Table 1.

Applying a health system governance analysis framework to mental health in Ethiopia

	National level	District level
Rule of law
Legal framework	No mental health legislation, but political commitment to develop legislation. Moral imperative to scale up even without legislation. Important role of family and community in safeguarding people with mental illness
Regulation	Mechanisms exist to handle patient complaints, but limited regulation of clinical practice, no professional codes of conduct and proliferating cadres of mental health workers with unclear roles and responsibilities
Strategic vision
Policy	High level political support and momentum for change, with guiding framework of National Mental Health Strategy. Need for a national co-ordinating body for mental health scale up and engagement of planners at regional, zonal and district levels. Combining mental health with NCDs has potential opportunities and disadvantages	Importance of having a central policy to give legitimacy to implementation at the regional, zonal and district levels
Planning and co-ordination	Budget for scale-up committed by the Ministry of Health. Preliminary scale-up plan developed. However, poor co-ordination of activities, patchy capability and interest across the regions. Need for dedicated mental health co-ordinator at the regional level. Planning problems because programme is new	Essential to have mental health co-ordinator who takes responsibility for planning and implementing the service Need to build capacity in mental health planning
Leadership	Strong mental health leadership at highest levels but weak lower down in health system, with high turnover of staff. Perceived under-use of senior Ethiopian mental health professionals. Need to build leadership capacity of mental health professionals	Need for strong advocate for mental health at each administrative level of the health system
Participation and consensus
Participatory decision-making	Wide consultation with stakeholders to develop National Mental Health Strategy, but less ongoing consultation for planning and implementation. Gap in co-ordination of national level stakeholders. Strength of existing fora for involvement of community representatives in health planning. However, low levels of community mental health awareness may undermine involvement. Need for communities to own the programme	Systems already exist for consultation and involvement of healthcare providers and community in service planning, but no experience applying to mental health care. For successful implementation, need active community involvement and engagement with multi-sectoral stakeholders
Service user and caregiver participation	Importance of participation recognized, but no real forum for involvement of service users in planning. No culture of service user involvement in national level health system planning. Stigmatising attitudes an important barrier	Interest and willingness to involve service users and caregivers, with recognition of their potential contribution. Need to empower service users and caregiver to strengthen involvement. Precedent of involvement of people with HIV/AIDS
Responsiveness and integration of care
Prioritisation and meeting mental health needs	Mental illness perceived as neglected. Greater empowerment of service users required to ensure that services meet their needs. Vitally important to increase demand for services in order to increase the priority given	Improved awareness of the unmet need for care in people with mental illness since PRIME awareness-raising. Recognition of neglect of mental illness. Lack of parity between physical and mental health conditions that needs to be addressed
Integration at facility	Strong support for integration model as an effective way to improve access and reduce stigma. Supervision needed to supplement the brief training and to motivate primary care workers. Concern about feasibility and sustainability of current supervision framework which relies on psychiatrists	Strong support for integration model. Important to increase skills of primary care workers. Expected to improve job satisfaction. Potential barriers are additional workload, lack of space and negative attitudes of health workers. Concern about how competent health workers will feel after brief training
Integration in community	Community as pivotal to success. Inadequate engagement of community in mhGAP pilot associated with low demand. Network of community health workers and health volunteers offers great potential, but need to raise awareness in community	Familiar with community engagement and mobilization. Community can be part of a more holistic response to mental health needs e.g. tackling root causes such as poverty. Role in tracing defaulters and supporting re-engagement with care
Effectiveness and efficiency
Financing	Money committed to scale-up, but budget needed for wider health system change as well as brief training. Proposed health insurance scheme will cover mental health and reduce out-of-pocket payments. Integrating mental health in primary care expected to make mental health care affordable. Problem of low demand for accurate financial forecasting	Integrated care important for making care affordable by reducing transport and time costs, but medication costs may yet be prohibitive. No experience with health insurance scheme to date
Human resources	Integration of mental health care promises efficiencies, but does not take away need to expand specialist mental health workers. Need for political support to expand role of mental health professionals from direct clinical work to include service co-ordination, supervision and mentoring. Focus on in-service training rather than pre-service perceived as a barrier to efficiency due to high turnover of staff and difficulties offering timely extra in-service training. Not feasible to rely on health volunteers for psychosocial interventions	Low baseline capacity of health workers in mental health limits ability to benefit from stand-alone short courses. Lack of incentives for those taking on mental health care. High turnover of staff. Need to target new recruits as only expect staff to stay for 2 or 3 years. Possibility of leveraging HEWs and HDAs promises efficiency and effectiveness (affordable by the community). Concern about willingness of community actors to work without financial incentives. Problem of over-burdening of health extension workers
Infrastructure and equipment	Medication supply critical to the success of implementation. Problems with medication availability during pilot but not insurmountable. Need to stimulate demand to allow forecasting. Need for decision-support materials in local languages	Major concerns about medication supply: frequent stock-outs and medications close to expiry date. Depend on private sector which adds to cost. Concern about availability of space to manage people with behavioural disturbance and to ensure privacy
Equity and inclusiveness
Access	Government has prioritised equitable access to care. Health insurance has potential to improve access for the poor. However, limited information on extent to which implementation has led to equitable access to care and considered to be a future priority Cultural acceptability of available treatments and widespread stigma as potential barriers to accessing care	Accessibility expected to be improved by locally available care, but still concern about affordability of medication. Need to overcome low awareness and stigma
Stigma	Importance of stigma in impeding implementation and scale-up accepted by all. Anti-stigma campaigns supported by most. Service user involvement in antistigma campaigns considered to be essential. Caveat that might be better to focus on tackling discrimination rather than stigma	Familiar with anti-stigma campaigns (for HIV/AIDS) and receptive to involvement. Tackling stigma seen as essential for successful implementation. Supportive of service user and caregiver involvement in antistigma activities
Ethics
Quality assurance	Considered important but difficult and beyond what is achievable in the early stages of scale-up. For other illnesses, new quality assurance frameworks (and performance indicators) disseminated by MoH, but mental health not included. Community consultation as an important mechanism for evaluating quality	Strong existing mechanisms for quality assurance on paper. Quality assurance not applied to mental health to date
Safeguards for ethical research	No major concerns. Rigorous ethical review in place but unclear whether can monitor the actual conduct of studies	Low level of awareness about procedures to ensure ethical conduct of research
Intelligence and information
Monitoring and evaluation	Widely seen as challenging, with inadequate existing practice. The necessary information is not collected routinely. Need for better mental health HMIS indicators. New mental health indicators are proposed in the National Mental Health Strategy but not implemented. Means that unable to identify problems with implementation in a timely fashion and impedes planning	Very limited routinely collected mental health indicators. HMIS indicators for aspects of chronic care present for TB/HIV and could be collected for mental health. Well-established mechanisms for looking at aggregated HMIS and using for planning. Patient feedback obtained through service satisfaction forms and satisfaction surveys
Accountability and transparency	Reasonable faith in government accounting systems to minimize the risk of corruption. Question about accountability and transparency of decisions made by policy-makers and planners. Enforcement of systems considered weak. Difficult to access information about budgets and planning in the public domain	Robust systems for health facilities to be held accountable e.g. health facility boards. Transparency of appointing new heads questioned, although clear criteria on paper

mhGAP mental health Gap Action Programme, PRIME Programme for Improving Mental health carE, HEWs health extension workers, HDA health development army, HMIS health management information system, TB tuberculosis, HIV human immunodeficiency virus