Strengthening mental health system governance in six low- and middle-income countries in Africa and South Asia: challenges, needs and potential strategies

Abstract

Poor governance has been identified as a barrier to effective integration of mental health care in low- and middle-income countries. Governance includes providing the necessary policy and legislative framework to promote and protect the mental health of a population, as well as health system design and quality assurance to ensure optimal policy implementation. The aim of this study was to identify key governance challenges, needs and potential strategies that could facilitate adequate integration of mental health into primary health care settings in low- and middle-income countries. Key informant qualitative interviews were held with 141 participants across six countries participating in the Emerging mental health systems in low- and middle-income countries (Emerald) research program: Ethiopia, India, Nepal, Nigeria, South Africa, and Uganda. Data were transcribed (and where necessary, translated into English) and analysed thematically using framework analysis, first at the country level, then synthesized at a cross-country level. While all the countries fared well with respect to strategic vision in the form of the development of national mental health policies, key governance strategies identified to address challenges included: strengthening capacity of managers at sub-national levels to develop and implement integrated plans; strengthening key aspects of the essential health system building blocks to promote responsiveness, efficiency and effectiveness; developing workable mechanisms for inter-sectoral collaboration, as well as community and service user engagement; and developing innovative approaches to improving mental health literacy and stigma reduction. Inadequate financing emerged as the biggest challenge for good governance. In addition to the need for overall good governance of a health care system, this study identifies a number of specific strategies to improve governance for integrated mental health care in low- and middle-income countries.

Knowledge and training in paediatric medical traumatic stress and trauma-informed care among emergency medical professionals in low- and middle-income countries

“…Consistent with previous research conducted amongst both emergency staff and paediatricians in high-income countries, a lack of training and confusing evidence on what to do to assist children and families were identified as barriers to the provision of trauma-informed care (Banh et al, 2008; Horowitz et al, 2001). The experience of systemic barriers to the implementation of trauma-informed care (including a lack of support from supervisors and the system as a whole in doing so) are consistent with past research which has identified poor governance as a barrier to the integration of mental health care in LMICs (Petersen et al, 2017). Lack of referral resources for patients identified as being at risk compounds the problem as mental health resources, particularly those tailored to child and adolescent patients, are scarce in many LMICs (Kakuma et al, 2011; Kieling et al, 2011).…”

“…Lack of referral resources for patients identified as being at risk compounds the problem as mental health resources, particularly those tailored to child and adolescent patients, are scarce in many LMICs (Kakuma et al, 2011; Kieling et al, 2011). In addition to improving knowledge, reducing systemic barriers is an important step in creating trauma-informed health care systems, which requires organizations to be committed to addressing the impact of trauma on children and families (Kassam-Adams, 2014; Ko et al, 2008; Marsac et al, 2015; Petersen et al, 2017). Further, as time constraints were frequently identified as a barrier to providing trauma-informed care, training programmes that are developed for staff in these regions should aim to be brief and time efficient.…”

Assessing capability for implementing mental health counselling within primary care facilities in a middle‐income country: A feasibility study

“…In the past decade, there has been a drive to scale up the task sharing of mental health counselling in primary care services within LMICs (Lund et al, 2012;Petersen et al, 2017). While these efforts have identified systemic and policy barriers to implementation (Hanlon et al, 2017;Petersen et al, 2017), less attention has been given to the preparedness of PHC facilities for counselling implementation.…”

One year prevalence of psychotic disorders among first treatment contact patients at Butabika National Psychiatric Referral Hospital in Uganda

“…The hospital is located in the heart of the Greater Kampala Metropolitan Area (GKMA) where 10% of Uganda’s population reside and responsible for a third of the country’s gross domestic product (GDP) (36). Butabika National Psychiatric Referral and Teaching Hospital determines the policy agenda for mental health in the country together with the Ministry Of Health and is responsible for various levels of mental health training (37). It also plays a supervisory role over all mental health provision services in the country that include 12 regional referral hospitals and 96 district hospitals.…”