Cost and budget impact of layering depression care onto existing HIV and non-communicable disease care services in Western Kenya

Abstract

Objectives:

The WHO Mental Health Action Plan aims to increase mental health care coverage by half, by 2030. Reaching this target requires context-specific financial assessments. We estimated the cost and budget impact of integrating depression care into HIV, diabetes, and hypertension care programs in county-level health facilities in Kenya.

Methods:

We modelled the additional health system costs to provide depression care within chronic disease programs in six counties in western Kenya. We estimated per-patient-per-visit costs under four scenarios: a facility-based additive scenario; two economies of scale and scope scenarios: group session psychotherapy (GSP) delivered by a trained provider within a group of 5-10 patients, with and without artistic therapy; and a community-based task shifting scenario with chronic disease care provided by psychiatry nurses. For each scenario, we estimated the annual budget impact of increasing service coverage for depression to 50% of each county’s eligible population.

Results:

Offering facility-based GSP without artistic therapy was the least expensive scenario in all counties, with a pooled median per-patient cost of $6.74 (95% CI 6.08-7.40) per depression care visit. Facility-based GSP with artistic therapy was the most expensive scenario with a median per-patient-per-visit cost of $9.79 (8.83-10.7). An additional 3.54% (3.36-3.72) of 2023 county health budgets would be needed to increase mental health service coverage by 50% by 2030.

Conclusions:

Integrating facility-based group session psychotherapy within chronic disease care platforms offers a low-cost strategy for depression care provision. Reaching mental health service targets in Kenya may require 3% more of current health budgets.

Precis:

To increase mental health care coverage by 50% by 2030, counties in Kenya will need to spend an additional 3.5% of their current healthcare budgets.

INTRODUCTION

The economic burden of mental health conditions on the Kenyan economy in 2021 was 62.2 billion Kenyan Shillings (US$571.8 million), an equivalent loss of 0.6% of the GDP in 2020.¹ Results from a community-based survey in western Kenya reported a lifetime prevalence of depression of 12.3%,² as compared to other countries in sub-Saharan Africa (SSA) where the prevalence of major depressive disorders is at 4.5%.³ Inadequate investments in mental health result in poor mental health outcomes, and impact negatively on society as a whole and the economy. There is a need for interventions to address the high mental health burden in Kenya as well as scale up for cost-effective interventions for the management of mental health to achieve national and global targets.

Non-communicable diseases (NCDs) are one of the leading public health challenges in low and middle-income countries (LMICs), contributing to 38 million deaths globally each year with most of the deaths being preventable.⁴ Globally, mental health conditions account for 32.4% of years lived with disability (YLDs) and 13.0% of disability-adjusted life-years (DALYs).⁵ Depression care entails outpatient care and primary care basic psychosocial or pharmacological management for mild, moderate, and severe cases and appropriate referral for complicated cases, which entails monthly and bi-monthly visits at primary health care facilities, fit into any of the integrated models of care¹.

The Kenya Mental Health Policy 2015–2030 seeks to address systemic challenges, respond to emerging trends, mitigate the burden of mental disorders, and integrate mental health services within all levels of the health care system.⁶ The policy outlines the role of the national government as one responsible for policy development, national referral facilities, capacity-building, and technical assistance, while county governments are tasked with promotion and provision of mental health services, emergency services, and effective mental health referral systems in their local facilities. In Kenya only 13% of all health facilities (private and government-run) provide at least one mental health service, with most of the 13% of facilities offering outpatient treatment for severe mental disorders including depression, psychosis, or bipolar disorder (12%); only 2% of facilities offer inpatient treatment for mental health conditions.¹

With a limited number of dispersed mental health facilities, patients incur high out-of-pocket costs related to travel and accommodation. The limited availability of essential mental health medications also challenges public health facilities. Out-of-pocket expenditures associated with accessing mental health services or medicines at private institutions are prohibitive for many patients.^1,7 . There are several barriers that have been identified in accessing mental health care, including long distances to tertiary hospitals, a scarcity of qualified professionals, financial constraints, and stigma⁸ . Kenya’s National Health Insurance Fund (NHIF) provides only partial coverage for some mental health and substance use disorder treatments, while most private health insurance plans do not offer any coverage for mental health services and medicines.¹ Estimates from the Kenya Demographic Health Survey (KDHS) 2022 showed that 24% of Kenyans are covered under NHIF, with almost half of the facilities being in the public sector (46%) where most of the population seek care (63%) with only 17% having mental health services available.⁹ The limited availability and funding for mental health care necessitates identifying effective and affordable models of addressing the mental health burden in Kenya.

Integrated care refers to “health services that are managed and delivered so that people receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation, and palliative care services, coordinated across the different levels and sites of service delivery within and beyond the health sector, and according to their needs throughout the life course”. People may receive all or some elements of one service incorporated into the regular functioning of another service. Models of integration can include task shifting/sharing, one-stop-shop (single facility/healthcare provider integration). In both high- and low-income countries, various models of care integration have been shown to improve treatment outcomes, reduce fragmentation, improve continuity of care, and reduce costs.^10,12 In SSA the costs of providing integrated adult mental health services for a limited number of priority mental disorders using a task-shifting approach (dedicating and supporting counselors and community health workers to the clinics) at the primary care level was estimated at USD$0.44 per person in the population served by the primary health care facility.¹⁵ Additionally, a key target of the Kenya Mental Health Action Plan 2021-2025 is to integrate mental health services into at least 50% of primary health facilities in all counties by 2022/23, and into 100% of facilities by 2025.³⁸

NCD care embedded within the Chronic Disease Management (CDM) care model is being implemented at the Academic Model Providing Access to Health Care (AMPATH), which provides health education, care, and medication to patients enrolled at Moi Teaching and Referral Hospital (MTRH).¹⁸ The AMPATH programme is an academic global health partnership between MTRH, Moi University, and a consortium of North American universities led by Indiana University.¹⁸ Since 2001, AMPATH has grown to provide care to over 165,000 people with HIV across more than 800 clinical care sites in western Kenya. AMPATH serves those from primary health care facilities through task shifting within the catchment of western Kenya for specific clinic days, to provide NCD and HIV care with coordinated referrals for specialized care at higher-level facilities.¹⁷

Despite the epidemiological need to increase access to mental health treatment services, especially for people living with HIV and other chronic conditions, there is limited data on the financial and economic resources needed to provide and scale up these services efficiently. Thus, the purpose of this study was to estimate the cost of integrating depression care into already existing HIV, diabetes, and hypertension care programs in western Kenya under different integration scenarios (facility-based additive, facility-based group session psychotherapy (GSP) with artistic therapy, facility-based GSP without artistic therapy and a community-based task shifting scenario), and to project the budget impact of scaling up integrated depression care to reach policy targets by 2030.

METHODS

Study design

We performed a cost and Budget Impact Analysis (BIA) modelling study of integrating depression care into existing HIV and NCD care. We obtained secondary data on the cost of mental health care particularly for depression in Kenya from published papers, grey literature, and expert information. The International Society for Pharmacoeconomics and Outcomes Research (ISPOR)²¹ was applied as a guidance to carry out the BIA. We first quantified the cost of depression care added onto already existing HIV and NCD care services in western Kenya from a health system provider perspective considering screening and overall care costs, which excluded treatment costs paid directly by the patient (out-of-pocket costs). We then estimated the budget impact of integrating depression care into existing HIV and NCD care platforms to achieve the WHO Mental Health Action Plan 2013-2030 target, set to attain a 50% increase in service coverage for mental health conditions by 2030.

Study setting

Western Kenya was taken as our case study setting. We focused on six counties: Uasin Gishu, Bungoma, Trans Nzoia, Nandi, Busia, and Kisumu. Counties were selected following a prior cost and budget impact analysis of CDM care layered on existing HIV services done in these counties.¹⁷ This allowed us to build the mental health care component on the existing program. HIV and CDM care services within the western Kenya region are largely provided by AMPATH.

Description of integrated care scenarios

We performed the cost and BIA for four scenarios that have been shown in literature and confirmed through expert opinion, with an assumption that all the hospitals and clinics have already existing HIV and NCD care. The base case scenario reflected a facility-based additive scenario where depression care services are provided at specialty hospitals with already existing HIV/NCD care. In this scenario, a clinical officer diagnoses and treats every patient separately on independent occasions and refers severe mental health cases to a consultant psychiatrist.

The second scenario is the economies of scale and scope scenario which offers facility-based group session psychotherapy (GSP).²⁹ Patients are given depression care within a group of 5-10 patients. Groups are led by one mental health specialist, preferably a registered psychiatry nurse with special training in mental health care. The consultant psychiatrist may be consulted when needed. This enables seeing more patients and providing care services at the same time. The third scenario offers facility-based GSP and additionally includes artistic therapy in the form of painting, drawing, or another kind of guided art practice in a group setting.

The fourth scenario is based on community-based task shifting³⁰, where trained registered psychiatry nurses are delegated to the chronic disease management (CDM) local clinics to diagnose and treat patients with HIV, NCDs, and mental health issues at the community located primary care facilities (health centers). Patients are only referred for further care to a consulting psychiatrist for acute or complicated conditions that cannot be addressed in the community. This reduces the number of patients going to referral hospitals for mental health care and subsequently cuts the costs, especially for transport that each patient would have incurred (even though we did not factor out-of-pocket costs in our analysis).

Input data and sources

We modelled the additional costs incurred by offering a depression care program on top of HIV and CDM care to allow patients to be screened and treated for depression during routine HIV and NCD care appointments. Tables S1, S2, and S3 outline the assumptions made during the analysis, the population targets considered, and the equations used in all the calculations respectively.

We extracted data from published papers, grey literature, and expert information from a Kenyan consultant psychiatrist with vast mental health experience. This included information on number of patients seen in MTRH psychiatry clinics, visit procedures undertaken, models of care, tools used for screening (DSM-V tool³¹), management procedures undertaken, cadre of professionals managing various cases, visit timelines for cases seen, common drugs used for common cases, and costs for treatment included, costs covered by insurance and management of cases in primary care clinics. The costs obtained from county documents included clinical staff salaries³²; travel costs were obtained from literature³³; equipment costs were for printing of the DSM-V screening tool obtained from expert opinion; and administrative costs were obtained from a prior study¹⁷ that utilized facility based costs. Administrative costs included the cost of engaging a consultant physician who is a psychiatrist, administrative staff for coordinating clinical officers and nurses and the clinics, data entry, and data cleaning.¹⁷ The cost of medication and patient consumables were not factored in as these costs would be borne by the patient.

For the facility-based additive scenario, the costs included were the clinical officer's salary, equipment costs, and administrative costs. The facility-based GSP costs included registered psychiatry nurse III salary, equipment cost, administrative costs and artistic therapy costs.²⁹ The task-shifting scenario costs included transport cost and salary for the delegated psychiatry nurse, equipment cost, and administrative costs. Travel costs are incurred when the delegated clinical staff travel to facilities from MTRH. The real-time cost of transport was extracted from a freely available website for transport costs to different locations worldwide.³³ The input information is summarized in Table 1.

Table 1:

Median per patient per visit input cost of depression care in the six counties

	Integrated care scenarios
	Facility based additive	Facility-based GSP (without artistic therapy)	Facility-based GSP (with artistic therapy)	Community-based task shifting
Cost type*	Amount ($)	Amount ($)	Amount ($)	Amount ($)	Source
Specialist officer salary	0.56 (0.53-0.59)	0.22 (0.21-0.23)	0.22 (0.21-0.23)	0.56 (0.53-0.59)	County Dept of Health32
Equipment	0.43 (0.41-0.45)	0.43 (0.41-0.45)	0.43 (0.41-0.45)	0.43 (0.41-0.45)	Expert opinion
Admin cost	6.09 (5.79-6.39)	6.09 (5.79-6.39)	6.09 (5.79-6.39)	6.09 (5.79-6.39)	Literature estimate17
Artistic therapy	-	-	3.04 (2.89-3.19)	-	Literature estimate29
Transport	-	-	-	0.24 (0.23-0.25)	Website33

Data show median (95% confidence interval) costs. GSP: Group Session Psychotherapy

^*The costs obtained from county documents included clinical staff salaries.³² Equipment costs were required for printing of the depression screening tool obtained from expert opinion; costs for artistic therapy were obtained from literature.²⁹ Admin costs (included the cost of a supervising physician that is the psychologist or psychiatrist, administrative staff for coordinating clinical officers and nurses and the clinics, data entry, and data cleaning) were obtained from a prior study¹⁷ that utilized facility-based costs. Transport costs included costs are incurred when the delegated clinical staff travel to facilities from MTRH obtained from a website.³³

Cost analysis

All costs were standardized to 2023 payment schedules, and an exchange rate of approximately 1 USD=140 KES was used in all calculations. The cost analyses included the estimated cost of depression care per patient for a single visit, as well as the annual cost, assuming an average of four visits per year from the health care provider's perspective. An inflation factor was added to the costs published in previous years to account for the change in consumer prices according to the Central Bank of Kenya (CBK) reported inflation rates.

For each of the four integrated care scenarios, we estimated the annual budget impact of increasing depression service coverage to 50% of the eligible population, in line with the World Health Organization’s Mental Health Action Plan 2013-2030 target 2.1 which states that “service coverage for mental health conditions will have increased at least by half, by 2030”.²² This estimation utilized the budget allocation figures from the 2022-2023 County Integrated Development Plans (CIDPs).

Target population

The eligible population targeted for depression care included 3,129,446 Kenyan adults, at least 18 years of age, living in the six counties in western Kenya extracted from the 2019 Kenya population census. ³⁵ The adult population at risk of depression was estimated based on the prevalence of how many people have depression in a community setting in western Kenya (12.3%)² and the population of patients currently under depression care in the six counties (52,734) was calculated based on a study that showed that approximately 13.7% of the population receive treatment for depression care in LMICs.³⁶

Budget holder

The county governments were regarded as budget holders. County governments are responsible for implementing national policies and the primary role as budget holder is to allocate funding for healthcare delivery at primary care level. The total allocation for health for the 2022-2023 financial year was derived from each county’s County Integrated Development Plans.

Budget impact model

Figure 1 shows the BIA analytical framework. The BIA framework takes into consideration health system features, population eligibility, and resources used to understand what current and future costs are for adding depression care into existing HIV and NCD services. The current program environment is based on the target population at risk of depression in western Kenya looking at the available resources set to aid in the integration of depression care to existing HIV and NCD care services based on the observation that few patients seek care for depression. The model is set to aid in quantifying the incremental cost to achieve the WHO target of 50% of service coverage for depression by 2030 under the four treatment scenarios described above.

Figure 1:

Budget impact schematic. Adapted from ISPOR Budget-Impact Principals of Good Practice Taskforce.

Sensitivity analyses

One-way sensitivity analysis was conducted of median per-patient-per-visit cost estimates for depression care across four integrated care scenarios (Facility-based additive, Facility-based GSP (no artistic therapy), Facility-based GSP (with artistic therapy), and Community-based task shifting). We also conducted one-way sensitivity analysis of budget impact estimates by varying population size and budget allocation by ±20% for six counties in Western Kenya, under two population targets (current number of individuals under depression care and projected population under the WHO 2030 growth target).

RESULTS

Figure 2 provides the median per-patient cost of depression care per visit for the six counties under study. The costs of the facility-based additive and facility-based GSP (with or without artistic therapy) were similar across all counties. The per-patient cost of a community-based task-shifting visit differed across counties due mainly to differences in transportation costs (incurred by the delegated health specialist) to deliver community care.

Figure 2:

Barplot of median per-patient cost ($) of depression care per visit (shown inside the barplots) across the 6 western Kenya counties (Bungoma, Busia, Kisumu, Uasin-Gishu, Trans Nzoia, and Nandi). The error bars represent the 95% confidence intervals around the median costs.

In Figure 2, we observe that the facility-based GSP scenario without artistic therapy was the cheapest integrated care model, incurring a median cost of $6.74 (95% CI 6.08-7.40) per patient per visit. On the other hand, providing artistic therapy alongside community-based GSP became the most expensive scenario costing $9.79 (95% CI 8.83-10.7) per patient per visit. The community-based task-shifting scenario was slightly more expensive than the facility-based additive scenario, costing $7.32 (95% CI 6.60-8.04) and $7.08 (95% CI 6.38-7.77) per patient per visit, respectively. Supplementary Figure S1 shows the annual cost of providing depression care to the population of patients currently under depression care in each county. We observe similar trends to those of the per patient per visit costs, with annual costs to provide depression care via GSP with artistic therapy to the current patient population under care being the most costly.

Table 1 illustrates the breakdown of costs for each scenario, detailing the input expenses involved. The facility-based additive scenario includes costs such as specialist officer salaries, equipment expenses, and administrative fees. Meanwhile, the facility-based GSP encompasses specialist officer salaries, equipment costs, and administrative fees, with the additional inclusion of artistic therapy costs for GSP involving artistic therapy. In contrast, the community-based task-shifting scenario covers specialist officer salaries, equipment costs, administrative fees, and transportation expenses for the health provider. We assume that the health provider commutes from MTRH to local clinics across all counties. The administrative costs of artistic therapy amounted to the largest proportion of the total costs. Provider round trip travel costs per patient per visit ranged from $0.06 to $0.46 across the counties representing the costs from MTRH to clinics in the nearest county, Uasin Gishu, and in the farther county, Busia. Specialist officer (Registered Nurse III/ Clinical Officer) salaries ranged from $0.22 to $0.55 per patient per visit assuming that the consultation time for the facility-based additive and community-based task shifting per patient was 15 minutes while the facility-based GSP scenario consultation time lasted for about 1 hour with all the patients as a group (Supplementary Table 3). Additionally, the clinical officer salary was considered to be approximately equal to the registered nurse III salary as documented by the remunerations in the counties. Equipment cost was constant as the DSM-V tool was assumed to be the standard tool used in depression screening in all the scenarios.

Table 2 shows a summary of the budget impact analysis for the six counties based on the four different integrated care scenarios for two population targets: (i) care delivered to the population under siloed depression care within the financial year 2022-2023, and (ii) care delivered to achieve the WHO 2030 global target set to increase service coverage for mental health conditions by 50%. The budget allocation for the six counties, according to CIDP 2022/2023, is shown in Table 2. The lowest and highest additional expenditure on the population currently under depression care was 0.78% (95% CI 0.741-0.819) and 2.12% (95% CI 2.01-2.23) respectively. On average, 3.54% (95% CI 3.36-3.72) more of the health budget would need to be spent by the six western Kenya counties under study, to achieve the WHO 2030 growth goal of increasing the service coverage for mental health conditions by 50%. On the other hand, 1.34% (95% CI 1.27-1.41) more will be needed for the population currently under depression care.

Table 2:

Additional amount of current budget to be spent by counties to provide depression care within existing HIV/NCD programs

				Integrated care scenarios (% of budget to be spent)
Population target	County	Population	Current Budget allocation	Community - based task shifting (%)	Facility-based additive (%)	Facility based GSP without artistic therapy (%)	Facility based GSP with artistic therapy (%)	Average
Number of population currently under depression care	Bungoma	13034	24 021 659	1.55	1.54	1.46	2.12	1.67
	Busia	6973	16 270 226	1.25	1.21	1.16	1.68	1.32
	Kisumu	9016	25 653 805	1.02	1.00	0.95	1.38	1.08
	Nandi	6910	23 813 156	0.83	0.82	0.78	1.14	0.89
	Trans Nzoia	7727	15 502 950	1.44	1.41	1.34	1.95	1.54
	Uasin Gishu	9075	18 479 263	1.39	1.39	1.32	1.92	1.51
	Average	8789	20 623 510	1.25	1.23	1.17	1.70	1.34
WHO 2030 growth goal	Bungoma	34535	24 021 659	4.11	4.07	3.88	5.63	4.42
	Busia	18475	16 270 226	3.32	3.22	3.06	4.44	3.51
	Kisumu	23889	25 653 805	2.70	2.64	2.51	3.64	2.87
	Nandi	18310	23 813 156	2.21	2.18	2.07	3.01	2.37
	Trans Nzoia	20473	15 502 950	3.81	3.74	3.56	5.17	4.07
	Uasin Gishu	24046	18 479 263	3.70	3.68	3.51	5.09	4.00
	Average	23288	20 623 510	3.31	3.25	3.10	4.50	3.54

Table 2 shows the percentage of the health budget (recurrent and developmental) to be spent on depression care by the counties. The budget allocation is based on the County's Integrated Development Plan (CIDP) budget allocations for the financial year 2022/2023. The status quo in Kenya is less than 1% of the health budget spent on mental health care ²⁶. WHO Global Target 2.1 states that service coverage for mental health conditions will have increased at least by half, by 2030 ¹⁹. The proportion of people under depression care in LMICS according to the WHO mental health survey (13.7%) ³⁰ . WHO 2030 growth goal does not include the population currently under depression care.

Sensitivity analysis

Figure S2 illustrates how sensitive the total cost of depression care is to individual input parameters under each care scenario. Across all scenarios, administrative costs consistently had the largest impact on total costs, reflecting their high baseline contribution. In the facility-based GSP (without artistic therapy) scenario, artistic therapy costs also contributed substantially, while in the community-based task shifting scenario, transport costs showed some influence, though relatively small. Figure S3 illustrates how sensitive county-level budget impact estimates are to changes in population size and budget allocation. For both targets (current depression care and the WHO 2030 goal), increasing the population under care resulted in higher estimated budget proportions across all counties, while increasing the total health budget allocation reduced the relative budget impact. The variation was more pronounced under the WHO 2030 growth scenario due to the larger target population. Counties like Bungoma and Trans-Nzoia consistently showed higher sensitivity due to a combination of larger populations and lower health budget allocations.

DISCUSSION

Integration of depression care to HIV and NCD care is key to addressing the gap in the provision of services in Kenyan counties. The WHO mental health plan highlights the principle of universal health coverage where there is the need for equity in access to mental health services by all persons and the importance of integration in ensuring achievement of access to care and service quality. The mental health auditors' report on the provision of mental health services in Kenya 2017 highlighted the need for the Ministry together with the County Governments to integrate mental healthcare services at all levels of healthcare facilities so that all citizens can easily access these services. The findings provide four scenarios (Facility-based additive, Facility-based GSP (no artistic therapy), Facility-based GSP (with artistic therapy), and Community-based task shifting), that can be undertaken by counties to implement the integration of mental health into NCD care building on previous work that has been done in Kenya.^17,39 The GSP scenario without artistic therapy was the cheapest incurring $6.74 (95% CI 6.08-7.40) per patient on one visit. GSP is effective in reducing depressive symptoms and improving mental health outcomes in various populations in LMICs.^40,41 Since the calculations were obtained using the health care provider perspective, transportation costs which are borne by the patients when traveling to a central site for the sessions might affect their participation and attendance of the sessions.⁴² However, incorporating artistic therapy in the GSP became the most expensive scenario costing $9.79 (95% CI 8.83-10.7) per patient per visit. Artistic therapy is beneficial when incorporated into individual or group session therapy and there is evidence of improved outcomes among patients with depressive disorders in various contexts.⁴³

There is a need for counties to increase budgetary allocation for depression care since the budget impact analysis showed that the additional amount of the current budget to be spent by counties to provide depression care in all the scenarios was higher than the status quo of the current national budget allocation for depression care. Specifically, the highest amount of the health budget needed to be spent by counties to currently manage depression care under the facility-based GSP scenario with artistic therapy scenario was 2.12% (95% CI 2.01-2.23), whereas the lowest scenario was 0.78% (95% CI 0.741-0.819) of the health budget to manage depression care under facility-based GSP without artistic therapy.

Demand generation activities to raise awareness about mental health are scarce in Kenya mostly because of the stigma and taboos that surround the illness. Estimates from literature show that demand generation activities are not as costly to implement when compared to supply side activities in this context and can be embedded within the essential packages of care at primary care level. ⁴⁴ The supply side which has been estimated in this study is more needed in this context and can be enhanced by taking into consideration supply side factors and improving health system structures at primary care level and appropriate sensitization to reduce stigmatization.

Studies show that there is limited funding for mental health in low-income countries of up to less than 1% of the total health budget²⁶ and funds are mostly used to treat severely ill patients.^2.45 From the findings, there is still a lot that needs to be done by counties to improve depression care. On average, more of the health budget would need to be spent by all the counties to achieve the WHO 2030 growth goal of increasing the service coverage for mental health conditions by 50%. There was no huge variation in the sensitivity analysis compared to the base values. The findings from this study emphasize the importance of tailoring scale-up strategies to local demographic and fiscal contexts to ensure sustainability and equity. There is also great emphasis from the Kenya Mental Health Action Plan 2021-2025 to address mental health as a key determinant of overall health and well-being.

CONCLUSIONS

This study provides preliminary findings to guide counties in formulating their health budgets with more emphasis on depression care under various scenarios. Integration of depression care to HIV and NCD care at the county level is key to addressing the gap in the provision of services in Kenyan counties. Facility-based group session psychotherapy scenario without artistic therapy was the cheapest option for integration where patients are given care as a group or 5-10 by a mental health specialist. Facility-based GSP with artistic therapy was the most expensive due to administrative costs and costs for artistic therapy. To achieve the 2030 growth goal, all counties will have to spend up to three percent more of their current budget to increase service coverage for mental health. Key limitations of this study include the use of assumptions to conduct data analysis on costs for depression care in Kenya, especially with the different scenarios, there was however no huge variation in the sensitivity analysis. Appropriate measures need to be taken to address capacity gaps that would be required to implement the task-shifting scenarios. Further research needs to be done to understand the cost implications of integrating depression care into HIV/NCD care at the national level and the direct costs related to offering these services in Kenya.

HIGHLIGHTS.

• The World Health Organization’s Mental Health Action Plan prioritizes increasing access to mental health care in Kenya by at least half, by 2030. Achieving this target requires national and county-level budget assessments.

• Our results showed that the cost of integrating mental health services within existing chronic disease care programs in Kenya ranges from $6.74 per patient per depression care visit (for facility-based group psychotherapy) to $9.79 per patient per visit (for group psychotherapy with additional artistic therapy).

• In rural western Kenya and similar East African settings, counties can reasonably expect to spend an additional 3.5% of their current overall health budgets to achieve the WHO mental health service coverage target.