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Challenges and Opportunities for Implementing Integrated Mental Health Care: A District Level Situation Analysis from Five Low- and Middle-Income Countries
Open accessAbstract
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.
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![Figure 1 Requirements for integrating mental health into primary health care [14]–[17].](/paper-figures/de0e97da5958491285622b9ec34da5ac/challenges-and-opportunities-for-implementing-integrated-mental-health-care-a-figure-1.jpg)
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“but a relative lack of these types of networks made implementation more difficult [78].”
From Barriers and facilitators to implementation of evidence-based task-sharing mental health interventions in low- and middle-income countries: a systematic review using implementation science frameworks (2022) · cites this paper as [78]
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“Several of the papers assessed this issue, in general finding low levels of preparedness 50 .”
From Integrated care for people with long-term mental and physical health conditions in low-income and middle-income countries (2019) · cites this paper as [50]
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“where [18]; this paper presents in depth data regarding the current mental health situation in Nepal and de-”
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BackgroundDevelopment of a scalable mental healthcare plan for a rural district in Ethiopia
Fekadu, A., Hanlon, C., Medhin, G., Alem, A., Selamu, M., Giorgis, T. W., Shibre, T., Teferra, S., Tegegn, T., Breuer, E., et al. (2016) · British Journal of Psychiatry · doi:10.1192/bjp.bp.114.153676 · Cited by 147
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Self-citationEnablers and Barriers in Implementing Integrated Care
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BackgroundSelf-citationTreatment gap and help-seeking for postpartum depression in a rural African setting
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Self-citationTreatment gap, help-seeking, stigma and magnitude of alcohol use disorder in rural Ethiopia
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“implemented in the Sodo district of the Gurage zone, which neighbours the Silte zone [32, 33].”
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“Work packages 1–3, 6 and 7 conduct situation analyses of primary health facilities using an adapted version of the situation analysis tool developed by Programme for Improving Mental Health Care (PRIME) [19].”
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“This debate taps into ongoing questions about the limitations of tasksharing and the extent to which non-specialist workers in primary care may be expected to integrate mental health into their role whilst delivering high quality care to people with SMD (Hanlon et al. 2014; Lund et al. 2012).”
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“A number of studies have reported the process of implementing new MHISs in different countries, including the various challenges that were experienced in each of these [5, 10, 11].”
BackgroundBeyond the Biomedical: Community Resources for Mental Health Care in Rural Ethiopia
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“We propose that existing resources could potentially support the following aspects of the MHCP in Sodo district: 1.”
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Self-citationStakeholder analysis of the Programme for Improving Mental health carE (PRIME): baseline findings
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“In the last decade, substantial advances have been made in global mental health (for some reviews see [4, 12–14]).”
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“Adaptation of the task-sharing model for the study setting was informed by extensive formative work and community consultation in the study site [40] and from findings arising from a sister project implementing integrated mental health care in a neighbouring district [43, 44].”
MethodSelf-citationThe Emerging Global Health Crisis: Noncommunicable Diseases in Low- and Middle-Income CountriesPreprint
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Involvement of people with schizophrenia in decision-making in rural Ethiopia: a qualitative study
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“Sodo district is a rural area located 100 km south of Addis Ababa, the capital of Ethiopia, which is characterized by a lack of infrastructure in terms of electricity and sanitation, and a low population literacy level (45%) [46, 47].”
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“The questionnaires for the documentary analysis were based on an existing case study methodology outlined for mental health projects in LMIC [23] as well as a situational analysis tool developed for a large international program of mental health interventions in primary care [24].”
MethodSelf-citationHealth system governance to support scale up of mental health care in Ethiopia: a qualitative study
Hanlon, C., Eshetu, T., Alemayehu, D., Fekadu, A., Semrau, M., Thornicroft, G., Kigozi, F. N., Marais, D. L., Petersen, I., & Alem, A. (2017) · International Journal of Mental Health Systems · doi:10.1186/s13033-017-0144-4 · Cited by 66
“The district has a population of approximately 160,000 people and is almost 90% rural and predominantly Orthodox Christian in religion [28].”
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“Full details of the country sites are presented elsewhere [21].”
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“Although screening and treatment for mental health conditions are limited in many healthcare settings in SSA and globally [86], the integration of mental health care into Hiv testing and care settings must be a priority.”
BackgroundRecognition of depression by primary care clinicians in rural Ethiopia
Fekadu, A., Medhin, G., Selamu, M., Giorgis, T. W., Lund, C., Alem, A., Prince, M., & Hanlon, C. (2017) · BMC Family Practice · doi:10.1186/s12875-017-0628-y · Cited by 61
“As part of the PRogramme for Improving Mental health carE (PRIME), which aims to support integration of mental healthcare in five low and middle income countries [31], we conducted a study to determine the detection rate of depression in the eight primary care facilities that provide care to a population of over 160,0…”
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“Other studies have shown elsewhere the need for specialized mental health professionals to drive the process of developing and integrating mental healthcare as part of the primary healthcare system [64, 65].”
Hanlon, C., Medhin, G., Selamu, M., Birhane, R., Dewey, M. E., Tirfessa, K., Garman, E. C., Asher, L., Thornicroft, G., Patel, V., et al. (2019) · Epidemiology and Psychiatric Sciences · doi:10.1017/s2045796019000398 · Cited by 62
“Sodohas an estimated population of around160 000people (Hanlon et al., 2014).”
BackgroundSelf-citationTeferra, S., Medhin, G., Selamu, M., Bhana, A., Hanlon, C., & Fekadu, A. (2016) · BMC Public Health · doi:10.1186/s12889-016-2911-6 · Cited by 67
Self-citationAbayneh, S., Lempp, H. K., & Hanlon, C. (2020) · Research Involvement and Engagement · doi:10.1186/s40900-019-0175-x · Cited by 62
Self-citationTopp, S. M., Abimbola, S., Joshi, R., & Negin, J. (2018) · Health Policy and Planning · doi:10.1093/heapol/czx169 · Cited by 60
“…et al. 2012 Liambila et al. 2009 Chaudhary et al. 2005 Shelley et al. 2014 Kouam et al. 2014 Green et al. 2010 Sarnquist et al. 2014 Wright et al. 2014 Hanlon et al. 2014 Li et al. 2012 Kalyango et al. 2012 Smit et al. 2012 Schaan et al. 2012 Awadhi et al. 2012 Winestone et al. 2012…”
BackgroundInfluentialRathod, S. D., Roberts, T., Medhin, G., Murhar, V., Samudre, S., Luitel, N. P., Selohilwe, O., Ssebunnya, J., Jordans, M. J. D., Bhana, A., et al. (2018) · BMJ Open · doi:10.1136/bmjopen-2018-023421 · Cited by 59
Self-citationCluver, L. D., Sherr, L., Toska, E., Zhou, S., Mellins, C.-A., Omigbodun, O., Li, X., Bojo, S., Thurman, T., Ameyan, W., et al. (2022) · The Lancet Child & Adolescent Health · doi:10.1016/s2352-4642(22)00101-8 · Cited by 58
Self-citationDevelopment of a district mental healthcare plan in Uganda
Kigozi, F. N., Kizza, D., Nakku, J. E. M., Ssebunnya, J., Ndyanabangi, S., Nakiganda, B., Lund, C., & Patel, V. (2015) · The British Journal of Psychiatry · doi:10.1192/bjp.bp.114.153742 · Cited by 56
Self-citationA guide to systems-level, participatory, theory-informed implementation research in global health
Seward, N., Hanlon, C., Hinrichs, S., Lund, C., Murdoch, J., Salisbury, T. T., Verhey, R., Shidhaye, R. R., Thornicroft, G., Araya, R., et al. (2021) · BMJ Global Health · doi:10.1136/bmjgh-2021-005365 · Cited by 55
Self-citationBrooke‐Sumner, C., Lund, C., & Petersen, I. (2016) · International Journal of Mental Health Systems · doi:10.1186/s13033-016-0042-1 · Cited by 62
Self-citationAsher, L., Silva, M. J. D., Hanlon, C., Weiss, H. A., Birhane, R., Ejigu, D. A., Medhin, G., Patel, V., & Fekadu, A. (2016) · Trials · doi:10.1186/s13063-016-1427-9 · Cited by 52
“The work included a literature review, situational analysis [43, 44], an intervention development workshop, participatory meetings, qualitative interviews with a range of stakeholders, including people with schizophrenia, their caregivers, psychiatrists and community leaders, and collaboration with an existing CBR pro…”
BackgroundSelf-citationA qualitative study of methamphetamine initiation in Cape Town, South Africa
Hobkirk, A. L., Watt, M. H., MYERS, B. J., Skinner, D. G., & Meade, C. S. (2015) · International Journal of Drug Policy · doi:10.1016/j.drugpo.2015.10.006 · Cited by 52
“In a situational analysis of mental health services in multiple LMIC sites involved in the PRIME study (Lund et al., 2012), the South African site located in the North West Province had a number of advantages compared to other sites (Hanlon et al., 2014).”
InfluentialLund, C., Docrat, S., Abdulmalik, J., Alem, A., Fekadu, A., Gureje, O., Gurung, D., Hailemariam, D., Hailemichael, Y., Hanlon, C., et al. (2019) · BJPsych Open · doi:10.1192/bjo.2019.20 · Cited by 44
Self-citationMental health care and delivery system at Temeke hospital in Dar es Salaam, Tanzania
Ambikile, J. S., & Iseselo, M. K. (2017) · BMC Psychiatry · doi:10.1186/s12888-017-1271-9 · Cited by 55
“This corroborates findings from low income countries which show that many health service organization requirements for mental health care are absent [10, 18].”
BackgroundResultInfluentialUpadhaya, N., Jordans, M. J. D., Abdulmalik, J. O., Ahuja, S., Alem, A., Hanlon, C., Kigozi, F. N., Kizza, D., Lund, C., Semrau, M., et al. (2016) · International Journal of Mental Health Systems · doi:10.1186/s13033-016-0094-2 · Cited by 50
“The capacity to track changes in treatment coverage and quality of care is essential for monitoring the impact of mental health programs [22].”
Self-citationLovero, K. L., Lammie, S. L., van Zyl, A., Paul, S. N., Ngwepe, P., Mootz, J. J., Carlson, C., Sweetland, A. C., Shelton, R. C., Wainberg, M. L., et al. (2019) · BMC Health Services Research · doi:10.1186/s12913-019-3912-9 · Cited by 49
Hailemichael, Y., Hanlon, C., Tirfessa, K., Docrat, S., Alem, A., Medhin, G., Fekadu, A., Lund, C., Chisholm, D., & Mariam, D. H. (2019) · International Journal for Equity in Health · doi:10.1186/s12939-019-1020-4 · Cited by 52
Self-citationJordans, M. J. D., Chisholm, D., Semrau, M., Upadhaya, N., Abdulmalik, J. O., Ahuja, S., Alem, A., Hanlon, C., Kigozi, F. N., Mugisha, J., et al. (2016) · Health Policy and Planning · doi:10.1093/heapol/czw040 · Cited by 49
Self-citationGarman, E. C., Rathod, S. D., Hanlon, C., Prince, M. J., Fekadu, A., Kigozi, F. N., Jordans, M. J. D., Luitel, N. P., Medhin, G., Murhar, V., et al. (2018) · BMC Psychiatry · doi:10.1186/s12888-018-1642-x · Cited by 48
“graphical, social and cultural profile [14].”
Self-citationChase, L., & Sapkota, R. P. (2017) · Transcultural Psychiatry · doi:10.1177/1363461517703023 · Cited by 50
“In global mental health research currently being carried out in Nepal, informal care systems are not routinely factored into assessments of mental health needs and resources; although efforts have been made to document the ‘‘community context’’ of global mental health interventions, these have identified more formaliz…”
BackgroundHailemariam, M., Fekadu, A., Medhin, G., Prince, M., & Hanlon, C. (2019) · International Journal of Mental Health Systems · doi:10.1186/s13033-019-0332-5 · Cited by 44
Self-citationMartin, P., Murray, L. K., Darnell, D., & Dorsey, S. (2018) · Clinical Psychology: Science and Practice · doi:10.1111/cpsp.12270 · Cited by 53
“In LMIC, options for addressing the mental health treatment gap must be those that are effective, but also sustainable and affordable (Hanlon et al., 2014).”
Fekadu, A., Medhin, G., Selamu, M., Shiferaw, T., Hailemariam, M., Rathod, S. D., Jordans, M. J. D., Teferra, S., Lund, C., Breuer, E., et al. (2016) · BMC Psychiatry · doi:10.1186/s12888-016-0784-y · Cited by 46
Self-citationService user involvement for mental health system strengthening in India: a qualitative study
Samudre, S., Shidhaye, R. R., Ahuja, S., Nanda, S., Khan, A., Evans-Lacko, S. E., & Hanlon, C. (2016) · BMC Psychiatry · doi:10.1186/s12888-016-0981-8 · Cited by 44
“mental health program has been functioning through collaboration between the DMHP and the PRogram for Improving Mental health carE (PRIME) since 2011 [10, 20].”
MethodSelf-citationSubba, P., Luitel, N. P., Kohrt, B. A., & Jordans, M. J. D. (2017) · Conflict and Health · doi:10.1186/s13031-017-0132-y · Cited by 50
“Although specialized mental health services from psychiatrists were available in Chitwan through tertiary level health facilities, mental health services were non-existent in the community-based health facilities prior to PRIME implementation [9].”
BackgroundSelf-citationGyimah, F. T., & Dako‐Gyeke, P. (2019) · Globalization and Health · doi:10.1186/s12992-019-0459-9 · Cited by 43
Hailemichael, Y., Mariam, D. H., Tirfessa, K., Docrat, S., Alem, A., Medhin, G., Lund, C., Chisholm, D., Fekadu, A., & Hanlon, C. (2019) · International Journal of Mental Health Systems · doi:10.1186/s13033-019-0294-7 · Cited by 45
Self-citationCulture and mental health in Nepal: an interdisciplinary scoping review
Chase, L., Sapkota, R. P., Crafa, D., & Kirmayer, L. J. (2018) · Cambridge Prisms Global Mental Health · doi:10.1017/gmh.2018.27 · Cited by 44
“Nepal became an implementation site for several high-profile global mental health projects (Hanlon et al. 2014; Mendenhall et al. 2014; Kohrt et al. 2015; Jordans et al. 2016).”
BackgroundAgyapong, V. I. O., Osei, A. O., Farren, C. K., & McAuliffe, É. (2015) · Global Health Action · doi:10.3402/gha.v8.28955 · Cited by 42
“In a situational analysis of the challenges and opportunities at the district level of five LAMICs implementing integrated mental health care, it was reported that across all sites, community mental health literacy was low and there were no models of multisectoral working or collaborations with traditional or religiou…”
BackgroundAngdembe, M., Kohrt, B. A., Jordans, M., Rimal, D., & Luitel, N. P. (2017) · International Journal of Mental Health Systems · doi:10.1186/s13033-017-0176-9 · Cited by 39
“Many studies have recommended that formation of self-help groups, along with the family support is the major component in the process of integrating mental health services for severe mental disorders in PHC levels and community settings [44, 61].”
BackgroundSelf-citationMental health in primary health care in a rural district of Cambodia: a situational analysis
Olofsson, S., Sebastiån, M. S., & Jegannathan, B. (2018) · International Journal of Mental Health Systems · doi:10.1186/s13033-018-0185-3 · Cited by 42
“In this study, key themes from the original PRIME study were the frame for the qualitative interviews and for the structure of this article [25].”
MethodWeobong, B., Ae-Ngibise, K. A., Sakyi, L., & Lund, C. (2023) · PLoS ONE · doi:10.1371/journal.pone.0285324 · Cited by 41
“Details of the tool are provided elsewhere in the main report by Hanlon and colleagues [16], but in summary the tool comprises six sections with 156 items.”
MethodResultInfluentialSelf-citationDewidar, O., John, J., Baqar, A., Madani, M. T., Saad, A., Riddle, A. Y., Ota, E., Kung’u, J. K., Arabi, M., Raut, M. K., et al. (2023) · Campbell Systematic Reviews · doi:10.1002/cl2.1361 · Cited by 38
Jordans, M. J. D., Aldridge, L. R., Luitel, N. P., Baingana, F. K., & Kohrt, B. A. (2017) · International Journal of Mental Health Systems · doi:10.1186/s13033-017-0177-8 · Cited by 38
“Background In most low- and middle income countries (LMIC) decentralized mental health services often range from inadequate to nonexistent [1], which is particularly concerning in light of the high burden of disease associated with mental illness globally [2].”
BackgroundMethodSelf-citationMental health services in Cambodia, challenges and opportunities in a post-conflict setting
Jegannathan, B., Kullgren, G., & Deva, P. (2014) · Asian Journal of Psychiatry · doi:10.1016/j.ajp.2014.12.006 · Cited by 39
“The evidence for efficacy of mental health programs that are integrated at primary health care setting in LMICs is reassuring (Hanlon et al., 2014), and this may be a golden opportunity to”
Backgroundvan Rensburg, B. J., Kotzé, C., Moxley, K., Subramaney, U., Zingela, Z., & Seedat, S. (2021) · Health Policy and Planning · doi:10.1093/heapol/czab144 · Cited by 37
Shidhaye, R. R., Raja, A., Shrivastava, S., Murhar, V., Ramaswamy, R., & Patel, V. (2015) · Community Mental Health Journal · doi:10.1007/s10597-015-9893-1 · Cited by 37
“…of the PRIME project, a new situation analysis tool (downloadable from http://www.prime.uct. ac.za/index.php/research/tools.html) was developed (Hanlon et al. 2014) as existing methods and tools for appraising mental health systems and services in LMICs did not meet the needs of PRIME either…”
BackgroundMethodInfluentialSelf-citationFurst, M. A., Gandré, C., Romero López-Alberca, C., & Salvador-Carulla, L. (2019) · BMC Health Services Research · doi:10.1186/s12913-019-4005-5 · Cited by 45
Mental health literacy among primary healthcare workers in South Africa and Zambia
Korhonen, J., Axelin, A., Stein, D. J., Seedat, S., Mwape, L., Jansen, R., Groen, G., Grobler, G. P., Jörns‐Presentati, A., Katajisto, J., et al. (2022) · Brain and Behavior · doi:10.1002/brb3.2807 · Cited by 34
“PHC workers require specific professional training on the identification and management of mental health problems (Hanlon et al., 2014; Kapungwe et al., 2011; Marais & Peterson, 2015; Mwape et al., 2010).”
BackgroundMurphy, A., Chikovani, I., Uchaneishvili, M., Makhashvili, N., & Roberts, B. (2018) · BMC Health Services Research · doi:10.1186/s12913-018-3113-y · Cited by 31
Dadi, A. F., Miller, E. R., Azale, T., & Mwanri, L. (2021) · International Journal of Mental Health Systems · doi:10.1186/s13033-021-00466-y · Cited by 35
Community Mental Health Competencies: A New Vision for Global Mental Health
Burgess, R. A., & Mathias, K. R. (2017) · Palgrave Macmillan UK eBooks · doi:10.1057/978-1-137-39510-8_11 · Cited by 33
“For example, a recent study exploring the foundations for integrated mental health care in five low-income countries (Hanlon et al., 2014) asserts the importance of ‘community’ interventions such as adherence support, screening, and community-based psychosocial prevention.”
BackgroundDocrat, S., Besada, D., Cleary, S., & Lund, C. (2020) · Health Economics Review · doi:10.1186/s13561-020-00268-x · Cited by 32
Self-citation
Metadata
- Authors
- Hanlon, C., Luitel, N. P., Kathree, T., Murhar, V., Shrivasta, S., Medhin, G., Ssebunnya, J., Fekadu, A., Shidhaye, R., Petersen, I., Jordans, M., Kigozi, F., Thornicroft, G., Patel, V., Tomlinson, M., Lund, C., Breuer, E., De Silva, M., & Prince, M.
- Affiliations
- King's College London (GB)
- University of KwaZulu-Natal (ZA)
- Sangath (IN)
- Addis Ababa University (ET)
- Butabika Hospital (UG)
- Public Health Foundation of India (IN)
- London School of Hygiene & Tropical Medicine (GB)
- University of Cape Town (ZA)
- Corresponding author
- Hanlon, Charlotte
- ORCID
- Venue
- PLoS ONE
- Publisher
- Public Library of Science (PLoS)
- Published
- 2014-02-18
- Volume
- 9
- Issue
- 2
- Pages
- e88437
- ISSN
- 1932-6203 (ISSN-L)
- PMC
- PMC3928234
- OpenAlex
- W2151272134
- Cited by
- 339
- References
- 46
- Citations by year
- 2026: 14 · 2025: 22 · 2024: 26 · 2023: 18 · 2022: 33 · 2021: 24 · 2020: 61 · 2019: 27 · 2018: 32 · 2017: 24 · 2016: 23 · 2015: 26 · 2014: 9
- FWCI
- 40.50
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- PLoS ONE (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Research Portal (King's College London) (publishedVersion, cc-by)
- LSHTM Research Online (London School of Hygiene and Tropical Medicine) (acceptedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
- Open University of Cape Town (University of Cape Town) (submittedVersion, cc-by)
- Edinburgh Research Explorer (University of Edinburgh) (submittedVersion, cc-by)
- SUNScholar (Stellenbosch University) (submittedVersion, public-domain)
- Greater South Information System
- Funders
- Wellcome Trust (084674, 100714)
- Government of the United Kingdom
- National Institute for Health and Care Research (NF-SI-0611-10053)
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Mental Health Treatment and Access
- Social Sciences › Psychology › Clinical Psychology › Psychiatric care and mental health services
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Keywords
- integrated mental health care, primary care integration, health system preparedness, mental health literacy, community health workers, mental health professionals, intersectoral collaboration, low- and middle-income countries, district health planning
- MeSH terms
- Community Health Workers, Community Mental Health Services, Cross-Sectional Studies, Developing Countries, Ethiopia, Health Services Accessibility, Humans, India, Nepal, Poverty, Primary Health Care, Public Health, South Africa, Tuberculosis, Uganda, Program Evaluation, HIV Infections
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