Health systems context(s) for integrating mental health into primary health care in six Emerald countries: a situation analysis

All study countries reported to be under democratic political systems. Ethiopia, Nepal and Uganda are classified as low income countries with population and gross domestic product (GDP) of just under 100 million people and 61 billion US dollars (Ethiopia); 28.4 million people and 60.4 billion US dollars (Nepal); while Uganda has 39 million people and 23.6 billion US, dollars respectively. The two countries of India and Nigeria are classified as lower middle income countries with respective population and GDP of 1.31 billion and 2.07 Trillion US Dollars (India); and 182 million and 481.07 billion US Dollars (Nigeria). South Africa is classified as an upper middle income country, with a population of 55 million and a GDP of 312.80 billion US dollars. Most of the health systems in the study countries are overstretched by an overall high burden of disease amidst limited resources [11]. Some of the study countries have some pockets of civil conflict (Nigeria) while others are emerging from conflict (Uganda, Nepal). The numerous indicators of development of the study countries are summarized in Table 1.

A qualitative document review approach was adopted by this study. The documents reviewed were purposively identified on the basis of providing information on vital building blocks of a health system, as defined in the World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS), [12]. These include: mental health legislation, mental health policies and plans, general health policies that included mental health into general health policy, financing, human resources, range and availability of mental health services in the country, integration of mental health into information, education and communication (IEC); synergies among HIV/AIDS and mental health, maternal health care and mental health. In addition, other resources include, integration of mental health into general hospital services, equity in relation to existing policies, monitoring and evaluation, mental health rights and benefits. The tool used to review these resources was a checklist based on the themes identified in the WHO-AIMS [12] and modified to suit the country contexts (see Additional file 1: Appendix). In this study, we depended on purposively selected grey literature because little scientific evidence exists in this field for LMICs in general, and in the study countries in particular. Review of documents was cross-sectional as a way of ascertaining the current status of resources available for integration of mental health into PHC. In essence, different countries were at different stages of developing mental health resources. In some study countries (such as Uganda) some of the vital documents that were included in this review were identified by contacting senior managers at the Ministry of Health. Each country’s research team conducted a review of policy documents, plans, legislative frameworks and other relevant program documents that were available at the Ministry/Department of Health. Some of the vital documents reviewed in the study countries included: mental health bills/acts, health policies and strategic plans, mental health policies and plans (where available), Ministry of health budgets, human resources plan and staff deployments, ethical guidelines (e.g. for research), monitoring and evaluation plans, program/sector performance reports, among others. The specific documents that were reviewed in each study country are summarized in Table 2.

All the data collected from the study sites were summarized in a matrix. Content thematic analysis was used to analyze the data. A priori themes comprised the pre-conceived categories from the WHO-AIMS (12), with subcategories and emerging themes were developed under each category.

All study sites had secured ethical approval from their respective ethical boards and this research project was one of the ongoing Emerald project activities. Ethics approval was also obtained from King’s College London and the WHO.

In terms of legislation, South Africa has the Mental Health Care Act No. 17 of 2002 [13]. India has a Mental Health Care Act, 2016. Nigeria has the Nigerian Mental Health Bill (2013) which is undergoing consideration by the country’s National Assembly. Currently however, it is the old Lunacy Act of 1958 that still exists in the country. In Uganda, a Mental Health Bill was produced in 2009. A revised version was produced in 2011 and it is still before the cabinet.

Nepal has a draft Mental Health Bill (Treatment and Protection) Act 2006 [14] which was revised in 2012 but has still not been passed by the parliament. There is also the Disabled Welfare and Protection Act, 1982 and The Protection and Welfare of the Disabled Persons Rules, 1994. In Ethiopia, dedicated mental health legislation does not exist but is currently under development. This movement towards development of new legislations in some of the study countries is inconformity with the provisions of WHO which endorsed mental health as a universal human right and a fundamental goal for health care systems of all countries [15], as evident from the content of the newer legislations.

In terms of human rights, the draft mental health bill of Nepal, has provisions for managing patients who require treatment against their will. In South Africa, the Mental Health Care Act of 2000 [13] provides that designated general hospitals are required to admit and assess people who are admitted involuntarily with psychiatric emergencies for a minimum of 72-h before they may be referred to psychiatric hospitals. If after a 72-h observation, a patient requires in-patient treatment they must be admitted to a specialist psychiatric ward or hospital. Review Boards in each province oversee involuntary admission and related appeals. In Uganda, the old law and the current draft mental treatment Act (2011), have protocols for managing patients who require treatment against their will; replacing the old “Mental Treatment Act of 1938 (Ch 279)”, amended 1964 (section 10). As Uganda awaits the passage of the new law by cabinet and parliament, the old protocol is still being utilized to administer treatments to patients against their will. While Nigeria similarly awaits the passage of its new mental health bill, sections 10–13 of Nigeria’s old Lunacy Act permits involuntary hospitalization for less than 7 days and requires a Magistrate’s order if it is longer than 7 days. The mental health bills of South Africa and India and the draft mental health Bills of Uganda, Nepal, Nigeria are aligned to the United Nations Convention on the Rights of People with Disability (CRPD), and most of the issues on human rights are also inherent in the national Constitutions of the study countries.

Mental health plans are essential for guiding the activities that have to be implemented to meet policy objectives and typically include vital elements such as budgets and time frames [4]. South Africa has a Mental Health Action Plan [16] which provides a roadmap for the implementation of the mental policy. Nigeria’s mental health action plan is being developed. In the rest of the study countries, mental health is directly mentioned in some of the strategic plans in the general health sector. For example, in Ethiopia, it is mentioned in the Health Sector Transformation Plan (2015/2016–2019/2020), within the domain of prevention and control of Non-communicable diseases (NCDs). The Ethiopia health plan includes a target to make mental health services available in every district in the country by 2020. In India, the National Mental Health Program is a comprehensive program which includes plans to deliver community-based mental health care in 100 districts all over the country [19]. There were also efforts towards modernization of state-run mental hospitals; upgrading of psychiatry wings in the government medical colleges and general hospitals; Information, Education and Communication (IEC) activities; as well as research and training in mental health for improving service delivery. In Nepal, mental health is part of the essential health care services in the government’s second long term Health Plan (1997–2017) and the National Health Sector Support Program (NHSSP II 2010–2015). In Uganda, mental health is under the section on “prevention and control of non-communicable diseases (NCDs), disabilities and injuries” in the general health policy as well as the National Health Sector Investment Plan (1999/2000–2009/10) [20]. Uganda, Ethiopia and Nepal do not comprehensively define the objectives, activities and indicators of success relating to mental health in national plans where mental health is placed. Also, key elements such as community involvement, advocacy, user involvement in mental health service delivery among others; are missing.

At district/regional level, the health plans of Uganda and Nigeria do not specifically mention mental health. However, in the two study countries mentioned above, integrated mental health packages are delivered through the pilot implementation of the WHO’s Mental health gap action programme (mhGAP) in selected districts [21]. The mhGAP project is meant to provide lessons for further integration of mental health in other districts. In Ethiopia, the Federal Ministry of Health is scaling up mental health care integrated into primary care. Memoranda of Understanding have been signed with the Regional Health Bureaus and a dedicated budget availed to support the scale-up plan.

In South Africa, at the district level, mental health is specifically mentioned in the program for “Integration of mental health into PHC” and district guidelines have been developed [22]. In Nepal, the National Health Policy (1991) devolves mental health delivery to regional hospitals where specialized mental health services are provided. In Ethiopia, there is the district-based planning which takes the Ministry of Health plan as the starting point but may adapt to local conditions. Mechanisms for coordination at the district level exist within the national strategic plans in Ethiopia, Uganda and South Africa and this creates opportunity for integration of mental health into PHC. In Nigeria, there is no systematic mental health activities going on at the district and primary health care level, except where this is occurring in the context of a research project.

The volume of funds allocated for mental health service delivery can facilitate or hinder integration of these services into PHC. The volume of financial resources available in the different countries for mental health is summarized in Table 1. Among all the study countries, Nepal spends the lowest percentage (0.06%) of the health budget on mental health while South Africa spends the highest percentage (5%) of its health budget on mental health. Given the size of the budgets allocated to the mental health sector in all the study countries, it is unlikely that adequate and quality health services can be provided. Private sector contributions are not reflected in the existing plans reviewed and are difficult to assess. However, it is unlikely that the high poverty levels in most of the study countries can allow adequate private contributions to bridge the gap in financing the mental health sector.

The human resources available in the health system to support integration of mental health into PHC are summarized in Table 1. Documents reviewed during this study indicated that South Africa has 0.28 per 100,000 populations Uganda has 0.09 psychiatrists per 100,000 populations. Nigeria has 0.1 per 100,000 populations; India and Ethiopia have 0.07 psychiatrists per 100,000 populations while Nepal has 0.13 per 100,000 populations. Our findings above indicate that the number of psychiatrists in relation to the population of the study countries is still unacceptably low. The number of other critical cadres such as psychiatric nurses were also insufficient (Table 1).

As indicated in Table 1, in terms of mental health services, South Africa has 23 mental hospitals and 41 psychiatric units in the general hospitals. Uganda has 1 mental hospital, and 16 units in general hospitals; while Nigeria has 8 mental hospitals, and 28 units in general hospitals. India has 43 mental hospitals and 10,000 units in general hospitals; while Nepal has 1 mental hospital and 17 units in general hospitals. The number of psychiatric beds per 100,000 population was also insufficient in all countries (Table 1).

In Ethiopia, the national mental health strategy has programs specified and some are related to IEC. In Nepal and Uganda, integration of mental health into IEC is not explicitly stated. For Nigeria and South Africa, National Mental health policies include integration of mental health into information, education and communication and set the specific indicators. No integration of mental health into information, education and communication programs was reported at district/regional level in all the study countries. It is however, important to note that even when integration of IEC is stated in the policy framework(s), IEC programs might not exist in the study countries.

In Nepal and Nigeria, the general mental health policy does not directly focus on HIV and mental health. In Ethiopia, Uganda and South Africa, people living with HIV and AIDS are identified as a vulnerable group needing targeted mental health interventions.

It is only South Africa where treatment programs for maternal mental health are specifically mentioned in the mental health policy. The new policy of India also focuses on maternal mental health as a sector. It emphasizes the need to increase access to mental health services along with child and reproductive health services. There is no specific mention of maternal mental health in the National Mental Health Policy of Nepal and Nigeria. In Ethiopia, maternal mental health is mentioned under vulnerable groups in the National Mental Health Strategy.

Review of national health plans and program reports indicated that there is limited provision for integration of mental health in general health services in all study countries. Though mental health care is part of the pre-service training for most health workers in the study countries, there is no uniform in-service training in any of the countries. Levels of skill to manage mental health issues were reported to be low at district levels in all the study districts. Most study districts had low level mental health cadres (for example nurses). There are in-service training opportunities in selected districts (sites) to facilitate the integration of mental health into primary health care (public health centers) using the mhGAP Intervention Guide training module (http://​www.​who.​int/​mental_​health/​mhgap/​en/​). However, no comprehensive evaluation reports are available so far on the impact of these trainings in the study countries with the exception of Nigeria [22].

In terms of equity, the South Africa mental health policy and the draft Uganda mental health policy recognize gender issues in mental health service provision. Nigeria’s mental health policy recognizes women under the category of the disadvantaged, requiring special care. In Nepal and India, no gender related issues are directly addressed in the existing general health policy. In Ethiopia, perinatal mothers with mental health problems are recognized as a special group, and for Uganda, all women (perinatal mothers inclusive) are mentioned among the vulnerable groups in the draft mental health policy.

In Uganda and South Africa, the existing mental health policies are linked to poverty reduction and the poor are a special category to be targeted. Similarly, in the rest of the study sites, the poor are targeted under the general health policies. No policy or strategy explicitly addresses issues of equity in relation to rural/urban residence in any EMERALD country.

In South Africa, disability issues are addressed in the mental health policy. In Uganda, Nigeria, India, and Nepal, disability is classified under disadvantaged groups or groups with special needs in the general mental health policy. In Ethiopia, it is not specified in the disadvantaged groups or those identified with special needs. For South Africa, a disability grant is available nationally for persons with physical or mental disability that renders person unfit for work for a period longer than 6 months. Furthermore, there is a strategy to address vulnerable members of society including children and the disabled to promote integration into workplace and communities and enhance skills development to promote self-worth and enhance quality of life. However, there is no evaluation as to whether these services are equitable in the study countries, where they are available.

The National Health Management Information System (HMIS) system of Nepal, South Africa, Ethiopia and Uganda capture mental health indicators; but the HMIS of India and Nigeria do not have mental health indicators. The content of each HMIS for mental health is detailed in our paper on indicators for routine monitoring of effective mental healthcare coverage in low- and middle-income settings: a Delphi study (Mark Jordan).

There are however challenges in study countries about the quality of indicators used to capture mental health issues. For example, in South Africa the mental health indicators at PHC level are only two: numbers screened and numbers treated. These do not help with tracking identification and management of specific disorders where diagnosis and severity would be helpful.

This situation analysis is based purely on documents review. Since mental health is largely given low priority, the level of resources and documentation of mental health resources is low. However, with the support from the senior mental health workers in the study countries, vital documents were secured that have supported this review process. While some countries had new documents in terms of laws and policies, others had quite old legislation and polices. It was therefore difficult to set a uniform time frame for the review due to the above reason. Despite this limitation, study countries were using the old laws and policies to support integration of mental health into primary health care and this forms the major reason for their inclusion into this review. It would have been enriched further by interview data (such as key informant interviews; which were not conducted at that time due to resource limitations). Despite this limitation, this review provides useful information to deepen the understanding of the health systems resources available for integrating of mental health into PHC.