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BackgroundCurrent coverage of mental healthcare in low- and middle-income countries is very limited, not only in terms of access to services but also in terms of financial protection of individuals in need of care and treatment.AimsTo identify the challenges, opportunities and strategies for more equitable and sustainable mental health financing in six sub-Saharan African and South Asian countries, namely Ethiopia, India, Nepal, Nigeria, South Africa and Uganda.MethodIn the context of a mental health systems research project (Emerald), a multi-methods approach was implemented consisting of three steps: a quantitative and narrative assessment of each country’s disease burden profile, health system and macro-fiscal situation; in-depth interviews with expert stakeholders; and a policy analysis of sustainable financing options.ResultsKey challenges identified for sustainable mental health financing include the low level of funding accorded to mental health services, widespread inequalities in access and poverty, although opportunities exist in the form of new political interest in mental health and ongoing reforms to national insurance schemes. Inclusion of mental health within planned or nascent national health insurance schemes was identified as a key strategy for moving towards more equitable and sustainable mental health financing in all six countries.ConclusionsIncluding mental health in ongoing national health insurance reforms represent the most important strategic opportunity in the six participating countries to secure enhanced service provision and financial protection for individuals and households affected by mental disorders and psychosocial disabilities.Declaration of interestD.C. is a staff member of the World Health Organization.
Informed by frameworks developed for other disease priorities in the health sector – such as HIV – the Emerald project developed a streamlined, stepped approach to informing and evaluating country-level financing needs in the area of mental health. Key domains of the Emerald sustainable financing framework include: As shown in Fig. 1, the Emerald project has undertaken an interrelated series of specific research activities along the pathway to determining strategic financing needs for the future, some already reported. In support of domain 1, assessment of the economic burden of mental disorders has been accomplished via a household survey carried out in the six participating countries, which has provided new information on healthcare expenditures, income and production losses and coping mechanisms of households containing a member with MNS disorder.16 In support of domain 2, information on disease burden and health system capacities has been used to generate estimates of overall resource needs and costs associated with the scaled-up delivery of effective and cost-effective interventions in each of the Emerald countries, which has indicated the level of investment needed to move towards universal health coverage.17 Here in this and the associated country-specific papers, the remaining assessment domains of our framework are analysed. Emerald project’s conceptual framework for sustainable mental health financing. In each country, a detailed situational assessment was carried out to better understand the context, barriers and opportunities for more sustainable mental health financing. These national assessments were structured around several domains, subdomains and key indicators, and were subsequently aggregated into a synthesis report that highlighted strengths and weaknesses of the current system or situation, as well as opportunities for and threats to more equitable and sustainable mental health financing. Country-specific estimates of the public health consequences of mental disorders were obtained from local prevalence surveys as well as World Health Organization (WHO) global health estimates databases (http://www.who.int/healthinfo/global_burden_disease/), including rates of prevalence, suicide and disability-adjusted life years. WHO’s health systems framework was used as a suitable structure for carrying out this assessment, which includes six functions or ‘building blocks’ for health system strengthening: governance; health workforce; financing; service delivery; essential health technologies; and information systems.20 Application of this framework to the mental health (and overall health) situation of each country provides relevant contextual information and raises important questions for sustainable financing, such as whether a strategic vision for the future of mental health system and service development is in place and, if so, whether appropriate laws and resources have been committed to enable its realisation. Each country’s overall health system as well as mental health system was described and characterised, informed by nationally available reports and other documentation available through Ministries of Health, Finance and other relevant government departments concerning governance (policies, plans and laws), service availability and access (service organisation, programming and delivery), and financing, as well as health status or outcomes. Particular attention was given to understanding overall health expenditure trends and the contributions made by households towards the cost of healthcare, with reference made to WHO’s global health expenditure database (http://www.who.int/health-accounts). A further level of assessment involved building up an understanding of the broader macro-fiscal context within which scale-up plans and activities are to take place. A country that is experiencing and expecting a prolonged period of economic growth, with manageable levels of indebtedness and a robust tax collection system, is likely to have a very different set of policy options compared with a country with a stagnant economy and/or one with a high level of indebtedness and reliance on external development assistance. In other words, the former country can be expected to have fewer constraints on public spending and therefore more scope to expand services. Accordingly, measures of macroeconomic performance and progress were collated, including current and projected output (total and per capita gross domestic product (GDP)), levels of borrowing and debt (as a percentage of GDP), inflation (year-on-year change in consumer price levels) and (un)employment. Measures of poverty and income inequality provide important complementary information on the distribution of national wealth. Much of the cross-country comparison data were obtained from the World Bank’s development indicators database (https://data.worldbank.org/data-catalog/world-development-indicators). A critical phase of development for identifying potentially feasible strategies for more sustainable mental health financing was the conduct of a series of semi-structured interviews with a range of relevant stakeholders. The Emerald project developed an in-depth mental health financing diagnostic tool, which consisted of four semi-structured interview questionnaires that were adapted for local country use to guide the qualitative interviews with key stakeholders (available at https://www.emerald-project.eu/tools-instruments). These stakeholder interviews were designed to: (a) gain a deeper understanding of the processes for (and potential opposition to) health financing reform, including for mental health, (b) validate emerging findings and implications of the (desk-based) national situational assessments, and (c) activate a participatory, consensus-building approach towards the articulation of sustainable financing mechanisms for mental health services in each country. Findings from the in-depth interviews were grouped under three overarching themes: (a) perceived challenges/constraints (to increased public health financing, including for mental health); (b) options for change (for increased financing for public health including mental health); and (c) key elements/criteria (for improved public health financing, including mental health). Findings and insights from the national assessments and in-depth interviews, together with other accrued project evidence and information relating to resource needs for scale up and the extent of inadequate mental health service access or coverage on household welfare, enabled country teams to identify a set of options for moving towards more sustainable mental health financing (domain 6 of the framework). A generic mental health financing algorithm was developed by the project team to facilitate identification of the main possible mechanisms through which new or existing resources for mental health could be realised (Fig. 2). This algorithm was then populated and adapted as required by the country teams. Emerging options were subsequently subjected to a set of criteria to better isolate those with the greatest utility and feasibility, including: the potential for raising revenue (for health and mental health); the potential for increased equity and financial/social protection; the potential for stable and/or sustainable financing; feasibility (cost, implementation, political acceptability); and links to or integration with other priority health programmes (for example maternal and child health, non-communicable diseases). Emerald project’s mental health financing algorithm.
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