Appendix.

Overview of country-specific challenges, opportunities and strategies for sustainable mental health financing

Key opportunities and threats	Emerging issues and insights (in-depth interviews)	Proposed mental health financing strategies
Ethiopia
Opportunities: increasing political awareness (at federal level); roll-out of health insurance plus integrated primary care guidelines; gross national product (GDP) growth Threats: low and inequitable access to services; high poverty levels; weak information systems	Inadequate funding for mental health; slow/partial implementation of existing mental health and financing policies; integration into primary care is an efficient strategy to expand access; little donor interest in mental health and overall official development assistance may fall as GDP grows; sustained advocacy required	Enhance use of existing resources: advocate for/ensure mental health is included in primary care guidelines (mainstreaming) Increase domestic financing: ensure inclusion of mental disorders in social/community-based health insurance (increased public funds expected to flow that way); Increase external funding: make investment case by demonstrating links/synergies with maternal and child health and non-communicable diseases plus development priorities (universal health coverage, sustainable development goals)
India
Opportunities: new mental health policy and legislation, increased budgetary allocation to states Threats: out-of-pocket spending remains high; substantial inequities; underutilisation of funds at state level	The main problem is not too few funds but underutilisation of those funds; low prioritisation at this state level; health insurance/coverage for mental, neurological and substance use (MNS) disorders remains low	Enhance use of existing resources: implement/strengthen public–private partnerships; introduce results-based financing for mental healthcare Increase domestic financing: provide targeted financial protection for households with MNS conditions through inclusion of mental disorders in existing insurance schemes
Nepal
Opportunities: increasing awareness (post-earthquake) and new mental health policy; new health insurance plans; economy recovering Threats: low human/ financial resources for mental health; low treatment coverage; high out-of-pocket spending and inequalities; changes in government, including to a federated system	Mental health (still) seen as a low priority, resulting in low resources, especially at district level; even if allocation increased, very rigid budget headings and low capacity to spend allocated resources; national health insurance provides an important opportunity	Enhance use of existing resources: work to overcome underuse of allocated budget through improved planning and capacity-building; moving towards performance-related pay mechanisms was considered to be premature at this stage Increase domestic financing: ensure inclusion of mental disorders in national health insurance plan; increased payroll taxes and ‘sin taxes’ were considered to have limited potential Increase external funding: explore interest from donors, although overreliance on external funds is seen by government as regressive
Nigeria
Opportunities: receptive policy environment (health sector development); health insurance for government workers established; economic recovery expected and corruption being tackled Threats: high levels of poverty, inequality and unmet needs; mental health budget goes to specialist hospitals; low human resource capacity	Low priority and funding for mental health; new policies and laws stuck; link mental health to other priority programmes and associated donors; efficiency in the utilisation of allocated resources need to be demonstrated	Enhance use of existing resources: advance business case for mental health and ensure efficient use of available funds through community-based mental healthcare programmes; integrate mental health into globally funded and pre-existing programmes such as HIV/AIDS and maternal and child health Increase domestic financing: expand coverage of health insurance schemes to non-formal workers Increase external funding: leverage support from World Bank and European Commission for mental health and psychosocial support North-East Nigeria (entry point for further mainstreaming)
South Africa
Opportunities: current roll-out of national health insurance; integration of mental health into chronic disease management guidelines for primary care; low out-of-pocket spend Threats: insufficient funds for implementation of new mental health policy; larger inequalities between different geographical areas and population groups; weak economic growth	In face of other challenges (tuberculosis, HIV), mental health not a high priority; Ministry of Finance perspective is that a case can and should be made for mental health; empower mental healthcare users through education, particularly for those with intellectual disabilities; unlock mental health resources in the private sector	Enhance use of existing resources: pursue results-based financing (for example remuneration incentives in primary care); leverage the well-developed private mental health sector in South Africa through contracts with private providers as a means of improving coverage of mental health services in hard to reach and/or underserved areas of the country Increase domestic financing: in the short term, create new protected fund for mental health (conditional grant); in the long-term, include mental health in general health resource development focused on raising public funds through the implementation of a national health insurance system, funded by payroll taxes
Uganda
Opportunities: mental health forms part of essential healthcare package; mental health unit at Ministry of Health ensures political visibility Threats: no up-to-date mental health policy or law; high out-of-pocket spending; widespread poverty	The only specified budget for mental health is for specialised, referral hospital; the health sector is largely dependent on tax receipts; legislation to introduce expanded health insurance stuck	Enhance use of existing resources: re-distribute a proportion of existing resources to community-based services; explore the use of results-based financing mechanisms Increase domestic financing: ensure mental health remains in health insurance plan; make business case Increase external funding: build commitment from existing and new development partners