Three quarters of the global disease burden associated with mental, neurological and substance use (MNS) disorders occur in low- and middle-income countries (LMICs). Despite this high burden, a large treatment gap exists in many LMICs as there are insufficient resources available to provide adequate mental health care. It is estimated that 80% of people with MNS disorders in low-income countries do not receive treatment. In addition, the social stigma attached to mental illnesses in many LMICs can result in economic and social disadvantage for those with MNS disorders and their families.
Much of the current work on global mental health is focused on the prevalence of MNS disorders and evidence building for effective and feasible localised interventions. There is currently limited knowledge on the mechanisms needed to strengthen mental health services and integrate them into health systems at the district, regional and national levels in LMICs.
The European Union funded Emerging Mental Health Systems in Low- and Middle-Income Countries (Emerald) programme aims to improve mental health outcomes in six LMICs (Uganda, Ethiopia, India, Nepal, Nigeria, and South Africa). The programme’s objective is to generate evidence and capacity to enhance the integration of mental health care into the health systems of these six countries, whilst improving service performance in order to reduce the treatment gap.
Emerald aims to achieve this by identifying key barriers to the effective delivery of mental health services, and through consultation with country stakeholders, offer solutions for improved delivery in the future. The project’s three main objectives are: 1) to identify health system resources, financing mechanisms and information to provide adequate, fair and sustainable resourcing for scaled-up mental health services and universal coverage, 2) to understand the governance processes that facilitate or impede the development of policies and system planning for integrated physical and mental health service provision, and 3) to develop and use indicators to monitor the coverage of mental health care and the system’s performance.
A key aim of the Emerald project is to empower, equip and facilitate the involvement of service users and their caregivers in the strengthening of mental health care, as evidence of such activities is limited in LMICs. Engaged service users and caregivers can provide important insights into system challenges and help to create a mental health system which is accountable and responsive to the needs of its users. In India, situation analysis found extremely low levels of service user and care giver involvement due to unmet treatment needs, high levels of social stigma and provider-centric systems, which lead to substantial power differentials between service users and providers. Overcoming these barriers is likely to be a stepwise progression, which begins by assessing and meeting the needs of service users and their caregivers, followed by the empowerment and mobilization of service users in their individual care, before meaningful collective involvement. Societal and system-level barriers must first be identified and addressed in order to facilitate effective strengthening of mental health care within health systems in LMICs.
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