In its recently published Mental health Gap Action Programme (mhGAP) operations manual, the World Health Organization stressed the enormous global disease burden that mental, neurological and substance use (MNS) conditions impose – with low- and middle-income countries (LMICs) bearing the brunt. The lack, and poor structuring, of the most basic mental health care services contribute to 76 – 85% of people with MNS conditions living without appropriate care. In many LMICs, this treatment gap exceeds 90% .
Over the past eight years the Programme for Improving Mental Healthcare (PRIME), a research consortium led from the University of Cape Town, has been conducting research in five LMICs to develop models to addressing this ever-growing problem in low-resource settings. Planning, piloting and then scaling up district-specific integrated mental healthcare plans  in Ethiopia, India, Nepal, South Africa and Uganda has allowed us to gain insight into the complex issues informing the mhGAP. The plans included interventions at three levels: the healthcare organization, the facility and the community. At each of these levels intervention packages were delivered to raise awareness, improve detection, increase access to care, support recovery and enable health systems strengthening.
Our evaluation of the implementation of these district mental healthcare plans shows that it is feasible to integrate mental health into primary care in low resource settings. Our findings show significant improvements in facility-level case detection in most sites, and significant improvements in individual level clinical and functioning outcomes for most cohorts of people living with psychosis, epilepsy, depression and alcohol use disorders. But this requires substantial investment in training, supervision, and health system strengthening. For example, in India and South Africa, continuous quality improvement cycles were introduced to strengthen health systems, and in Ethiopia and Nepal, community-based case detection methods were introduced to increase demand and improve access to care.
Participation by all stakeholders in the development of district level mental health care plans is vital. We used a Theory of Change  approach to obtain stakeholder views on the intended impact of the district plans, and to articulate the steps along the causal pathway from entry to the system, to attaining the desired impact.
If we are to make an improvement in population level treatment coverage, we need demand-side interventions as well as supply-side interventions. Demand-side interventions enable and encourage individuals with MNS conditions to seek care. At the community level, these should include pro-active community case detection (as shown in the Community Informant Detection Tool using community health workers in Nepal  ), stigma reduction activities, and community education programmes.
Further research is needed on the scaling up of such treatment packages for larger populations, and the implementation of treatment packages for other priority disorders, for example disorders of childhood and adolescence. We are currently exploring funding opportunities to do further work with this neglected age group. Particularly important is the evaluation of health systems strengthening interventions that are essential if we are to deliver integrated packages of mental health care in low resource primary care settings.
 World Health Organization. “mhGAP operations manual.” (2018).
 Hanlon, Charlotte, et al. “District mental healthcare plans for five low-and middle-income countries: commonalities, variations and evidence gaps.” The British journal of psychiatry 208.s56 (2016): s47-s54.
 Breuer, Erica, et al. “Planning and evaluating mental health services in low-and middle-income countries using theory of change.” The British journal of psychiatry 208.s56 (2016): s55-s62.
 Jordans, Mark JD, et al. “Proactive community case-finding to facilitate treatment seeking for mental disorders, Nepal.” Bulletin of the World Health Organization 95.7 (2017): 531.
 Jordans, Mark JD, et al. “Accuracy of proactive case finding for mental disorders by community informants in Nepal.” The British Journal of Psychiatry 207.6 (2015): 501-506.