title: Challenges and opportunities for implementing integrated mental health care: a district level situation analysis from five low- and middle-income countries.
abstract: BACKGROUND
  Little is known about how to tailor implementation of mental health services in low- and middle-income countries (LMICs) to the diverse settings encountered within and between countries. In this paper we compare the baseline context, challenges and opportunities in districts in five LMICs (Ethiopia, India, Nepal, South Africa and Uganda) participating in the PRogramme for Improving Mental health carE (PRIME). The purpose was to inform development and implementation of a comprehensive district plan to integrate mental health into primary care.
  
  
  METHODS
  A situation analysis tool was developed for the study, drawing on existing tools and expert consensus. Cross-sectional information obtained was largely in the public domain in all five districts.
  
  
  RESULTS
  The PRIME study districts face substantial contextual and health system challenges many of which are common across sites. Reliable information on existing treatment coverage for mental disorders was unavailable. Particularly in the low-income countries, many health service organisational requirements for mental health care were absent, including specialist mental health professionals to support the service and reliable supplies of medication. Across all sites, community mental health literacy was low and there were no models of multi-sectoral working or collaborations with traditional or religious healers. Nonetheless health system opportunities were apparent. In each district there was potential to apply existing models of care for tuberculosis and HIV or non-communicable disorders, which have established mechanisms for detection of drop-out from care, outreach and adherence support. The extensive networks of community-based health workers and volunteers in most districts provide further opportunities to expand mental health care.
  
  
  CONCLUSIONS
  The low level of baseline health system preparedness across sites underlines that interventions at the levels of health care organisation, health facility and community will all be essential for sustainable delivery of quality mental health care integrated into primary care.
authors.affiliation: Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia ; Centre for Global Mental Health, Institute of Psychiatry, King's College London, London, United Kingdom.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Hanlon
authors.affiliation: Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal.
authors.forename: Nagendra P
authors.initials: NP
authors.lastname: Luitel
authors.affiliation: School of Psychology, University of KwaZulu-Natal, Durban, South Africa.
authors.forename: Tasneem
authors.initials: T
authors.lastname: Kathree
authors.affiliation: PRIME India team, Sangath Non-Governmental Organisation, Goa, India.
authors.forename: Vaibhav
authors.initials: V
authors.lastname: Murhar
authors.affiliation: PRIME India team, Sangath Non-Governmental Organisation, Goa, India.
authors.forename: Sanjay
authors.initials: S
authors.lastname: Shrivasta
authors.affiliation: Aklilu-Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia.
authors.forename: Girmay
authors.initials: G
authors.lastname: Medhin
authors.affiliation: Butabika National Mental Hospital, Kampala, Uganda.
authors.forename: Joshua
authors.initials: J
authors.lastname: Ssebunnya
authors.affiliation: Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
authors.forename: Abebaw
authors.initials: A
authors.lastname: Fekadu
authors.affiliation: Centre for Mental Health, Public Health Foundation of India, New Delhi, India.
authors.forename: Rahul
authors.initials: R
authors.lastname: Shidhaye
authors.affiliation: School of Psychology, University of KwaZulu-Natal, Durban, South Africa.
authors.forename: Inge
authors.initials: I
authors.lastname: Petersen
authors.affiliation: Department of Research and Development, HealthNet Transcultural Psychosocial Organisation, Amsterdam, The Netherlands ; Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Mark
authors.initials: M
authors.lastname: Jordans
authors.affiliation: Butabika National Mental Hospital, Kampala, Uganda.
authors.forename: Fred
authors.initials: F
authors.lastname: Kigozi
authors.affiliation: Health Service and Population Research Department, Institute of Psychiatry, King's College London, London, United Kingdom.
authors.forename: Graham
authors.initials: G
authors.lastname: Thornicroft
authors.affiliation: Sangath Non-Governmental Organisation, Goa, India ; Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Vikram
authors.initials: V
authors.lastname: Patel
authors.affiliation: Centre for Public Mental Health, Department of Psychology, Stellenbosch University and Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa.
authors.forename: Mark
authors.initials: M
authors.lastname: Tomlinson
authors.affiliation: Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa.
authors.forename: Crick
authors.initials: C
authors.lastname: Lund
authors.affiliation: Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa.
authors.forename: Erica
authors.initials: E
authors.lastname: Breuer
authors.affiliation: Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Mary
authors.initials: M
authors.lastname: De Silva
authors.affiliation: Centre for Global Mental Health, Institute of Psychiatry, King's College London, London, United Kingdom.
authors.forename: Martin
authors.initials: M
authors.lastname: Prince
mesh_terms: D003150:Community Health Workers; D003156:Community Mental Health Services / Q000191:economics* / Q000458:organization & administration*; D003430:Cross-Sectional Studies; D003906:Developing Countries; D005002:Ethiopia; D015658:HIV Infections / Q000628:therapy; D006297:Health Services Accessibility; D006801:Humans; D007194:India; D009390:Nepal; D011203:Poverty; D011320:Primary Health Care / Q000458:organization & administration; D015397:Program Evaluation; D011634:Public Health; D013019:South Africa; D014376:Tuberculosis / Q000628:therapy; D014454:Uganda