title: 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.
authors.affiliation: School of Nursing and Public Health and School of Applied Human Sciences, University of Kwazulu-Natal, Howard College, Mazisi Kunene Road, Glenwood, Durban 4001, South Africa.
authors.forename: Inge
authors.initials: I
authors.lastname: Petersen
authors.affiliation: Undergraduate Research Office, Research Development and Support Division, Faculty of Medicine & Health Sciences, University of Stellenbosch, P.O. Box 241, Cape Town 8000, South Africa.
authors.forename: Debbie
authors.initials: D
authors.lastname: Marais
authors.affiliation: Department of Psychiatry, University of Ibadan, Queen Elizabeth Road, Ibadan 1205, Nigeria.
authors.forename: Jibril
authors.initials: J
authors.lastname: Abdulmalik
authors.affiliation: Public Health Foundation of India, Plot Number 47, Sector 44, Gurgaon, Delhi 122002, India.
authors.forename: Shalini
authors.initials: S
authors.lastname: Ahuja
authors.affiliation: Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Tikur Anbessa Hospital, Addis Ababa, P.O. 9086, Ethiopia.
authors.forename: Atalay
authors.initials: A
authors.lastname: Alem
authors.affiliation: Department of Mental Health and Substance Abuse, World Health Organization, 20 Avenue Appia, Geneva 1211, Switzerland.
authors.forename: Dan
authors.initials: D
authors.lastname: Chisholm
authors.affiliation: School of Nursing and Public Health and School of Applied Human Sciences, University of Kwazulu-Natal, Howard College, Mazisi Kunene Road, Glenwood, Durban 4001, South Africa.
authors.forename: Catherine
authors.initials: C
authors.lastname: Egbe
authors.affiliation: Department of Psychiatry, University of Ibadan, Queen Elizabeth Road, Ibadan 1205, Nigeria.
authors.forename: Oye
authors.initials: O
authors.lastname: Gureje
authors.affiliation: Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Tikur Anbessa Hospital, Addis Ababa, P.O. 9086, Ethiopia.|Institute of Psychiatry, Psychology and Neuroscience, Center for Global Mental Health, King's College London, De Crespigny Park, London, SE5 8AF, UK.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Hanlon
authors.affiliation: Institute of Psychiatry, Psychology and Neuroscience, Center for Global Mental Health, King's College London, De Crespigny Park, London, SE5 8AF, UK.|Department of Psychiatry and Mental Health, Alan J Flisher Centre for Public 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: Public Health Foundation of India, Plot Number 47, Sector 44, Gurgaon, Delhi 122002, India.
authors.forename: Rahul
authors.initials: R
authors.lastname: Shidhaye
authors.affiliation: Institute of Psychiatry, Psychology and Neuroscience, Center for Global Mental Health, King's College London, De Crespigny Park, London, SE5 8AF, UK.|Department of Research and Development, HealthNet TPO, Lizzy Ansinghstraat 163, Amsterdam, RG 1073, Netherlands.
authors.forename: Mark
authors.initials: M
authors.lastname: Jordans
authors.affiliation: Butabika National Referral and Teaching, Mental Hospital, P.O. Box 7017, Kampala, Uganda.
authors.forename: Fred
authors.initials: F
authors.lastname: Kigozi
authors.affiliation: Butabika National Referral and Teaching, Mental Hospital, P.O. Box 7017, Kampala, Uganda.
authors.forename: James
authors.initials: J
authors.lastname: Mugisha
authors.affiliation: Transcultural Psychosocial Organization (TPO), Kathmandu, CPC 612, Nepal.
authors.forename: Nawaraj
authors.initials: N
authors.lastname: Upadhaya
authors.affiliation: Institute of Psychiatry, Psychology and Neuroscience, Center for Global Mental Health, King's College London, De Crespigny Park, London, SE5 8AF, UK.
authors.forename: Graham
authors.initials: G
authors.lastname: Thornicroft
mesh_terms: D000349:Africa; D001208:Asia; D003695:Delivery of Health Care / Q000191:economics / Q000331:legislation & jurisprudence* / Q000458:organization & administration; D003906:Developing Countries; D005260:Female; D006078:Government Programs; D006291:Health Policy; D006801:Humans; D008297:Male; D008605:Mental Health Services / Q000191:economics / Q000331:legislation & jurisprudence* / Q000458:organization & administration; D011320:Primary Health Care / Q000458:organization & administration
keywords: Africa; Asia; governance; mental health