually achieve. In comparison, the costs of providing adequate housing and meaningful employment to individuals in developed countries are often significantly higher. In addition, it often has been difficult for governments to provide coordinated sustained funding for such programs across a range of different government departments that have responsibility for each program. The difficult task of addressing the above issues in the developed world is exemplified in a recent evaluation of the cost of mental illness in Canada in 2003. The review found that the cost of undiagnosed mental illness was about 28% of a total cost of \$50,847 million dollars with direct medical costs of treating mental illness contributing only about 10% of this amount with the remainder being attributed to lost productivity (Lim et al 2008).

#### **6. The Australian mental health plans and the Canadian Mental Health Commission**

Federal Governments in both Australia and Canada have attempted to develop strategies to enhance services for those people affected by severe mental illness in a variety of ways. Since the early 1990's, the Federal, in co-ordination with the State and Territory Governments of Australia have developed four successive mental health plans through the Australian Council of Health Ministers. The most recent plan of 2009-2014 has the following five priority areas for government action in mental health:

1. Social inclusion and recovery

222 Health Management – Different Approaches and Solutions

Amartya Sen. Davidson et al (2010) note "the capabilities approach diverts our attention away from the possession of resources to the exercise of freedoms. This shift is not meant to deny the crucial role that resources play in social and political life but rather places emphasis on the fact that the usefulness of wealth lies in the things that it allows us to dothe substantive freedoms it helps us to achieve". The authors go on to argue that Sen's concepts of active agency and freedoms should apply to the "here and now" in respect to people's choices on a daily basis rather than some theoretical ideal future. In addition, the pursuit of agency generates diversity as each individual will pursue such agency according to individual need and a supporting system needs to accommodate such diversity (ibid). The end result should be to "increase the access of people with serious mental illness to opportunities and supports that allow them to live a decent and self determined quality of life" (ibid). Sen's economic concepts are also closely aligned to emerging discussions of

Piat et al (2010) review a range of government initiatives to develop the recovery model. The US President's New Freedom Commission identified a fragmented health system and gaps in care as obstacles to recovery and this led to all 50 US States adopting recovery mission statements and implementing at least one evidence-based service. In New Zealand, discrimination and stigma were identified as most problematic and this led to a significantly enhanced role for psychiatric patients (consumers) within the system with good consumer-

Unfortunately, the economic basis of supporting effective recovery does not appear to have matched the theoretical process of empowerment and particularly so in the developed world. The observation that people suffering from schizophrenia often have a better outcome from disease in the third world (Warner 1986) may be related to the situation where economic opportunity (such as having meaningful work on a family farm or in a family kitchen) along with a place to sleep and adequate diet may be much easier to provide within the economic restraints and social supports of third world countries. Warner (ibid) has also commented on the nature of work in less developed countries that may be protective for someone suffering from severe mental illness. He notes that the person's family is less likely to emotionally smother the individual and the tasks allocated to the individual are likely to be geared to the level of performance that the person can actually achieve. In comparison, the costs of providing adequate housing and meaningful employment to individuals in developed countries are often significantly higher. In addition, it often has been difficult for governments to provide coordinated sustained funding for such programs across a range of different government departments that have responsibility for each program. The difficult task of addressing the above issues in the developed world is exemplified in a recent evaluation of the cost of mental illness in Canada in 2003. The review found that the cost of undiagnosed mental illness was about 28% of a total cost of \$50,847 million dollars with direct medical costs of treating mental illness contributing only about 10% of this amount with the remainder being attributed to lost

provider being identified as a key indicator for recovery orientated services (ibid).

**6. The Australian mental health plans and the Canadian Mental Health** 

Federal Governments in both Australia and Canada have attempted to develop strategies to enhance services for those people affected by severe mental illness in a variety of ways.

social capital that are discussed later in the chapter.

productivity (Lim et al 2008).

**Commission** 


The authors of the plan note that "the plan is ambitious in its approach and for the first time includes a robust accountability framework. Each year, governments will report progress on implementation of the plan to the Council of Australian Governments. The plan includes indicators for monitoring change in the way the mental health system is working for people living with mental illness as well as their families and carers. Health ministers have agreed to develop targets and data sources for each of the indicators in the first twelve months of the plan." (ibid). Although the plan stresses "A Whole of Government Approach", it is unlikely that it will develop the appropriate sustained funding strategy to support outcomes similar to that initiated by the Council of Australian Governments National Action Plan on Mental Health 2006-2011 (COAG 2006), a government response to substantial deficiencies in public mental health provision outlined in the "Not For Service" Report (MHCA 2005). This contrasts with the normal rather disorganised system of mental health funding in Australia where one recent review (AHHA et al 2008) commented "there is still no single agency, organization or level of government with the remit and responsibility for the setting of strategic mental health policy or for the oversight, monitoring or operationalisation of mental health care. Funding methodologies and funding amounts vary between jurisdictions and have traditionally not been based on population need. This and the range of agencies and providers involved in the provision of mental health care has lead to inequities in access, service provision and health outcomes".

The Canadian Government established the Mental Health Commission for Canada in 2007. After extensive consultation with a range of stakeholders in Canada, the Commission published it's strategy document in 2009 (MHCC 2009). The strategy has seven goals: the engagement of people suffering from mental illness in the process of recovery, mental health promotion and mental illness prevention, a responsive mental health system, recognition of the role of families, equitable and timely access to effective treatments and support, actions informed by best evidence with measurable outcomes and support for research and social inclusiveness (ibid). The Commission was allocated \$130 million by the Canadian Federal Government for 10 years in 2008 with the money being targeted towards the three key initiatives of the Commission which were to conduct a 10-year anti-stigma campaign, build a pan-Canadian Knowledge Exchange Centre, and elaborate a national mental health strategy for Canada (Government of Canada 2008). However, there does not appear to be any overall funding strategy for mental health in Canada apart from this with services being provided through it's Medicare system and mental health services bundled in with other general health services through the Regional Funding Authorities within each Province (Block et al 2008) It has been estimated that funding of mental health for Canada in 2003- 2004 was 5% of total health spending which was lower than most developed countries (Jacobs et al 2008). Other authors have argued that the funding models of Medicare in Canada have led to the restriction of community services and other professional services

A New Economic and Social Paradigm for Funding Mental Health in the Twenty First Century 225

As a way of attempting to improve the co-ordination of the care of medical illness in those patients with serious mental illness, there has been a significant stimulus to develop shared care models between psychiatric specialists and general practitioners. Such models include a Consultation-Liaison model (Gask et al 1997), collaborative case discussions between specialist psychiatrists and groups of General Practitioners (Davies et al 1997) and shared care projects with extensive education for involved General Practitioners (Meadows 1998). There have also been substantive improvements in remuneration for shared care in

The General Practice Clinic operated within a mental health service (Symonds & Parker 2007) compensates for a number of the barriers to health engagement discussed above and allows for a high quality of health care with extended clinical review times and health screening significantly above the Australian national average. Other recommendations for improved health care for people suffering from severe mental illness are: improved health screening and health promotion along with systemic models of medical and mental health care integration such as the VHA system in the USA (Viron & Stern 2010). Increased awareness by psychiatrists of the metabolic effects of psychotropic medication along with improved information to carers of people affected by severe mental illness in respect to appropriate medical care (De Hert et al 2010). Better co-ordination of a range of specialist services such as occupational therapists, pharmacists and dieticians in respect to the medical health care of people affected by severe mental illness may also be useful (Heald et al 2010).

A socially inclusive society is defined as one where all people feel valued, their differences are respected, and their basic needs are met so they can live in dignity. Social exclusion is the process of being shut out from the social, economic, political and cultural systems which contribute to the integration of a person into the community (Cappo 2002). Leff & Warner (2006) have outlined factors that lead to social exclusion for people affected by severe mental illness. These include the disabilities produced by the illness itself (such as the negative features of schizophrenia which include apathy and reluctance to engage with others), disabilities produced by professional care (including institutionalization and side effects of medication), stigmatizing attitudes of the public and self stigma of individuals (which may affect recognition of illness and ability to obtain appropriate treatment), media influences,

Some of these factors are going to be considered in other sections of this chapter. The key focus on this area of social inclusion in the current context is addressing stigma and the maintenance of people suffering from severe mental illness within their social group. Sartorius (2010) discusses a range of barriers to effective campaigns to reduce stigma. He notes that anti-stigma campaigns have to be longer than a year to be effective. Sartorius comments that other factors that have been proven to reduce stigma such as legislation to effect employment and housing, ongoing promotion of useful strategies (such as education of health care professionals, public education forums for members of the public by people who have suffered from mental illness and avoidance of pejorative comments in the media) and permanent networks of interested business people, professionals, patients and their

To an extent, the *headspace* Model of Care for young people suffering from severe mental illness in Australia attempts to fulfill some of the above requirements in an organizational

poverty and discrimination in housing and employment.

families that respond to local issues within cultures and communities.

Australia with the Medicare Plus program encouraging a collaborative care mode.

**9. Social Inclusion** 

such as psychologists for people suffering from mental illness (Mulvale et al 2007, Moulding et al 2009)
