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

Robert Parker *Northern Territory Clinical School, Darwin, Northern Territory, Australia* 

#### **1. Introduction**

214 Health Management – Different Approaches and Solutions

Young, F. W. (2001). An Explanation of the Persistent Doctor-Mortality Association. *Journal* 

Mental illness is a significant factor in disease related disability throughout the world. About 16% of the global burden of disease not attributable to communicable disease has been attributed to mental disorders (Prince et al 2007) with substance abuse disorders contributing to a further 4% of this burden (ibid). In Australia, "Mental Disorders" were considered to be the third major cause of health loss (behind cancer and cardiovascular disease) in 2003 but were estimated to increase at a significant rate to move ahead of cancer and become the second major cause of "health loss" by 2013 (Begg et al 2008). This burden of mental illness is particularly pronounced in the youth of Australia with disabilityadjusted life years (DALY's) for mental illness calculated to be above 90,000 (compared to the next highest of 48,000 DALY's due to injury) for the 15 to 24 year old age group in 2003 (Eckersley 2011). Along with the current burden of disease attributed to mental illness, there is a number of challenges facing societies in the developed and developing world that are likely to lead to an increase in mental illness. Sartorius (pers comm) has recently outlined some of these challenges. They include: weakening of community resilience mechanisms, increasing awareness of gaps and unreachable opportunities, migration of people, talents and capital with the subsequent loss of social capital in some societies, the challenges of increased urbanisation on community supports and family structures, the changing nature of privileged families in developed society with less children, longer life spans and more fragile family structures, the decrease of middle class "norms" in developed countries and the additional increase of the middle class in developing countries with potential economic and social alienation from less privileged groups, the changing role of women and the implications that this has for child care and care of the elderly and the changing paradigms of medicine itself with increasing use of technology in addition to evolving ethical issues such as euthanasia.

The severity of personal disability from mental illness is pervasive.

The poetry of Anne Sexton in the poem "Sickness unto Death" (1977) helps describe some of this inner experience for severe mood disorder:

A New Economic and Social Paradigm for Funding Mental Health in the Twenty First Century 217

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

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.

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

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

**4. Effective funding models for primary health care: The indigenous** 

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

lives in ways that have real meaning and real value….".

on the desire to enhance substantive freedoms as promoted

**paradigm in Canada and Australia** 

*"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)

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

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