title: Health systems context(s) for integrating mental health into primary health care in six Emerald countries: a situation analysis.
abstract: BACKGROUND
  Mental, neurological and substance use disorders contribute to a significant proportion of the world's disease burden, including in low and middle income countries (LMICs). In this study, we focused on the health systems required to support integration of mental health into primary health care (PHC) in Ethiopia, India, Nepal, Nigeria, South Africa and Uganda.
  
  
  METHODS
  A checklist guided by the World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS) was developed and was used for data collection in each of the six countries participating in the Emerging mental health systems in low and middle-income countries (Emerald) research consortium. The documents reviewed were from the following domains: mental health legislation, health policies/plans and relevant country health programs. Data were analyzed using thematic content analysis.
  
  
  RESULTS
  Three of the study countries (Ethiopia, Nepal, Nigeria, and Uganda) were working towards developing mental health legislation. South Africa and India were ahead of other countries, having enacted recent Mental Health Care Act in 2004 and 2016, respectively. Among all the 6 study countries, only Nepal, Nigeria and South Africa had a standalone mental health policy. However, other countries had related health policies where mental health was mentioned. The lack of fully fledged policies is likely to limit opportunities for resource mobilization for the mental health sector and efforts to integrate mental health into PHC. Most countries were found to be allocating inadequate budgets from the health budget for mental health, with South Africa (5%) and Nepal (0.17%) were the countries with the highest and lowest proportions of health budgets spent on mental health, respectively. Other vital resources that support integration such as human resources and health facilities for mental health services were found to be in adequate in all the study countries. Monitoring and evaluation systems to support the integration of mental health into PHC in all the study countries were also inadequate.
  
  
  CONCLUSIONS
  Integration of mental health into PHC will require addressing the resource limitations that have been identified in this study. There is a need for up to date mental health legislation and policies to engender commitment in allocating resources to mental health services.
authors.affiliation: Kyambogo University, Kampala, Uganda ; Butabika Hospital Emerald Project, Kampala, Uganda ; Stellenbosch University, Stellenbosch, South Africa.
authors.forename: James
authors.initials: J
authors.lastname: Mugisha
authors.affiliation: Department of Psychiatry, WHO Collaborating Centre for Research and Training in Mental Health and Neuroscience, University of Ibadan, Ibadan, Nigeria.
authors.forename: Jibril
authors.initials: J
authors.lastname: Abdulmalik
authors.affiliation: College of Health Sciences, School of Medicine, Department of Psychiatry, Addis Ababa University, Addis Ababa, Ethiopia ; Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Hanlon
authors.affiliation: EMERALD Project, School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa.
authors.forename: Inge
authors.initials: I
authors.lastname: Petersen
authors.affiliation: Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK ; Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, 46 Sawkins Road, Rondebosch, Cape Town, 7700 South Africa.
authors.forename: Crick
authors.initials: C
authors.lastname: Lund
authors.affiliation: Transcultural Psychosocial Organization (TPO) Nepal, Baluwatar, 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, London, UK.
authors.forename: Shalini
authors.initials: S
authors.lastname: Ahuja
authors.affiliation: Public Health Foundation of India, Gurgaon, India.
authors.forename: Rahul
authors.initials: R
authors.lastname: Shidhaye
authors.affiliation: EMERALD Project, School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa.
authors.forename: Ntokozo
authors.initials: N
authors.lastname: Mntambo
authors.affiliation: College of Health Sciences, School of Medicine, Department of Psychiatry, Addis Ababa University, Addis Ababa, Ethiopia.
authors.forename: Atalay
authors.initials: A
authors.lastname: Alem
authors.affiliation: Department of Psychiatry, WHO Collaborating Centre for Research and Training in Mental Health and Neuroscience, University of Ibadan, Ibadan, Nigeria.
authors.forename: Oye
authors.initials: O
authors.lastname: Gureje
authors.affiliation: Butabika Hospital Emerald Project, Kampala, Uganda.
authors.forename: Fred
authors.initials: F
authors.lastname: Kigozi