Commissioning of health services has become an intensely political issue in the UK and there is no reason to believe that the conflicts that have arisen domestically would not be mirrored overseas. A key ideological issue in the UK concerns the relative merits of public and private provision of services. In their guest editorial in this issue, ‘Governance, choice and the global market for mental health’, Sugarman & Kakabadse take a particular ideological stance: they write on the one hand of commercial-style efficiency and on the other of monopoly state provision risking inefficiency and ineffectiveness. This perspective is addressed here.

Intellectual disability was recognised in ancient Indian literature, but organised services have a history of just five decades. India shares many features of low- and middle-income (LAMI) countries regarding intellectual disability. There is a low level of awareness about its nature, causes and interventions. One can come across many superstitions, myths and misconceptions about intellectual disability. In general, services are inadequate, being concentrated in big cities and urban areas. There is generally limited access to support services and few government benefits, and these, in any case, are often of little value (World Health Organization, 2007). Locally and nationally, there are few relevant and reliable epidemiological data on the prevalence of intellectual disability. However, there have been some positive developments within the past three decades, and they are the focus of this paper.

The Middle East has been in conflict for many decades and wars have become the ‘normative reality’ of children residing in the area. Questions have been raised about children's vulnerability to the stresses that come with living in a war area. Are children more resilient because they are more flexible in their ways of coping? Or are children more vulnerable because their psychological development is influenced by the environment?

Children and adolescents constitute half of Iraq's population of over 30 million. Mental health problems experienced by Iraqi children and adolescents are a hidden problem. Many factors contribute to the mental health problems of young Iraqis, including being victims and witnesses to violence, seeing family members become victims, being displaced from their homes, and experiencing the instability that still plagues their nation. Iraqis have experienced severe deprivation caused by many years of war, economic embargoes and civil unrest. Violence, poverty and the failure of the education and health systems have severely undermined the well-being of Iraqis, especially children (AlObaidi et al, 2009).

Aboriginal Australians have relatively high rates of intellectual disability, a situation that is probably due mainly to poor health and social disadvantage. Populations with high rates of intellectual disability are more at risk of developmental disorders and mental ill health. We explore the training needs for psychiatrists working with indigenous people and how they can be met.

In 2001, an initiative to provide effective treatment for people with depressive disorders in primary care clinics was introduced in Chile, the Programme for Screening, Diagnosis and Comprehensive Treatment of Depression (PSDCTD) (Ministerio de Salud, 2001). It was extended to all primary care clinics in the country 4 years later.

Common human questions include ‘Why are we here?’ and ‘How should we live?’ The search for meaning, purpose and values is fundamental to most religions and philosophies. In the UK these views used to be derived from a shared Judaeo-Christian faith. People defined themselves as accepting or rebelling against the faith community. In postmodern times we no longer trust in meta-narrative and there is no consensus on how to deal with existential issues, nor on how to label and map the territory; some would deny that the territory even exists.

The Gaza Strip has been badly affected by war and conflict over the past four decades. Palestinians are exposed to repeated incursions of the border areas, with many resulting casualties. At the end of December 2008, more than 230 Palestinians were killed and at least 770 were injured, including 100 in critical condition, after an Israeli airstrike. This was followed by a military operation that continued for 23 days, in which 1420 Palestinians, including 446 children, were killed. At least 4000 houses were totally destroyed and 16000 partially damaged (Palestinian Red Crescent, 2008).

The children who experienced the genocide against the Tutsi in Rwanda are now in their mid to late 20s. It is almost impossible to comprehend the scale of the terror and destruction of Rwanda's societal infrastructure between 6 April and 16 July 1994. While the world remained inactive, Rwanda, a small impoverished central African state, experienced the murder of about 1 million of its citizens; it also saw the terrorising, humiliation and rape of countless thousands. Although women and children were directly targeted, some actively engaged in atrocities. About 300000 children were murdered, a significant number at the hands of other children. The level of terror differed across the country and escape was frequently by luck alone. A UNICEF (2004) study of 3000 children revealed that 80% had experienced death in the family, 70% had witnessed a killing or injury, 35% saw other children killing or injuring other children, 61% were threatened with being killed and 90% believed they would die (Human Rights Watch, 2003). Of the 250000 women raped, 30% were between 13 and 35 years of age, 67% developed HIV/AIDS and 20 000 births resulted (Donovan, 2002).

In Ghana, the main burden of ill-health, as in many sub-Saharan countries, consists of communicable disease, illnesses due to inadequate nutrition and poor reproductive health. As these conditions are tackled, other diseases, such as mental disorders and substance misuse, are also becoming the focus of development efforts. In Ghana, it has been estimated that there are 2166 000 individuals experiencing a mild to moderate mental disorder, with a further 650000 suffering from a severe mental disorder, out of a population of 21.6 million (World Health Organization, 2007). In 2003, the country's mental health workforce consisted of 9 psychiatrists (only 4 of whom worked in mental health services), 451 nurses and 160 community psychiatric nurses (World Health Organization, 2003). Currently there are just 5 consultant psychiatrists in active service in the public sector and 11 retired psychiatrists. As just under 33 000 individuals are seen each year in Ghana by mental health services, there is an estimated treatment gap of 98% (World Health Organization, 2007). Most mental healthcare is undertaken at the three large psychiatric hospitals, in the south of the country. This is reflected in the ratio of out-patient attendance to admission, which is 4.64 for mental health, compared with 14.6 for all health conditions (Ghana Health Service, 2005).

We have conducted a qualitative study to collect information about services for adults and older adolescents with intellectual disability in Mexico, as part of ongoing research on intellectual disability from a public health and rights-oriented perspective. Our focus is on existing services and outstanding needs. One of our main goals is to provide an opportunity for people with intellectual disability to convey their experiences and express their opinions about the additional services they require. Three types of service are included: those supporting autonomy or independence (personal and economic); those enhancing community inclusion; and those providing vocational opportunities.

The World Health Organization's International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders is currently working on the development of ICD-11 (World Health Organization, 2007). A more responsive ICD coding system should incorporate recent work which suggests that the religious and spiritual domain is important for a comprehensive, culturally sensitive diagnosis and management plan (e.g. Sims, 1992, 2004; Koenig et al, 2008). A ‘religious or spiritual problems’ category, similar to that in DSM-IV (American Psychiatric Association, 1994), should be included in ICD-11.