This blog is written with the intention to reflect on the findings and discussion in relation to mental health and poverty in the context of low- and middle-income countries in the Middle East.
This is the third and final blog in the series.
The Middle East and North Africa is home to approximately 6% of the world’s population and rich in its history and its cultural diversity. The region is abundant in resources and assets, one of which is its youth — more than 28% of the population in the region are aged 15-29. The nature of poverty in the region is both persistent and multidimensional.
Persistent poverty means that there is little class mobility, within and across generations. This is mainly due to the dynamics of the labour market and the frailty of the private sector. Violence and war have also impacted the region’s economies and has contributed to deprioritising development policies and focusing instead on security policies.
This has a crippling effect on education, health status and living standards of those in the region, leading many to be multidimensionally poor. Multidimensional poverty implies that the level of deprivation goes beyond income status, affecting other dimensions such as education, health status and living standards-. In the 2018 Multidimensional Poverty Index (MPI) results, 70% of multidimensionally poor people in the Arab States lived in Sudan, Yemen and Somalia. The results also suggest that lack of access to education contributes the most to multidimensional poverty across the Arab region. The value of studying deprivation and poverty from these multiple and interrelated dimensions reinforces the need for anti-poverty policies to acknowledge and address poverty as interdisciplinary and multidimensional.
Multidimensional poverty can leave young people particularly vulnerable to mental health problems as there is often a lack of access to professional health care or support for their mental well-being. This negative impact is further exacerbated as a result of mental health being under-discussed and unaddressed in both academia and policy in the region.
Conditional Cash Transfer (CCT) to address poverty dimensions
Conditional Cash Transfer (CCT) programmes are amongst the policies that acknowledge the multidimensionality and persistence in the very nature of poverty. In response to an increase of poverty in the Middle East, some countries have piloted and adopted the CCT programme. For example, in 2015 Egypt launched the Takaful programme for vulnerable families, specifically targeting female heads of households. Conditionalities specify that children in the household must have at least 80% school attendance, and for mothers and children to have at least four visits a year to health clinics. Another example of a piloted and adopted CCT programme is Turkey’s Conditional Cash Transfer for Education Programme. The programme targets mainly refugee children and helps encourage them to send their children to school, with the incentive of bi-monthly cash transfers.
Some of the most common conditionalities of CCT programmes are school enrolment and health clinic visits. These criteria link back to policy objectives for improving basic education and health outcomes. The CHANCES-6 project looks at the intersection of poverty and mental illness, exploring how poverty-alleviation policies can better support young people living in poverty to face mental health challenges. Youth mental health represents another important area which could facilitate better education and physical health outcomes and thus help achieve these policy objectives and other social and economic outcomes. However, addressing youth mental health in the Middle East comes with its own cultural and contextual challenges. For instance, although schools and health clinics are important settings where mental health could be addressed, the knowledge and resources for how to support youth mental health in these settings is often lacking, and stigma may act as a further barrier. Thus, addressing youth mental health requires more direct attention and investment.
The CHANCES-6 findings showed that cash transfers were associated with some small but significant improvements in mental health in though findings were heterogeneous and may be influenced by cash transfer characteristics (for example, volume, duration, conditionalities) and social and contextual factors (for example, levels of income inequality, relative poverty, violence, surrounding infrastructure), but that addressing this issue requires more concerted attention and direct support for youth mental health alongside anti-poverty interventions. These findings can apply to other lower-middle-income countries in the Middle East where CCTs are already in operation but would benefit from complementing the intervention with further investment in mental health resources. Most schools in the Middle East, especially in rural and impoverished areas, are not institutionally equipped to focus on promoting youth mental health or the resilience and wellbeing of students. Rather, schools tend to focus on literacy and nutrition objectives with bare minimum education and healthcare obligations. Institutional capacity-building should include staff training on mental health issues and referral options, and other means to increase support for youth.
It is crucial to equip schools and rural health clinics with the necessary tools to address mental health illness in a much deprived and inaccessible context.
It was found that school-based interventions for mental health conditions, specifically preventing anxiety, depression and suicide, can provide a return on investment of US$21.5 for every US$1 invested over 80 years. The greatest return on investment was in lower-middle-income countries, which showed a return of US$88.7 on every dollar invested. This suggests that poverty-alleviation programmes, one of which is CCT, can be cost-effective interventions for improving mental health outcomes.
The need to promote mental health through institutional knowledge beyond basic education indicators is not unique to the Middle Eastern context. Conditional Cash Transfer programmes may be a useful tool to address issues surrounding poverty, mental health and improving life chances of young people in the region – considering how these programmes might go beyond offering cash to more directly supporting and improving youth mental health.
The views expressed in this post are those of the author and in no way reflect those of the Global Health Initiative blog or the London School of Economics and Political Science.