With the development of evidence-based interventions for treatment of priority mental health conditions in humanitarian settings, it is important to establish the cost-effectiveness of such interventions to enable their scale-up.

To evaluate the cost-effectiveness of the Problem Management Plus (PM+) intervention compared with enhanced usual care (EUC) for common mental disorders in primary healthcare in Peshawar, Pakistan. Trial registration ACTRN12614001235695 (anzctr.org.au).

We randomly allocated 346 participants to either PM+ (n = 172) or EUC (n = 174). Effectiveness was measured using the Hospital Anxiety and Depression Scale (HADS) at 3 months post-intervention. Cost-effectiveness analysis was performed as incremental costs (measured in Pakistani rupees, PKR) per unit change in anxiety, depression and functioning scores.

The total cost of delivering PM+ per participant was estimated at PKR 16 967 (US$163.14) using an international trainer and supervisor, and PKR 3645 (US$35.04) employing a local trainer. The mean cost per unit score improvement in anxiety and depression symptoms on the HADS was PKR 2957 (95% CI 2262–4029) (US$28) with an international trainer/supervisor and PKR 588 (95% CI 434–820) (US$6) with a local trainer/supervisor. The mean incremental cost-effectiveness ratio (ICER) to successfully treat a case of depression (PHQ-9 ≥ 10) using an international supervisor was PKR 53 770 (95% CI 39 394–77 399) (US$517), compared with PKR 10 705 (95% CI 7731–15 627) (US$102.93) using a local supervisor.

The PM+ intervention was more effective but also more costly than EUC in reducing symptoms of anxiety, depression and improving functioning in adults impaired by psychological distress in a post-conflict setting of Pakistan.

The Emerald project's focus is on how to strengthen mental health systems in six low- and middle-income countries (LMICs) (Ethiopia, India, Nepal, Nigeria, South Africa and Uganda). This was done by generating evidence and capacity to enhance health system performance in delivering mental healthcare.

A common problem in scaling-up interventions and strengthening mental health programmes in LMICs is how to transfer research evidence, such as the data collected in the Emerald project, into practice.

To describe how core elements of Emerald were implemented and aligned with the ultimate goal of strengthening mental health systems, as well as their short-term impact on practices, policies and programmes in the six partner countries.

We focused on the involvement of policy planners, managers, patients and carers.

Over 5 years of collaboration, the Emerald consortium has provided evidence and tools for the improvement of mental healthcare in the six LMICs involved in the project. We found that the knowledge transfer efforts had an impact on mental health service delivery and policy planning at the sites and countries involved in the project.

This approach may be valid beyond the mental health context, and may be effective for any initiative that aims at implementing evidence-based health policies for health system strengthening.

Successful scale-up of integrated primary mental healthcare requires routine monitoring of key programme performance indicators. A consensus set of mental health indicators has been proposed but evidence on their use in routine settings is lacking.

To assess the acceptability, feasibility, perceived costs and sustainability of implementing indicators relating to integrated mental health service coverage in six South Asian (India, Nepal) and sub-Saharan African countries (Ethiopia, Nigeria, South Africa, Uganda).

A qualitative study using semi-structured key informant interviews (n = 128) was conducted. The ‘Performance of Routine Information Systems’ framework served as the basis for a coding framework covering three main categories related to the performance of new tools introduced to collect data on mental health indicators: (1) technical; (2) organisation; and (3) behavioural determinants.

Most mental health indicators were deemed relevant and potentially useful for improving care, and therefore acceptable to end users. Exceptions were indicators on functionality, cost and severity. The simplicity of the data-capturing formats contributed to the feasibility of using forms to generate data on mental health indicators. Health workers reported increasing confidence in their capacity to record the mental health data and minimal additional cost to initiate mental health reporting. However, overstretched primary care staff and the time-consuming reporting process affected perceived sustainability.

Use of the newly developed, contextually appropriate mental health indicators in health facilities providing primary care services was seen largely to be feasible in the six Emerald countries, mainly because of the simplicity of the forms and continued support in the design and implementation stage. However, approaches to implementation of new forms generating data on mental health indicators need to be customised to the specific health system context of different countries. Further work is needed to identify ways to utilise mental health data to monitor and improve the quality of mental health services.

None.

Strengthening of mental health systems in low- and middle-income countries (LMICs) requires the involvement of appropriately skilled and committed individuals from a range of stakeholder groups. Currently, few evidence-based capacity-building activities and materials are available to enable and sustain comprehensive improvements.

Within the Emerald project, the goal of this study was to evaluate capacity-building activities for three target groups: (a) service users with mental health conditions and their caregivers; (b) policymakers and planners; and (c) mental health researchers.

We developed and tailored three short courses (between 1 and 5 days long). We then implemented and evaluated these short courses on 24 different occasions. We assessed satisfaction among 527 course participants as well as pre–post changes in knowledge in six LMICs (Ethiopia, India, Nepal, Nigeria, South Africa, Uganda). Changes in research capacity of partner Emerald institutions was also assessed through monitoring of academic outputs of participating researchers and students and via anonymous surveys.

Short courses were associated with high levels of satisfaction and led to improvements in knowledge across target groups. In relation to institutional capacity building, all partner institutions reported improvements in research capacity for most aspects of mental health system strengthening and global mental health, and many of these positive changes were attributed to the Emerald programme. In terms of outputs, eight PhD students submitted a total of 10 papers relating to their PhD work (range 0–4) and were involved in 14 grant applications, of which 43% (n = 6) were successful.

The Emerald project has shown that building capacity of key stakeholders in mental health system strengthening is possible. However, the starting point and appropriate strategies for this may vary across different countries, depending on the local context, needs and resources.

S.E.L. received consulting fees from Lundbeck.

Current coverage of mental healthcare in low- and middle-income countries is very limited, not only in terms of access to services but also in terms of financial protection of individuals in need of care and treatment.

To identify the challenges, opportunities and strategies for more equitable and sustainable mental health financing in six sub-Saharan African and South Asian countries, namely Ethiopia, India, Nepal, Nigeria, South Africa and Uganda.

In the context of a mental health systems research project (Emerald), a multi-methods approach was implemented consisting of three steps: a quantitative and narrative assessment of each country's disease burden profile, health system and macro-fiscal situation; in-depth interviews with expert stakeholders; and a policy analysis of sustainable financing options.

Key challenges identified for sustainable mental health financing include the low level of funding accorded to mental health services, widespread inequalities in access and poverty, although opportunities exist in the form of new political interest in mental health and ongoing reforms to national insurance schemes. Inclusion of mental health within planned or nascent national health insurance schemes was identified as a key strategy for moving towards more equitable and sustainable mental health financing in all six countries.

Including mental health in ongoing national health insurance reforms represent the most important strategic opportunity in the six participating countries to secure enhanced service provision and financial protection for individuals and households affected by mental disorders and psychosocial disabilities.

D.C. is a staff member of the World Health Organization.

There is a large treatment gap for mental, neurological or substance use (MNS) disorders. The ‘Emerging mental health systems in low- and middle-income countries (LMICs)’ (Emerald) research programme attempted to identify strategies to work towards reducing this gap through the strengthening of mental health systems.

To provide a set of proposed recommendations for mental health system strengthening in LMICs.

The Emerald programme was implemented in six LMICs in Africa and Asia (Ethiopia, India, Nepal, Nigeria, South Africa and Uganda) over a 5-year period (2012–2017), and aimed to improve mental health outcomes in the six countries by building capacity and generating evidence to enhance health system strengthening.

The proposed recommendations align closely with the World Health Organization's key health system strengthening ‘building blocks’ of governance, financing, human resource development, service provision and information systems; knowledge transfer is included as an additional cross-cutting component. Specific recommendations are made in the paper for each of these building blocks based on the body of data that were collected and analysed during Emerald.

These recommendations are relevant not only to the six countries in which their evidential basis was generated, but to other LMICs as well; they may also be generalisable to other non-communicable diseases beyond MNS disorders.

None.

In most low- and middle-income countries (LMIC), routine mental health information is unavailable or unreliable, making monitoring of mental healthcare coverage difficult. This study aims to evaluate a new set of mental health indicators introduced in primary healthcare settings in five LMIC.

A survey was conducted among primary healthcare workers (n = 272) to assess the acceptability and feasibility of eight new indicators monitoring mental healthcare needs, utilisation, quality and payments. Also, primary health facility case records (n = 583) were reviewed by trained research assistants to assess the level of completion (yes/no) for each of the indicators and subsequently the level of correctness of completion (correct/incorrect – with incorrect defined as illogical, missing or illegible information) of the indicators used by health workers. Assessments were conducted within 1 month of the introduction of the indicators, as well as 6–9 months afterwards.

Across both time points and across all indicators, 78% of the measurements of indicators were complete. Among the best performing indicators (diagnosis, severity and treatment), this was significantly higher. With regards to correctness, 87% of all completed indicators were correctly completed. There was a trend towards improvement over time. Health workers' perceptions on feasibility and utility, across sites and over time, indicated a positive attitude in 81% of all measurements.

This study demonstrates high levels of performance and perceived utility for a set of indicators that could ultimately be used to monitor coverage of mental healthcare in primary healthcare settings in LMIC. We recommend that these indicators are incorporated into existing health information systems and adopted within the World Health Organization Mental Health Gap Action Programme implementation strategy.

None.

Little is known about the household economic costs associated with mental, neurological and substance use (MNS) disorders in low- and middle-income countries.

To assess the association between MNS disorders and household education, consumption, production, assets and financial coping strategies in Ethiopia, India, Nepal, Nigeria, South Africa and Uganda.

We conducted an exploratory cross-sectional household survey in one district in each country, comparing the economic circumstances of households with an MNS disorder (alcohol-use disorder, depression, epilepsy or psychosis) (n = 2339) and control households (n = 1982).

Despite some heterogeneity between MNS disorder groups and countries, households with a member with an MNS disorder had generally lower levels of adult education; lower housing standards, total household income, effective income and non-health consumption; less asset-based wealth; higher healthcare expenditure; and greater use of deleterious financial coping strategies.

Households living with a member who has an MNS disorder constitute an economically vulnerable group who are susceptible to chronic poverty and intergenerational poverty transmission.

D.C. is a staff member of the World Health Organization. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy or views of the World Health Organization.

Contextually appropriate interventions delivered by primary maternal care providers (PMCPs) might be effective in reducing the treatment gap for perinatal depression.

To compare high-intensity treatment (HIT) with low-intensity treatment (LIT) for perinatal depression.

Cluster randomised clinical trial, conducted in Ibadan, Nigeria between 18 June 2013 and 11 December 2015 in 29 maternal care clinics allocated by computed-generated random sequence (15 HIT; 14 LIT). Interventions were delivered individually to antenatal women with DSM-IV (1994) major depression by trained PMCPs. LIT consisted of the basic psychosocial treatment specifications in the World Health Organization Mental Health Gap Action Programme – Intervention Guide. HIT comprised LIT plus eight weekly problem-solving therapy sessions with possible additional sessions determined by scores on the Edinburgh Postnatal Depression Scale (EPDS). The primary outcome was remission of depression at 6 months postpartum (EPDS < 6).

There were 686 participants; 452 and 234 in HIT and LIT arms, respectively, with both groups similar at baseline. Follow-up assessments, completed on 85%, showed remission rates of 70% with HIT and 66% with LIT: risk difference 4% (95% CI −4.1%, 12.0%), adjusted odds ratio 1.12 (95% CI 0.73, 1.72). HIT was more effective for severe depression (odds ratio 2.29; 95% CI 1.01, 5.20; P = 0.047) and resulted in a higher rate of exclusive breastfeeding. Infant outcomes, cost-effectiveness and adverse events were similar.

Except among severely depressed perinatal women, we found no strong evidence to recommend high-intensity in preference to low-intensity psychological intervention in routine primary maternal care.

None.

Few studies have evaluated the implementation and impact of real-world mental health programmes delivered at scale in low-resource settings.

To describe the cross-country research methods used to evaluate district-level mental healthcare plans (MHCPs) in Ethiopia, India, Nepal, South Africa and Uganda.

Multidisciplinary methods conducted at community, health facility and district levels, embedded within a theory of change.

The following designs are employed to evaluate the MHCPs: (a) repeat community-based cross-sectional surveys to measure change in population-level contact coverage; (b) repeat facility-based surveys to assess change in detection of disorders; (c) disorder-specific cohorts to assess the effect on patient outcomes; and (d) multilevel case studies to evaluate the process of implementation.

To evaluate whether and how a health-system-level intervention is effective, multidisciplinary research methods are required at different population levels. Although challenging, such methods may be replicated across diverse settings.

An essential element of mental health service scale up relates to an assessment of resource requirements and cost implications.

To assess the expected resource needs of scaling up services in five districts in sub-Saharan Africa and south Asia.

The resource quantities associated with each site's specified care package were identified and subsequently costed, both at current and target levels of coverage.

The cost of the care package at target coverage ranged from US$0.21 to 0.56 per head of population in four of the districts (in the higher-income context of South Africa, it was US$1.86). In all districts, the additional amount needed each year to reach target coverage goals after 10 years was below $0.10 per head of population.

Estimation of resource needs and costs for district-level mental health services provides relevant information concerning the financial feasibility of locally developed plans for successful scale up.

No systematic attempt has been made to calculate the costs of scaling up mental health services in low-and middle-income countries.

To estimate the expenditures needed to scale up the delivery of an essential mental healthcare package over a 10-year period (2006–2015).

A core package was defined, comprising pharmacological and/or psychosocial treatment of schizophrenia, bipolar disorder, depression and hazardous alcohol use. Current service levels in 12 selected low-and middle-income countries were established using the WHO–AIMS assessment tool. Target-level resource needs were derived from published need assessments and economic evaluations.

The cost per capita of providing the core package attarget coverage levels (in US dollars) ranged from $1.85 to $2.60 per year in low-income countries and $3.20 to $6.25 per year in lower-middle-income countries, an additional annual investment of $0.18–0.55 per capita.

Although significant new resources need to be invested, the absolute amount is not large when considered at the population level and against other health investment strategies.