Caillin Dunsford, The One Planet Fight

A stakeholder analysis can be used as a tool or approach to understand the role and influence of stakeholders in decision making or policy making processes. Stakeholder analyses can be used to understand the interests, intentions, behaviours and agendas of relevant stakeholders and their influence in decision-making processes (Brugha & Varvasovsky, 2000). There are eight key steps in undertaking a stakeholder analysis: planning the process, selecting and defining a policy, identifying key stakeholders, adapting the tools, collecting and recording the information, filling in the stakeholder table, analysing the stakeholder table, and using the information (Schmeer, 1999).  With this information, it is then possible to facilitate the development and implementation of policy processes, through management of stakeholders and a deeper understanding of the policy context.

In this context, this essay will conduct a stakeholder analysis with the aim of understanding the rise of mental health on the global health policy agenda over the 5 years leading up to the Special Initiative for Mental Health. The rise of mental health first became prevalent on the global agenda when researchers applied the Disability Adjusted Life Years (DALY) metric to global mortality in the Global Burden of Disease Study in 1997 (Keating, 2018).  The DALY provided a new way of identifying the contributions of diseases and allowed for the analysis of global health policy with an evidence-based approach. Most notably, the DALY revealed that mental disease is one of the leading causes of disability globally, now accounting for approximately 10 per cent of the overall burden of disease, and resulting in a global cost of approximately $2.5 trillion in lost productivity in 2010, with this number expected to rise to $6 trillion in 2030 (Marquez & Saxena, 2016). This led to mental health becoming framed as an urgent development issue, and concern over its exclusion on the global development agenda saw many international stakeholders push for its inclusion in the 2015 United Nations Sustainable Development Goals (SDGs). This essay will explore a few of the key players that advocated for the reconceptualization of mental health as a global health policy priority, pushed for its inclusion in the SDGs and provided a platform for policy discussion in the lead up to the WHO’s Special Initiative for Mental Health.

The World Bank is classified as an international financial institution whose dual goal is to promote sustainable development through a reduction in poverty and increase in shared prosperity (World Bank, 2020). With one of the largest funding sources, the World Bank is responsible for aiding developing nations economic growth through financing, counselling and research. The World Bank has played a pivotal role in bringing mental health to the centre of attention in the global development agenda, most notably through the “Out of the Shadows: Making Mental Health a Global Priority” event that was co-hosted by the World Bank and World Health Organisation (WHO) in 2016 (World Bank, 2016). As mentioned previously, mental health is expected to cost the global economy $6 trillion in lost productivity by 2030 (Marquez & Saxena, 2016), however, the “Out of the Shadows: Making Mental Health a Global Priority” event also established that depression and anxiety disorders (only a subset of common mental disorders) alone cost in excess of $1 trillion every year to the global economy (World Bank, 2016). Moreover, there is clear evidence on the association between mental health interventions and poverty alleviation and improved local economic conditions. For every dollar spent on scaling up mental health treatments there is an estimated return on investment of four dollars, realised through improved health conditions and in populations ability to work (World Bank, 2016). These statistics provide a coherent rationale for the World Bank’s interest in and support for pushing mental health on the global policy agenda, as economic support for mental health interventions directly contributes to the World Bank’s ability to fulfil its’ goals. 

The World Bank has considerable resource-based power as a consequence of its position as the principle financier for the economic growth of developing nations. The World Bank chairs numerous bilateral donor organisations who negotiate with the governments of recipient World Bank funds. As such, when the World Bank withdraws their support from a government ministry, often donors also withdraw their support (Clemens & Kremer, 2016). This has significant impacts on the overall flow of donations and provides the World Bank with negotiation leverage over national governments, essentially enabling the World Bank to influence the setting of agendas and policy priorities on a global scale. The World Bank also has soft, discursive power. Discursive power is the ability to frame or shape the way actors think about and conceive issues, and soft power is the ability to attract others to your way of thinking (Thow, 2020). The World Bank is a platform for independent policy conversations by providing a venue for finance ministers, multilateral organisations, innovators, researchers and society to engage regarding the investments needed to support issues and their expected economic, social and health returns (Marquez, Dutta & Balafoutis, 2018). This engagement influences how ideas are moved into global policy through the collection of data, generation of ideas, bringing these ideas to global audiences, and translating these ideas into policies.

FundaMentalSDG is another stakeholder that contributed to the rise of mental health on the global health policy agenda. FundaMentalSDG is an initiative and advocacy group that started its mission of campaigning for mental health to be included in the Sustainable Development Goals (SDGs) in 2014 (Mills, 2018). FundaMentalSDG’s interest in mental health originated over their concern regarding the absence of mental health’s inclusion in the SDGs, thereby being an obstacle to the achievement of many other development goals due to the close correlations between mental health and development (Mills, 2018). Their position on mental health is that it is ultimately fundamental for sustainable development overall, and that addressing mental health can lead to further steps taken to address other development issues such as universal health coverage, economic development and social equity (#FundaMentalSDG, 2020). The FundaMentalSDG initiative began in 2014 when members of the Steering Group engaged a number of international leaders and organisations, national mental health policy makers, and civil society who collectively pressed the United Nations to include specific and measurable indicators of mental health, namely indicators on suicide mortality and the coverage of treatment for people with severe mental illnesses, in the SDGs (Votruba, Thornicroft & FundaMentalSDG Steering Group, 2016). After more than a year of continuous engagement and advocacy, the UN included mental health in the SDGs and declared it a global development priority.

FundamentalSDG used its intangible power to project discursive power in its mission to get mental health on the global policy agenda. In other words, FundaMentalSDG used its access to experts, decision-makers and the media to re-frame mental health in the global policy arena. The reconceptualization of mental health as a global development priority led to material changes to the draft SDGs and the eventual direct inclusion of mental health in SDG 3 and in the preamble (Votruba, Thornicroft & FundaMentalSDG Steering Group, 2016). When considering the impact and influence of FundamentalSDG’s advocacy work, they have been commended for being able to globally unite large numbers of mental health stakeholders, all of whom have a variety of positions and aims, for the first time. Thus, FundaMentalSDG demonstrate the value and impact continuous concerted advocacy and mobilisation can have in driving policy changes. 

Academics are often consulted during the policy cycle for their expertise on a number of issues. Academics can take a wide variety of stances on any particular topic, however, the academics to be discussed in this essay on the topic of mental health are in support of its inclusion as a global health policy priority. The WHO consulted a number of academics in the lead up to the WHO Special Initiative for Mental Health who have had their research and expertise highlighted at previous events. For example, the joint 2016 World Bank Group and WHO Global Mental Health Event was convened with the aim of pushing mental health away from the periphery of the international development agenda (Marquez & Saxena, 2016). At this event Gustavo Roman was just one academic called upon for his expertise in neurological conditions; he emphasised that the concept of mental illness as a brain disease had been lost and ignored by policy makers over the years (Marquez, 2013), and therefore Gustavo advocated categorising mental illness as a neuropsychiatric disease (a term already in use by WHO) to group mental illness with other neurological disorders (Marquez & Saxena, 2016). This grouping allowed for a more coordinated effort to address mental health together with neurological disorders, as this categorisation greatly inflates the DALYS for the global burden of disease and creates a stronger argument for mental health as a global development priority (Mills, 2018).

Concurrently to FundaMentalSDG’s advocacy work, Thornicroft and Patel also advocated for mental health’s inclusion in the SDGs, not only because more than 450 million people worldwide have unmet mental illness needs, but because mental health bridges many other SDG goals too. For example, Thornicroft and Patel (2014) framed mental health as a barrier to the SDG goals ‘that aim to promote peaceful and inclusive societies’ (Mills, 2018), due to mental health acting as a precursor to a reduced capacity for resilience to conflict.

As the above examples highlight, academics are commonly called upon and noted for their expertise on particular issues. Academics are also an additional source of advocacy that can help push agendas forward. As such, academics are equipped with intangible, resource-based power in global policy processes. They are often the ones on the ground consulting local populations to research and test theories and gather data to better classify and approach issues. The WHO has called upon academics for their ‘expertise in implementation and prevention relevant to mental health’ (Keating, 2018). Academics can also possess discursive-based power, exemplified by Thornicroft and Patel’s (2014) ability to frame mental health as a barrier to achieving numerous SDG goals and, therefore, as a development priority in global health policy. Whilst academics have some level of discursive- and resource-based power, their level of influence is limited to providing research and acting as consultants for global policy, for they do not hold a seat at the decision-making policy table.

This essay has focused on only a handful of the stakeholders involved in the rise of mental health on the global health policy agenda over the 5 years leading up to the Special Initiative for Mental Health. However, arguably, what’s more important is the interconnectedness between these stakeholders and their collective influence. For example, the World Bank engages foreign finance ministers, multilateral organisations, national governments and more on the need for urgent economic investments for mental health; FundaMentalSDG’s whole initiative is based upon uniting world leaders to take a collaborative approach to elevate mental health on the global health policy agenda; and academics unite together to share their expertise with those who have policy influence, and to aid in the implementation and prevention of mental health issues. This highlights the interconnectedness of stakeholders in the global policy arena, where it is fundamental for all stakeholders interested in a specific issue to unite to make a lasting and significant change as collective influence is stronger than isolated, disconnected efforts. Thus, the rise of mental health on the global health policy agenda in the lead up to the Special Initiative for Mental Health was a unified effort from multiple stakeholders.

Although this essay mainly focused on stages 3-8 of the stakeholder analysis process, I have found the stakeholder analysis to be very useful in understanding the relative positions and powers of each of the stakeholders analysed in this essay. This understanding allowed me to weigh up and balance the explicit interests of a stakeholder and determine how they used their interests, connections and resources to influence policy agendas and processes. This is useful to examine the influences behind policies and can be used to provide input into further policy decisions, in developing policy action plans, increasing support for policies and in managing relevant stakeholders. However, perhaps my biggest takeaway from this stakeholder analysis is the need for stakeholders to share the responsibility for the promotion and advocacy of the importance of mental health as a global health policy priority to ensure long term sustainable development is achieved.