The use of indicators for the management of Mental Health Services

Objective: to identify indicators that can be used in the management of Mental Health Services. Method: an integrative review in which we adopted the Population, Concept, and Context strategy to formulate the following Guiding Question: “Which indicators can be used for the management of mental health services?”. Results: a total of 22 articles were included and divided into two main groups: countries with initial high income (54%) as well as low- and middle-income countries (46%). We identified 5 studies that had experienced the use of indicators, 5 studies that had reported partial implementation, 9 studies that did not report use or implementation, 1 study on the indicator selection process, 1 as an implementation pilot, and a final study with a discussion for implementation. High-income countries also find it difficult to implement mental health indicators. The main difficulties in adopting the use of indicators are lack of basic mental health services, financial resources, legislation, political interest, and guidelines for its management. Conclusion: it is unusual to find a descriptive comparison of quality monitoring programs at the system level in the technical-scientific literature related to mental health indicators.


Introduction
The World Health Organization (WHO) has set four priority objectives in its Mental Health Action Plan 2013-2020 (1) : strengthen effective leadership and governance for Mental Health (MH); provide comprehensive, integrated and responsive mental and social health services in community settings; implement strategies for promotion and prevention in MH; and strengthen information systems, evidence and research for MH (1)(2) .
One of the principles for achieving these WHO goals is the use of indicators that are important for monitoring MH systems data. The WHO recommends that 80% of all countries collect and report at least one core set of Mental Health Indicators (MHIs) and that this action should happen through their national health and social information systems by the year 2020 (3) . Moreover, it also provides a set of key indicators to assess the levels of implementation, progress, and impact of defined targets. After the publication of the action plan, the WHO launched the Mental Health Atlas of 2014 and 2017 to monitor the progress of countries in achieving the established targets (4)(5) .
More than 450 million people are afflicted by mental illness and the global burden of mental illness is underestimated. Recent research suggests that this burden accounts for 32.4% of years lived with disability and 13.0% of disability-adjusted life-years. This is a particular concern in low-and middle-income countries (LMICs) where more than 70% of the mental illnesses occur (6) .
In the last two decades, there have been a large number of publications and reviews on the use of MH guidelines (7)(8) . Despite the proliferation of evidence-based guidelines for the treatment of mental disorders, there is no consensus as to which recommendations should be used (9) . A set of indicators should follow expected patterns of use, along with relevant and necessary data, in addition to validity accuracy to inform the merits of the evaluated practices and processes (10) . There were a limited number of "evaluative indicators" in MH related findings to record or measure properties, process, and interpretation of use and outcomes (10)(11) .
This scenario shows the lack of focus on this aspect prior to the publication of the WHO's Mental Health Action Plan from 2013 to 2020, and that it is now necessary to know the possible progress derived from the action based on such a document.
In spite of the WHO's recommendations, it is possible to find in the literature differences in the groups of indicators, the name of the indicators, how they are defined and which category each one belongs to (1,12) .
Thus, it is important to seek evidence on the indicator's performance for MH management based on the experience of use analysis, highlighting the differences and consensus of interpretations. In this way, we will carry out an integrative review of the technical-scientific literature, with the main objective of identifying indicators that can be used for the management of MH services. In this study, we will also analyze the evolution of MH services in different contexts and countries, the development of indicators and the progress of their implementation.
Finally, it is important to highlight that this study is part of an international multicenter study, involving researchers from Brazil and Portugal.

Method
This Integrative Review study was prepared according to the method described in the Joanna Briggs Institute Reviewers' Manual 2015 -JBISRIR (13)(14) .  (13) .
To construct the research GQ, we adopted the It should be emphasized that the population may include the articles selected for inclusion and must be related to the objectives of the integrative review. The Concept should be clearly articulated for the integrative character and breadth of the survey. The Context should be clearly defined and can include considerations of cultural factors, such as geographic location and/or specific racial or gender interests. In some cases, the context may also cover details about specific scenarios such as the health care system (15) .
The framework suggests a broad, clearly articulated research GQ, defining concepts, target population, health outcomes, and integrative, whilst also accounting for the aim and rationale of the review (15)   Uncontrolled descriptors for Population: "Quality Indicators, Healthcare" OR "Healthcare Quality Indicator" OR "Healthcare Quality Indicators" OR "Indicator, Healthcare Quality" OR "Indicators, Healthcare Quality" OR "Quality Indicator, Healthcare" OR "Global Trigger Tool, Healthcare" OR "Healthcare Global Trigger Tool" OR "Health Status Indicator" OR "Indicator, Health Status" OR "Indicators, Health Status" OR "Health Status Index" OR "Health Status Indices" OR "Index, Health Status" OR "Indices, Health Status" OR "Health Status Indexes" OR "Indexes, Health Status" OR "Health Risk Appraisal" OR "Appraisal, Health Risk" OR "Appraisals, Health Risk" OR "Health Risk Appraisals" OR "Risk Appraisal, Health" OR "Risk Appraisals, Health" OR "Guideline, Health Planning" OR "Guidelines, Health Planning" OR "Health Planning Guideline" OR "Planning Guideline, Health" OR "Planning Guidelines, Health" OR "Guidelines for Health Planning. Controlled descriptors for Concept

Results
We executed a structured search with defined strategies in the respective database platforms, along with controlled descriptors, uncontrolled descriptors, and keywords. It resulted in 929 papers among all databases and, after a duplicity analysis, 125 papers were removed. Then, using the procedures defined and refined from the inclusion and exclusion criteria combined with this study's GQ, an initial screening of the papers' titles and abstracts resulted in an exclusion of 804 records. Afterward, a full-text reading was performed on the papers left aiming to identify articles that addressed the GQ of this study. As a result of this step, a total of 22 articles were selected to be part of the Integrative Review. The selection criteria applied in this Integrative Review were performed by two researchers and submitted to a third one for review.
In order to organize reports and present systematic results according to the proposed approach, we used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The screening of the selected studies in this study was summarized in the 4-step prism flowchart: identification, screening, eligibility, and included (18) .
A brief presentation of this process and its characteristics can be seen in the PRISMA flow chart presented in Figure 1. We present the analysis of the 22 studies identified in the database search. Initially, we divided the findings into two main groups: HICs (54%) and LMICs (46%).
Also, the studies were organized in chronological order.
In the first group, we present studies conducted for HICs, while the main characteristics of the second group are LMICs. Then, each group was classified into conforming subgroups in characteristic of the population studied, i.e., studies involving a group of countries, countries or regions of countries were categorized. Next, we showed a more detailed analysis of the studies found, following the previous division described, in accordance with their income level.
Considering the studies in the main group of HICs, we identified 5 papers related to the group of countries, the papers belonging to the WHO, the Organization for Economic Cooperation and Development (OECD), the Statistical Office of the European Communities (Eurostat) and the Intercontinental Marketing Services (IMS) (19)(20)(21)(22)(23) , as shown in Figure 2 below.

Study Study Objective Territorial dimension Implementation of indicators
Psychosocial well-being and psychiatric care in the European Communities: analysis of macro indicators (19) To review macro indicators capable of providing a synthetic description of mental health status and the availability of psychiatric care in European countries Europe (OECD, EUROSTAT ‡ and IMS § ) The authors do not report the experience of using the indicators in the management New perspectives of mental health service (20) The study searches methodologies for the use of health indicators, based on characteristics of the users of health services Italy, Austria, Estonia, Finland, France, Italy, Spain, Norway, Romania and UK (England, Scotland, Wales and Northern Ireland) The authors do not report the experience of using the indicators in the management Monitoring of mental health care at the system level: country profiles and EU * country status (21) To provide a descriptive overview of Quality Monitoring Programs status in European countries England, Denmark, France, Germany, Italy, Netherlands, Portugal, and Sweden

Partial implementation
Reporting and use of OECD † Quality Indicators for Health Care at the national and regional levels in 15 countries (22) To explore reports on the use of quality indicators in OECD member countries  The remaining studies consisted of 6 related to HICs (24)(25)(26)(27)(28)(29) and one related to a high-income specific region (30) , as shown in Figure 3 below.

Study Study Objective Territorial dimension Implementation of indicators
Overview of the healthcare system in the Czech Republic (24) To describe the Czech mental health system through population indicators Czech Republic The authors do not report the experience of using the indicators in the management Development of Mental Health Indicators in Korea (25) To develop ways to measure the state of mental health in Korea by analyzing indicators in other regions Korea South Indicators were only selected Call for information, call for quality in mental health care (26) To build a model to improve the quality of mental health services mediation system at regional and local levels

Italy
The authors do not report the experience of using the indicators in the management Size Matters -Determinants of Modern, Community-Oriented Mental Health Services (27) To explore the quality and quantity of substance abuse-related mental health services, and evaluate the correlation between the needs of the population and the availability of those services Finland Implementation in use Quality indicators for the referral process from primary to specialized mental health care: an explorative study in accordance with the RAND* appropriateness method (28) To develop quality indicators to detect the impact of quality of primary care referral information to specialized mental health care has on the quality of mental health services

Norway
The authors do not report the experience of using the indicators in the management (the Figure 3 continue in the next page...) Rev. Latino-Am. Enfermagem 2021;29:e3409.

Study Study Objective Territorial dimension Implementation of indicators
Mental health quality, outcome measurement, and improvement in Germany (29) To describe the most recent results of quality assurance programs for mental health services in Germany Germany Implementation in use Composing a Core Set of Performance Indicators for Public Mental Health Care: A Modified Delphi Procedure (30) To describe the development of a set of performance indicators that are feasible, meaningful and useful for assessing the quality of the public mental health system in Amsterdam For the other group of selected studies, we identified 7 articles related to groups of LMICs (31)(32)(33)(34)(35)(36)(37) , as shown in Figure 4 below.

Study Study Objective Territorial dimension Implementation of indicators
Financing mental health services in lowand middle-income countries (31) To where are we now? (33) To analyze ways to improve health systems in low-and middle-income countries Brazil, India and South Africa Partial implementation Three models of community mental health services in low-income countries (34) To compare three models of community mental health services in low-income settings Nigeria, Philippines, and India The authors do not report the experience of using the indicators in the management Situational analysis: preliminary regional review of the Mental Health Atlas 2014 (35) To  (36) To identify indicators for the measurement of effective coverage of mental health treatment through a Delphi Study Ethiopia, India, Nepal, Nigeria, South Africa and Uganda The authors do not report the experience of using the indicators in the management Evaluating capacity-building for mental health system strengthening in low-and middle-income countries for service users and caregivers, service planners and researchers (37) To evaluate the impact of human resources training in low-and middle-income countries Ethiopia, India, Nepal, Nigeria, South Africa and Uganda The authors do not report the experience of using the indicators in the management

Figure 4 -Low-income and middle-income regions
We also identified one study that describes LMICs individually (38) , while the other two refer to specific regions of LMICs (39)(40) . As shown in Figure 5 below:

Implementation of indicators
Public sector mental health systems in South Africa: Inter-provincial comparisons and policy implications (38) To document current levels of provision of public health mental health services in South Africa and to compare services between provinces South Africa Implementation in use Evaluation of results and impact of the first phase of a community based mental health model in localities in Bogotá, D.C. (39) To evaluate the impact of the Community Based Mental Health Model through indicators Colombia Implementation in use Development of mental health indicators at the district level in Madhya Pradesh, India: mixed methods study (40) To develop a basic set of indicators to monitor mental health in primary care settings through a Mixed Methods Study India Implementation in discussion less presence. The least mentioned indicator was "excess mortality due to mental disorders" (22) .
In a more specific study for HICs, the Italian experience in the use of clinical indicators is uneven, although Italy's psychiatric reform in 1978 and recent legislation have delegated responsibility for planning, coordinating and delivering MH care to regions (26) . After  (28) .
The EMR group of countries has 11 LMICS countries that do not have an MH policy, program and/or legislation.
In the Africa and Southeast Asia regions, a total of 70% and 50% of their countries, respectively, spend less than 1% of their health budget on MH care. While 60% of the European countries spend more than 5% of their health budget on MH care. Only three African countries reported spending more than 5% of their MH financial resources (33) .
Another study finding is that the treatment gap for people with MH problems in LMICs is marked by the number of people who need care and those who receive such care. Moreover, a recent study aimed to improve MH outcomes in environments from six LMICs -Ethiopia, According to the subject matter presented, we identified that 5 studies effectively reported the experience of using MHIs and 3 of them described high-income environments (23,27,29,(38)(39) . Another 5 studies reported partial implementation of MHIs (21)(22)(32)(33)35) . An additional 9 papers didn't report the use or implementation of developed indicators (19)(20)24,26,28,31,34,(36)(37) . Another study presented only the process of selection of indicators (25) .
The last two studies were about an implementation pilot of MHIs (30) and a discussion of MHIs for implementation (40) .  (19) .
Another study pointed out the profile of 8 countries  (21) .
The Organization for Economic Co-operation and Development (OECD) conducted a study between June and December of 2014 among its 37 member countries (22) .
The objective of this particular study was to explore the reporting and use of OECD Health Care Quality Indicators India, Nepal, Nigeria, South Africa and Uganda -in which they seek evidence and capacity to improve the health system, including the development, use and monitoring of indicators (36,41) .
Through a 10-year study, it was estimated that an additional investment of up to USD 20 per person/year would be needed for low-income countries, and of up to USD 30 for middle-income countries, which would result in a target expense of USD 2 and USD 3-4 per person, respectively. Compared to other investments, for example, the estimated total costs of increasing the neonatal health care package to 90% coverage was estimated at USD 5-10 per capita. Meanwhile, the cost of universal provision access to basic health services has been estimated at more than USD 30 per person per year (32) .
Another study showed that 22 Member States in the EMR have independent MH policies that have been updated over the past 10 years. Legislation needs to be reviewed among MH policies by international human rights instruments and indicated that they are partially implemented (35) . Countries from the region have the government as its main funding source (77%). However, in the remaining countries, the main funding source can be households (2 countries), non-government organizations (1 country) or unknown (2 countries did not report) (35) .

Discussion
In all selected studies, the authors point to the relevance of using MHIs. According to the WHO guidelines in their Action Plan, several countries have attempted to define an appropriate set of indicators in the practice of MH services (1,35) . However, the results shown by MHIs have different uses for management, policy and service improvement (22,35) . Also, some countries are involved in the discussion process and in gathering the necessary indicators (21,33) . Nevertheless, some initiatives for the implementation of MHIs are in the process of partial implementation or in the implementation of pilot projects, suggesting that the effectiveness of these indicators is still unknown (26) . In LMICs countries, the research studies on MHIs were performed with many difficulties due to: lack of basic MH services; financial resources; legislation and political interest; MH management guidelines; and MH data integration systems (36,(41)(42) .
Outcome quality indicators are only occasionally used to analyze MH services, and that is because most jurisdictions do not have clinical data systems to meaningfully incorporate indicators among MH providers.
Nevertheless, the effectiveness of the health services remains unknown (44) . in France, where they have been reporting significant regional disparities in the MH system, without significant change, in recent decades (45) .
The process of implementing MHIs is a difficult task even for European countries. Portugal can be used as an example, with its National Health Plan being carried out throughout the 2017-2020 period; however, MHIs have not been implemented using proposals made by the Working Group. However, these proposed measures do not have an integrated strategy for the promotion and prevention of MH. According to the report, these changes will only be possible if they are developed within the framework of coordination teams that have the capacity for action at the inter-sectorial level (46) .
Moreover, this is a particular concern in LMICs, where more than 70% of mental illnesses occur. Poor access to MH services has been highlighted, ranging from less than 50% to less than 10% in many countries. In LMICs, the difference between those in need of treatment and resource availability is almost 90% (47) .  (42) . Nowadays, Brazil has been utilizing an indicator defined through the Inter-Federative Pact 2017-2021, which refers to an action set of systematic matrices performed by the CAPS in partnership with primary care teams (49) .
Political reforms in the country and the commitment of health professionals to provide care in the primary process and, therefore, to the entire network of health services. With these results, it seems important that specialized psychiatric prevention services implement health promotion programs specifically targeting psychiatric patients (20,51) .
A limitation of this review is that it should involve a detailed search of the normative documents, we only consulted and compared data found in scientific papers, there were difficulties in finding data sources with indicator information, calculation method and information systems of each country. A complementary work to this study is being carried out to obtain MHIs that suit Brazilian Health Information Systems and that can be implemented using the available data (52) .
A strength to this review is that it shows that, by In addition, we confirm the previous findings that there is no consensus on the definition, method of calculation, and management level of the indicators that are used.

Conclusion
The main findings of this review show that it is unusual to find a descriptive comparison of qualitymonitoring programs at the system level in the technicalscientific literature related to MH. This occurs not only because such systems are rare or in development, but also because most programs are managed by national public agencies whose purpose is not to publish results in the scientific literature. Global initiatives are underway and seek to expand MH services to address the treatment and care gap.
Indicators are important information tools to map advances, setbacks or stagnation in different aspects and sectors of society. An analysis of indicators by the public and private health financing systems has not been found even in countries that have both systems. Indicators for each system may present relevant differences for analysis.
In this sense, this review contributes to this scenario by extracting knowledge and establishing an updated framework on the use of MHI for care and management.
When we mention the importance of using indicators, we point out that they are intended to help individuals, understand the performance of community health services, and provide information easily and conveniently to reflect changes in time and to assess protective factors, and so on. They enhance MH status, factors, system, and quality of MH services to include prevention, treatment, ongoing management, and early interventions. Developed countries invest in MHIs systematically based on theoretical foundations, such as national projects, that not only assess the population's MH status and monitor trends, but also provide scientific research to policymakers as well as monitor processes and policy outcomes. Indicators are useful screening tools for potential problems in preventive and primary care. They also determine if there is a quality problem and the need for further analysis on a given topic.
This scenario suggests the need for a set of indicators to be standardized by the WHO, serving as an evidencebased guide to best practices available. Also, we have suggested more flexibility and adaptability, taking into account the reality of each country. To achieve this goal, the development of indicators must be carried out by professionals within the entire health service network.