Mental health medicines exist. Why do so few people benefit from them?

By Deepti Mishra, Health Investment Specialist

Across sub-Saharan Africa, psychiatrists face a simple question: which antipsychotic medicine would they choose first for their patients? Often, the answer depends on whatever is in stock.

Patients and clinicians rely on treatments being available at the right time, in the right place and at an affordable price. Mental health conditions affect every community and age group, yet the WHO estimates that in many low-income countries, three in four people with a mental health condition receive no treatment at all.

For people with psychosis, at the most severe end of the spectrum, the treatment gap is even wider. Take schizophrenia, which affects 27 million people worldwide^[1]. Effective schizophrenia treatments exist. Indeed, many are available as generics and have been used for decades.

The impact on people living with untreated schizophrenia is stark. Symptoms such as hallucinations and delusions can stop people working, studying, caring for dependents or living independently. When treatment fails or a medicine runs out, relatives may have to miss work to provide care, pay for travel to distant clinics or find money for medicines from private pharmacies. A relapse can mean another hospital stay and another bill that a family cannot afford.

Medicines alone cannot put that right. Better care also needs trained health workers, community services, social protection, respect for human rights and action against stigma. But reliable access to the right treatment is an essential part of the answer.

Knowing which medicines should be available

The WHO recommends several oral antipsychotic medicines for adults with psychiatric disorders, including schizophrenia. But individual medicines have different profiles, side effects, formulations and cost. Clinicians need options because a medicine that controls one person’s symptoms may cause weight gain, movement problems, severe tiredness or other side effects that another person cannot tolerate.

With such a wide range of considerations, a comprehensive, accessible overview of treatment options is essential. The GALENOS programme, led by the University of Oxford and funded by Wellcome, is a living synthesis of the global evidence on treatments for anxiety, depression, and psychosis.

GALENOS researchers reviewed the latest evidence on antipsychotic medicines and facilitated a workshop with clinicians, people with lived experience, researchers and experts from Ethiopia, Nigeria, Rwanda and South Africa. This multidisciplinary consensus panel, convened with MedAccess in February 2026, considered how that evidence applied in real health systems.

The resulting study, published in The Lancet Psychiatry, recommends a prioritised set of antipsychotic medicines to guide future market shaping efforts in low- and middle-income countries. Its importance lies not only in asking which medicines work, but which offer the best balance of effectiveness, tolerability and practical use in the countries concerned. It also exposes a basic weakness in the evidence: too little research comes from low- and middle-income countries or reflects the systems and services found there.

A market dogged by scarcity

In many low resource settings, even older, inexpensive medicines fail to reach patients. And when they are available, the risk of stock outs looms. Patients feel the impact of markets that do not work for manufacturers or health systems.

And what do we see in those markets? Procurement is split across small and uncertain orders. Prices are hard to compare. Demand is poorly forecast. Products may not be registered, listed or approved for prescribing in countries where they are needed. Suppliers see risk and little commercial reward, so they do not invest in registration, distribution or steady supply.

Clinicians are then forced to prescribe what is available rather than what is right for the patient. When one medicine runs out, a person who has been stable may have to switch to another. That can lead to relapse or cause new side effects. Additionally, newer, but more expensive formulations, including long-acting injections that reduce the need to take a tablet every day, remain out of reach for many health systems.

An opportunity for change

This is where lessons from progress against infectious diseases matter. Market shaping has expanded access to medicines, vaccines and tests for HIV, tuberculosis and malaria by tackling the reasons markets fail. Market shaping tools such as demand aggregation, advance market commitments and volume guarantees have helped increase access to medical products for HIV, TB and malaria in markets that were previously marked by fragmentation, weak competition and opaque pricing.

Mental health markets are even more fragmented. There is no large global purchaser for antipsychotic medicines, governments often have small mental health budgets and many patients pay for the treatments themselves. Prescribing also depends on trained staff and services that can monitor patients and manage side effects.

But some market-shaping practices can be adapted for mental health treatments.

Ministries responsible for procurement can combine forecasts so manufacturers can see credible demand across several markets.

Buyers can share information on prices, orders and stockouts to negotiate, using facts rather than guesswork.

Regulatory work can be coordinated so priority products are registered in more countries.

Where uncertainty is stopping suppliers from entering or expanding a market, volume guarantees or other forms of risk-sharing can offer greater confidence in return for lower prices and more reliable supply.

The goal is to build a dependable range of quality-assured options. That starts with keeping recommended generic medicines in stock. It should also create a route for newer or better tolerated products when the evidence, health system capacity and value for money support their use. Better treatment choice can help people stay well, keep working and avoid repeated journeys to hospital.

An important part of a complex answer

With support from Wellcome, the Clinton Health Access Initiative (CHAI) has worked with governments in Ethiopia, Ghana, Nigeria, Rwanda and South Africa to understand why these markets fail, drawing on country market analysis and the views of clinicians and people with lived experience. At the global level, CHAI and MedAccess are working together to engage manufacturers, with MedAccess leading the design of financing tools that reduce the risks suppliers face and improve access. The work points to a practical opportunity: pair country-led improvements in policy, forecasting and procurement with market shaping tools that give suppliers confidence to scale up availability at affordable prices.

Market shaping will not close the treatment gap on its own. A supply agreement cannot train a nurse, create a referral system, reform harmful practice or end stigma. Governments also need to prioritise inclusion of adequate support for mental health services in budgets leading to timely procurement.

But wider reforms will have limited impact if a prescription lands on an empty shelf. Countries, manufacturers and market shapers can learn from market shaping successes for infectious diseases, adapt them to mental health, and work together to deploy creative financial agreements that build markets with reliable access to essential generics and a fair route to better treatments.

People living with schizophrenia should not have to accept whichever medicine happens to be available. They should be able to receive the treatment that helps them live the fullest possible life.

[1] https://www.who.int/news-room/fact-sheets/detail/schizophrenia