title: Mental health care in Nepal: current situation and challenges for development of a district mental health care plan.
abstract: BACKGROUND
  Globally mental health problems are a serious public health concern. Currently four out of five people with severe mental illness in Low and Middle Income Countries (LMIC) receive no effective treatment. There is an urgent need to address this enormous treatment gap. Changing the focus of specialist mental health workers (psychiatrists and psychologists) from only service delivery to also designing and managing mental health services; building clinical capacity of the primary health care (PHC) workers, and providing supervision and quality assurance of mental health services may help in scaling up mental health services in LMICs. Little is known however, about the mental health policy and services context for these strategies in fragile-state settings, such as Nepal.
  
  
  METHODS
  A standard situation analysis tool was developed by the PRogramme for Improving Mental health carE (PRIME) consortium to systematically analyze and describe the current gaps in mental health care in Nepal, in order to inform the development of a district level mental health care plan (MHCP). It comprised six sections; general information (e.g. population, socio-economic conditions); mental health policies and plans; mental health treatment coverage; district health services; and community services. Data was obtained from secondary sources, including scientific publications, reports, project documents and hospital records.
  
  
  RESULTS
  Mental health policy exists in Nepal, having been adopted in 1997, but implementation of the policy framework has yet to begin. In common with other LMICs, the budget allocated for mental health is minimal. Mental health services are concentrated in the big cities, with 0.22 psychiatrists and 0.06 psychologists per 100,000 population. The key challenges experienced in developing a district level MHCP included, overburdened health workers, lack of psychotropic medicines in the PHC, lack of mental health supervision in the existing system, and lack of a coordinating body in the Ministry of Health and Population (MoHP). Strategies to overcome these challenges included involvement of MoHP in the process, especially by providing psychotropic medicines and appointing a senior level officer to facilitate project activities, and collaboration with National Health Training Centers (NHTC) in training programs.
  
  
  CONCLUSIONS
  This study describes many challenges facing mental health care in Nepal. Most of these challenges are not new, yet this study contributes to our understanding of these difficulties by outlining the national and district level factors that have a direct influence on the development of a district level mental health care plan.
authors.affiliation: Research Department, Transcultural Psychosocial Organization (TPO), Kathmandu, Nepal.
authors.forename: Nagendra P
authors.initials: NP
authors.lastname: Luitel
authors.affiliation: Research and Development Department, HealthNet TPO, Lizzy Ansinghstraat 163, 1073 RG, Amsterdam, The Netherlands ; Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Box P029 De Crespigny Park, London, SE5 8AF UK.
authors.forename: Mark Jd
authors.initials: MJ
authors.lastname: Jordans
authors.affiliation: Research Department, Transcultural Psychosocial Organization (TPO), Kathmandu, Nepal.
authors.forename: Anup
authors.initials: A
authors.lastname: Adhikari
authors.affiliation: Research Department, Transcultural Psychosocial Organization (TPO), Kathmandu, Nepal.
authors.forename: Nawaraj
authors.initials: N
authors.lastname: Upadhaya
authors.affiliation: Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Box P029 De Crespigny Park, London, SE5 8AF UK ; Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Hanlon
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: Research and Development Department, HealthNet TPO, Lizzy Ansinghstraat 163, 1073 RG, Amsterdam, The Netherlands ; Faculty of Social and Behavioural Sciences, Utrecht University, Utrecht, The Netherlands.
authors.forename: Ivan H
authors.initials: IH
authors.lastname: Komproe
keywords: Integration of mental health into PHC; Mental health; Mental health care plan; Nepal; Situation analysis