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Mental Health Policy Responses in Chile to Challenges posed by the COVID-19 Pandemic

By: Matias Irarrazaval MD MPH, Child and Adolescent Psychiatrist, Director of Mental Health , Ministry of Health, Chile mirarrazavald@uchile.cl

Starting on June 1, 2020, SaludableMente was one of three presidential mental health programs launched during the pandemic. It included the intersectoral participation of nine ministries.

The Covid-19 pandemic, an unprecedented global socio-sanitary crisis, has impacted the mental health of the general population worldwide,  and particularly that of individuals with prior mental illness, those infected with SARS-CoV-2, and health workers (1). The exact extent of this impact has varied by country, as it is strongly shaped by local mental health policies that were implemented as part of the initial response to the pandemic (2)(3). The pre-pandemic development of each country’s mental health system, and its unique socio-economic context, largely define its ability to implement the proposed policies, especially in light of the economic recession that could deepen inequalities in access to and quality of mental health care (4). Under these circumstances, mental disorders co-occur with other chronic diseases that are rooted in social and economic inequities (5)(6).

Policies can play a relevant role in mitigating the impact of crises on mental health, either through new initiatives or by deepening health systems reforms, aimed at uplifting communities and increasing user participation (7)(8). Health systems across the Americas often lack resources to develop mental health services in response to crises, which results in an imbalance between the burden of mental disorders and the allocated mental health budget. There is also a wide variation between countries: before the pandemic, it was estimated that this imbalance ranged from 1.8 to 72.1 times the burden of mental illness in relation to spending, with a median of 6.1 in the region (9).

During the first stages of the pandemic, the Americas concentrated the largest number of COVID-19 cases in the world. The first confirmed case in Latin America was registered in Brazil (February 2020), and the first case in Chile was confirmed on March 3rd (10). Chile has a decades-long trajectory of promoting community-based mental health, with mental health services integrated into primary health care centers and general hospitals, in a consistent and sustained way, as outlined in three national mental health plans (from 1993, 2000, and 2017). Before the pandemic, these plans had achieved greater access to community care for people with mental illness, trained mental health workers in the community model,  developed evidence-based, technical guidelines that have improved the quality of care and contributed to a progressive construction of an information system on mental health services. Nevertheless, strategies to encourage user involvement in mental health services have been insufficient (11)(12). Although the public budget is growing, there is a significant gap between what is laid out in the country’s mental health plans and the reality of services.

The proportion of the total burden of disease attributable to mental disorders is 9.6 times the proportion of the health budget allocated to mental health (11). The current national mental health plan (2017-2025) includes cross-cutting principles and approaches, such as the respect and promotion of human rights, people-centered health services and equity, evidence-based practices, life-course and multisectoral interventions, and empowerment of persons with mental disorders and psychosocial disabilities. The plan prioritizes seven pillars of action: (i) policy, law, and human rights; (ii) mental health services; (iii) financing the mental health system; (iv) quality, information, and research systems; (v) human resource development; (vi) social participation, and (vii) intersectoral coordination (13).

Chile faced the start of the pandemic in the midst of a profound social and political crisis. In October 2019, a popular uprising emerged, demanding social justice and equity in numerous areas, including health (14). This ‘Social Outburst,’ triggered by secondary students in the face of a rise in the price of  metro tickets, paralyzed the country. Demonstrations in the streets turned violent and questioned the legitimacy of institutions, such as the police, military, and the political system. The political crisis gave rise to a referendum for a new constitution, which was postponed because of the pandemic but ultimately passed with overwhelming public support on October 25th, 2020.

Calls for greater equity in access to health services, in particular for mental health, foreshadowed the impact of the COVID-19 pandemic on mental health; the public health crisis has deepened social unrest and increased demands on the health system. For the first time, traditional political opinion polls incorporated questions about mental health (15), and 49.3% of the respondents said that their mood worsened during the pandemic (feelings of rage, sadness, fear), although 15% perceived that it improved. Toward the beginning of the pandemic, a presidential commission known as the ‘National Social Committee,’ made up of national and local government representatives, health specialists, and academics was formed to “strengthen the country’s strategy and organize a single voice in the fight against the coronavirus,” and the Committee incorporated mental health into the national plan to confront the pandemic (16).

Policy responses to the mental health challenges derived from the COVID-19 pandemic in Chile, may play a relevant role in mitigating the pandemic’s impact on the population’s mental health if they are integrated within the pre- pandemic mental health policy framework and service trajectory.

Mental Health and Disaster Risk Management Model

Chile began developing a Mental Health Care and Disaster Risk Management (MHCDRM) Model in 2018, in collaboration with Japan. The evidence-based model highlights national experience gleaned through major natural disasters that have affected Chile, and it complies with international humanitarian standards. Essential elements of the model include reducing vulnerability through strengthening community resilience and capacities and focusing on preventive, rather than reactive, interventions. It proposes the implementation of mental health and psychosocial support (MHPSS) actions throughout the risk management cycle and effective disaster risk reduction, adopting the integration of interventions at different levels, according to the Inter-Agency Standing Committee’s (IASC) recommendations (2). The MHCDRM Model is organized in eight strategic pillars – (i) intersectoral coordination; (ii) information management; (iii) social communication; (iv) community empowerment; (v) education; (vi) focus on vulnerable groups; (vii) technical guidelines; and (viii) care for frontline workers – and has led to the implementation of intersectoral mental health and psychosocial support committees and the development of a psychological first aid (PFA) training plan, which has a network of over 900 trainers and has produced more than ten thousand people qualified to provide PFA throughout the country.

Though the Quintero-Puchuncaví socio-environmental conflict and the social uprisings that recently affected the country were very different types of crises, they both effectively used the MHCDRM Model. In both emergencies, mental health was included in the first line of response, for the very first time, and the Model was relevant to define and organize pertinent actions. This Model has also been used as a referential framework to implement strategies to protect mental health during the COVID-19 pandemic, including strategies, focused on providing mental health support and responding to the psychosocial needs of specific groups that are in greater biopsychosocial vulnerability (17).

COVID-19 Mental Health Action Plan, headed by the Ministry of Health

To articulate and organize multiple interventions to protect mental health during the COVID- 19 pandemic, an action plan on Mental Health was developed by the Ministry of Health. The plan includes seven areas of action (Table 1): (i) Continuity of care and strengthening of mental health services; (ii) Intersectoral coordination; (iii) Specific populations; (iv) Care of the healthcare workforce; (v) Community strengthening and social communication; (vi) Information management; and (vii) Training and technical guidelines for the intervention.

As part of the implementation process of the plan, mental health care in primary health centers and outpatient specialty services were improved (18), and mental health services were incorporated into the rural and remote health care facilities. Additionally, inpatient psychiatric services were adapted to meet COVID-19 protocols, registration systems were updated, and an online monitoring system for the mental health network was developed.

Another achievement was the organization of a Mental Health Personnel Commission in the Ministry of Health, which recommended the implementation of a nationwide institutional care program with psychological support strategies for healthcare workers (19). To support this process, technical recommendations were distributed (20).

Furthermore, online and telephone support services were made available for health workers and the general population. With over 100 helplines from academic and civil society initiatives, a national registry was built, to strengthen technical capacities and coordinate actions, establishing referral flowcharts, and management protocols. These developments are detailed in two bulletins that provide information on remote mental health helplines and psychosocial support in the context of COVID-19 (21)(22).

Another relevant initiative within the framework of the plan was the organization of webinars and teleconferences, as an education and training strategy, targeting the workforce of health and social programs, to improve their preparation to provide psychosocial support for COVID-19 patients and their families. (23)(24)(25).

The framework set forth by the Mental Health Action Plan during COVID-19 continues to support the organization, implementation, and monitoring of public policy responses to the pandemic.

National Social Committee: Mental Health Strategy on the Political Agenda

The National Social Committee worked on a national strategy for mental health, formulated by researchers and academics from the Universidad de Chile. Their proposal was subsequently enriched with the contributions of other committee members and academics from other universities. The final strategy included mental health guidelines from the Ministry of Health and recommended adopting an intervention pyramid to provide mental health and psychosocial support during emergencies (2). As such, mental health became a part of the national pandemic response. The Strategy called for the protection of individuals who were most vulnerable to experiencing mental health crises during and after the pandemic, and it declared that efforts should not be limited to simply providing intensive care in hospitals. The main message was that “mental health is one of the keys to surviving this pandemic and all that it entails in the short, medium, and long term, from preventing a potential crisis in the provision of health services, to preserving and rebuilding a post-pandemic society” (26).

The strategy includes three goals: (i) to reduce population risk by strengthening psychosocial protective factors for mental health; (ii) to facilitate access to comprehensive, equitable, and quality mental health services; and (iii) to develop knowledge, practices, and mental health competencies among mental health workers. The document states that mental health policy must meet four criteria: (i) territorial articulation; (ii) intersectoral action; (iii) user involvement and participation; and (iv) economic, social, and human development. This statement emphasizes the need to conduct community-based interventions, and work with social institutions, to avoid reducing mental health problems to an individual level. The mental health policy thus conceived a ‘comprehensive perspective, without prioritizing economic factors over social and human ones’, to respond to the pandemic.

SaludableMente1 Initiative: the Presidential Strategy on Mental Health

On May 17, 2020, during a nationwide television broadcast, President Sebastián Piñera announced the creation of the Healthy Mind Initiative (Iniciativa SaludableMente) whose goal was “to improve the public and private mental health services in [Chile].” SaludableMente is defined as a “comprehensive pandemic response plan for mental health and well-being,” which includes two pillars: (i) a digital mental health platform and (ii) an experts committee.

The digital platform (38), created to immediately strengthen mental health services, houses all the current programs that promote the mental health and the emotional well-being of different priority groups, including children and adolescents, older adults, parents and caregivers, women who are victims of violence, and individuals with COVID-19, as well as the general population. The platform provides direct access to remote psychological support, which has been integrated into the geographical network of services to improve the continuity of care for patients with mental disorders.

[1] “SaludableMente” in Spanish means both “healthy mind” and “healthily.”

A digital platform was created to strengthen the mental health response to address the need for support, guidance, psychoeducation, and specialized care through an integrated platform, linked to health and social services. The platform included remote brief psychological intervention, case management and staff training and supervision.

At the same time, the initiative convened a panel of experts to develop proposals and guidelines to respond to the mental health needs of the population during the pandemic (39). The Healthy Mind Committee was officially established and convened its first meeting on June 1, with a period of 90 days to fulfill its mandate. Over thirty representatives were invited to form part of the Committee, including academic experts, representatives of scientific societies and other civil society organizations, members of Congress, and representatives of different ministries. The Committee’s first task was to review and expand the Ministry of Health’s diagnosis of the mental health situation in the context of COVID-19. From there, working groups were formed on specific topics. Each group developed a roadmap that includes a summary of the current situation, actions, expected results, monitoring activities, and a timeframe, to create an integrated strategy with clear deadlines.

SaludableMente generated a broad, intra-sectoral dialogue that guided government actions around the well-being and mental health of the population, beyond health services. This strategy is still ongoing but has already managed to give greater visibility to mental health, secure new resources, and facilitate the articulation of different perspectives and capacities.

Discussion

In Chile, five lines of action in mental health policy were included in the pandemic response. First, a pre-existing Mental Health Care and Disaster Risk Management Model that acknowledged the importance of preparedness to reduce vulnerability and negative outcomes at both the individual and community levels. Second, a COVID-19 Mental Health Response Plan, led by the Ministry of Health, that seeks to meet the population’s mental health and wellbeing needs to reduce the negative impacts of the pandemic in the short and long term. Third, the establishment of the National Social Committee, to ensure effective governance, intersectoral coordination, and implementation of mental health policies as part of the response to the pandemic. Fourth, partnerships and collaborations across health services, universities, and other sectors through SaludableMente enabled the optimum use of resources to deliver cohesive and coordinated care and support, although the participation of people with lived experiences and caregivers was very limited. Fifth, research support generates a local body of evidence around the impact of the pandemic on mental health.

These policies are characterized by a coordinated implementation of the mental health plan, from health system initiatives to inter-agency and inter-sectoral work, that included mental health in the national pandemic agenda. However, the pandemic has also revealed areas that need to be urgently addressed and exposed cracks in our already fragile mental health system.

This groundwork, and its achievements, have proved useful to the adequate deployment of emergency response strategies. On the one hand, the existence of a coherent network of services at primary, secondary, and tertiary care levels facilitate the provision of mental health services that are more connected to local contexts and needs. At the same time, this prior set of aims –expressed and organized in the latest mental health plan– has provided a strong and practical foundation: The Mental Health Strategy of the National Social Committee, the Mental Health Action Plan, and the SaludableMente Initiative follows the basic principles and structure of the National Mental Health Plan 2017-2021 which, in turn, follows the foundational community-based model. The model provides a shared language across the mental health field.

Nonetheless, two key weaknesses in the transformation of services in the country have also expressed themselves in the mental health response towards the pandemic. The first weakness is the low budget allocated to mental health in the country, a decades-long ‘debt.’ This impacts the ability to increase direct mental health services in the face of the growing demands of the population due to the pandemic. It also narrows the margin of actions that can be carried out beyond clinical care, such as community strengthening and directly supporting grassroots, bottom-up forms of services that have nonetheless emerged during the crisis.

The COVID-19 pandemic has highlighted the tremendous historical gap in funding and in mental health services but it has also shown that preparedness, international collaboration, and initiatives supported by evidence in global mental health can improve countries responses. Hopefully we can learn some lessons for the next pandemics to come.

References

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IACAPAP Bulletin, Issue 63