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Abstract The inclusion of mental health in the Sustainable Development Goals represents a global commitment to include mental health among the highest health and development priorities for investment. Low- and middle-income countries (LMICs), such as South Africa, contemplating mental health system scale-up embedded into wider universal health coverage-related health system transformations, require detailed and locally derived estimates on existing mental health system resources and constraints. The absence of these data has limited scale-up efforts to address the burden of mental disorders in most LMICs. We conducted a national survey to quantify public expenditure on mental health and evaluate the constraints of the South African mental health system. The study found that South Africa’s public mental health expenditure in the 2016/17 financial year was USD615.3 million, representing 5.0% of the total public health budget (provincial range: 2.1–7.7% of provincial health budgets) and USD13.3 per capita uninsured. Inpatient care represented 86% of mental healthcare expenditure, with nearly half of total mental health spending occurring at the psychiatric hospital-level. Almost one-quarter of mental health inpatients are readmitted to hospital within 3 months of a previous discharge, costing the public health system an estimated USD112 million. Crude estimates indicate that only 0.89% and 7.35% of the uninsured population requiring care received some form of public inpatient and outpatient mental healthcare, during the study period. Further, mental health human resource availability, infrastructure and medication supply are significant constraints to the realization of the country’s progressive mental health legislation. For the first time, this study offers a nationally representative reflection of the state of mental health spending and elucidates inefficiencies and constraints emanating from existing mental health investments in South Africa. With this information at hand, the government now has a baseline for which a rational process to planning for system reforms can be initiated.

Background The extent of catastrophic health expenditure and impoverishment associated with depression in low-and middle-income countries is not known. The aim of this study was to estimate the incidence and intensity of catastrophic out-of-pocket (OOP) health expenditure, level of impoverishment and coping strategies used by households of persons with and without depression in a rural Ethiopian district. Methods A comparative cross-sectional survey was conducted, including 128 households of persons with depression and 129 households without. Depression screening was conducted using the Patient Health Questionnaire, nine item version (PHQ-9). People in the depression group were classified into high and low disability groups based on the median value on the World Health Organization Disability Assessment Schedule (WHODAS) polytomous summary score. Health expenditure greater than thresholds of 10 and 25% of total household consumption was used for the primary analyses. The poverty headcount, poverty gap and normalized poverty gap were estimated using retrospective recall of total household expenditure pre- and post-OOP payments for health care. Linear probability model using binreg command in STATA with rr option was used to estimate risk ratio for the occurrence of outcomes among households with and without depression based on level of disability. Results Catastrophic OOP payments at any threshold level for households with depression and high disability were higher than control households. At the 10% threshold level, 24.0% of households of persons with depression and high disability faced catastrophic payments compared with 15.3% for depression and low disability and 12.1% for control households ( p  = 0.041). Depression and high disability level was an independent predictor of catastrophic OOP payments: RR 2.1; 95% CI:1.1, 4.6. An estimated 5.8% of households of persons with depression and high disability were pushed into poverty because of paying for health care compared with 3.5% for households of persons with depression and low disability and 2.3% for control households ( p  = 0.039). Conclusions Households of people with depression and high disability were more likely to face catastrophic expenditures and impoverishment from OOP payments. Financial protection interventions through prepayment schemes, exemptions and fee waiver strategies need to target households of persons with depression.

The aim of this study was to assess the association between depression symptom severity and household income, consumption, asset-based wealth, debt and use of distress financing strategies, to understand how depression symptom severity and household economic welfare are related. A household survey was administered to the households of primary health clinic-attenders who were screened for depression symptoms using the 9-item Patient Health Questionnaire in the chronic care units of four primary health clinics in the North West province of South Africa. Univariate and multivariable regression models were used to assess whether a range of household economic measures were significant predictors of depression symptom severity; and whether depression symptom severity significantly predicted changes to household economic welfare, across a number of different economic measures using both multiple linear regression and logistic regression analyses. On univariate analysis, certain characteristics were associated with significantly worse (higher) PHQ-9 scores, namely: households in which the household head was younger, female, and unmarried; households in which the indexed patient was younger, and did not receive an education beyond primary school; increasing household size, receipt of a social grant, households living in housing constructed of metal sheet walls and households making use of a public tap as their primary water source. In addition, univariate analysis demonstrated that higher log-transformed food expenditure, lower log-transformed capacity to pay, the presence of household debt and both reducing the size or frequency of meals and drawing up retail shop accounts in response to financial distress over the past three years were associated with significantly worse (higher) PHQ-9 scores. Multivariable analysis demonstrated that larger household sizes (p<0.05), receipt of social grants (p<0.05), higher food expenditure (p<0.01), and drawing up retail shop accounts in response to financial distress (p<0.05) were independently predictive of worse (higher) PHQ-9 scores. Inversely, increasing age of the household head (p<0.05), having piped water directly into the household (as opposed to making use of a public water sources) (p<0.01), and increasing capacity to pay (p<0.01) were independently predictive of better (lower) PHQ-9 scores. Similarly, multivariable analysis demonstrated that worse (higher) PHQ-9 scores were independently predictive of lower household capacity to pay (p<0.10) and higher food expenditure (p<0.01). This study is the first of its kind in South Africa, identifying household economic factors associated with increased depression symptom severity on a continuum; and demonstrating that financial risk protection efforts are needed across this continuum. The study demonstrates that the relationship between poverty and mental health extends beyond the individual to affect household economic functioning. These findings must be included in policy considerations to achieve effective protection for vulnerable households facing the interaction of depression and adverse economic circumstances.

Background With the implicit neglect for the integration of mental health services into general health service development in South Africa, there is an urgent need for an understanding of the ways in which existing reforms may be leveraged to incorporate the objectives of the National Mental Health Policy Framework and Strategic Plan (MHPF) and the mechanisms by which these reforms can be structured and financed in the context of fiscal constraint. Methods A situational analysis guided by a newly developed analytical framework for sustainable mental health financing was conducted. The review was followed by qualitative, indepth interviews with a range of expert national stakeholders. Results Although the MHPF is said to be consistent with ongoing efforts toward the implementation of National Health Insurance (NHI), there is clear evidence of discordance between the MHPF and the NHI. The most promising strategies for sustainable mental health financing include: increased decentralization of resources to primary and community mental health services; active integration of mental health into ongoing NHI implementation including expanding the mandate of District hospitals and drawing on the private sector; submission of costed budget bids to support a mental health conditional grant and ensuring that explicit outcomes and deliverables are in place to monitor Provincial implementation. Conclusion This paper has suggested several ways in which existing reforms may be leveraged to incorporate the objectives of the MHPF and achieve better mental health outcomes for South Africans, revealing critical opportunities for mental health service scale-up to be embedded in South Africa’s future health delivery strategy. The realization of a conditional grant for mental health will require technical expertise to cost existing services towards the development of an investment case for mental health service scale-up nationally, projecting potential resource requirements and returns on investment of a strong service platform. In the longer-term, the NHI benefit package must be expanded to include comprehensive mental health services at all levels. Explicit results-based financing mechanisms within the NHI Fund must also be incorporated for mental health to incentivise quality of care. Private providers engaged by the NHI must commit to make use of evidence-based mental health interventions.

BackgroundWhilst several systematic reviews conducted in Low- and Middle-Income Countries (LMICs) have revealed that coverage under social (SHI), national (NHI) and community-based (CBHI) health insurance has led to increased utilization of health care services, it remains unknown whether, and what aspects of, these shifts in financing result in improvements to mental health care utilization. The main aim of this review was to examine the impact of SHI, NHI and CBHI enrollment on mental health care utilization in LMICs.MethodsSystematic searches were performed in nine databases of peer-reviewed journal articles: Pubmed, Scopus, SciELO via Web of Science, Africa Wide, CINAHL, PsychInfo, Academic Search Premier, Health Source Nursing Academic and EconLit for studies published before October 2018. The quality of the studies was assessed using the Effective Public Health Practice Project quality assessment tool for quantitative studies. The systematic review was reported according to the PRISMA guidelines (PROSPERO;2018; CRD42018111576).ResultsEighteen studies were included in the review. Despite some heterogeneity across countries, the results demonstrated that enrollment in SHI, CBHI and NHI schemes increased utilization of mental health care. This was consistent for the length of inpatient admissions, number of hospitalizations, outpatient use of rehabilitation services, having ever received treatment for diagnosed schizophrenia and depression, compliance with drug therapies and the prescriptions of more favorable medications and therapies, when compared to the uninsured. The majority of included studies did not describe the insurance schemes and their organizational details at length, with limited discussion of the links between these features and the outcomes. Given the complexity of mental health service utilization in these diverse contexts, it was difficult to draw overall judgements on whether the impact of insurance enrollment was positive or negative for mental health care outcomes.ConclusionsStudies that explore the impact of SHI, NHI and CBHI enrollment on mental health care utilization are limited both in number and scope. Despite the fact that many LMICs have been hailed for financing reforms towards universal health coverage, evidence on the positive impact of the reforms on mental health care utilization is only available for a small sub-set of these countries.

Background and aims Current coverage of mental health care in low- and middle-income countries is limited, not only in terms of access to services but also in terms of financial protection of persons in need of care and treatment. This is especially pertinent considering the established relationship between mental illness and poverty and the need to ensure the financial risk protection of persons with mental disorders and their families as part of country’s efforts to attain universal health coverage. This study set out to review the health and socio-economic contexts of Nigeria as well as to generate strategies for sustainable mental health financing that will be feasible, within the specific context of the country. Methods A multi-methods approach was developed and applied, consisting of three steps: a situational analysis of Nigeria’s health system, macro-fiscal economic profile, and socio-political status, including a strengths, weaknesses, opportunities and threats (SWOT) analysis of the Nigerian socio-economic, general and mental health context; key informant interviews with 12 expert stakeholders drawn from state and non-state actors in the health and financial sectors; and a policy analysis of sustainable financing options. Results Key challenges identified were: poor funding; reduced access to care, resulting in a huge treatment gap; and out of pocket payment for services—leading to impoverishment. Comprehensive coverage of mental health conditions within the ongoing health insurance reforms was identified as a key strategy for moving towards sustainable mental health financing in Nigeria. Other identified strategies include enhanced integration of mental health into primary care; incorporation of mental health into other strategic and currently funded programmes; adoption of performance-based financing measures; and renewed engagement with stakeholders, including external donor institutions. Conclusions A suite of feasible and actionable measures can be implemented to increase mental health service financing, reduce health-related financial burden on households, increase help-seeking and access to quality mental health care and, ultimately, reduce the large treatment and financing gap for mental disorders in Nigeria.

A core element of the Strengthening Responses to Dementia in Developing Countries (STRiDE) programme was to generate novel data on the prevalence, cost and impact of dementia in low- and middle-income countries, to build better health policy. Indonesia and South Africa are two middle-income countries in need of such data. To present the STRiDE methodology and generate estimates of dementia prevalence in Indonesia and South Africa. We conducted community-based, single-phase, cross-sectional studies in Indonesia and South Africa, randomly sampling participants aged 65 years or older in each country. Dementia prevalence rates for each country were generated by using the 10/66 short schedule and applying its diagnostic algorithm. Weighted estimates were calculated with national sociodemographic data. Data were collected between September and December 2021 in 2110 people in Indonesia and 408 people in South Africa. The adjusted weighted dementia prevalence was 27.9% (95% CI 25.2-28.9) in Indonesia and 12.5% (95% CI 9.5-16.0) in South Africa. Our results indicate that there could be >4.2 million people in Indonesia and >450 000 people in South Africa who have dementia. Only five participants (0.2%) in Indonesia and two (0.5%) in South Africa had been previously diagnosed with dementia. Despite prevalence estimates being high, formal diagnosis rates of dementia were very low across both countries (<1%). Further STRiDE investigations will provide indications of the impact and costs of dementia in these countries, but our results provide evidence that dementia needs to be prioritised within national health and social care policy agendas.

Background Poverty and mental illness are strongly associated. The aim of this study was to investigate the economic impact of implementing a district level integrated mental healthcare plan for people with severe mental disorders (SMD) and depression compared to secular trends in the general population in a rural Ethiopian setting. Methods A community-based, controlled before-after study design was used to assess changes in household economic status and catastrophic out-of-pocket (OOP) payments in relation to expanded access to mental health care. Two household samples were recruited, each with a community control group: (1) SMD sub-study and (2) depression sub-study. In the SMD sub-study, 290 households containing a member with SMD and 289 comparison households without a person with SMD participated. In the depression sub-study, 129 households with a person with depression and 129 comparison households. The case and comparison cohorts were followed up over 12 months. Propensity score matching and multivariable regression analyses were conducted. Results Provision of mental healthcare in the district was associated with a greater increase in income (Birr 919.53, 95% CI: 34.49, 4573.56) but no significant changes in consumption expenditure (Birr 176.25, 95% CI: -1338.19, 1690.70) in households of people with SMD compared to secular trends in comparison households. In households of people with depression, there was no significant change in income (Birr 227.78, 95% CI: -1361.21, 1816.79) or consumption expenditure (Birr − 81.20, 95% CI: -2572.57, 2410.15). The proportion of households incurring catastrophic OOP health expenditure (COOPHE) at the ≥ 10% and ≥ 40% thresholds were significantly reduced after the intervention in the SMD (from 20.3 to 9.0%, p  = 0.002, and 31.9–14.9%, p  < 0.001) and in the depression intervention (from 19.6 to 5.3%, p  = 0.003, and 25.2–11.8%, p  = 0.015). Similarly, COOPHE has declined in the comparison households for SMD (from 15.6% (T1) to 8.2% (T2) ( p  = 0.035) and for depression comparison households (from12.1–4.1%( p  = 0.069). However, there was no significant difference in the proportion of households experiencing catastrophic OOP health care expenditure in the SMD, depression and the comparison groups ( p  = 0.808 and p  = 0.779 ). Despite improvement in income and COOPHE, households of persons with SMD or depression remained impoverished relative to comparison groups at follow-up. Households of people with SMD and depression were significantly less likely to be enrolled in community-based health insurance (CBHI) than comparison households. Conclusions The District mental health care plan intervention increased household income and reduced catastrophic out-of- pocket payment. Our findings support global initiatives to scale up mental healthcare as part of universal health coverage initiatives, alongside interventions to support social inclusion and targeted financial protection for vulnerable households.

Background There are limited data on healthcare spending by households containing a person with severe mental disorder (SMD) in low- and middle-income countries (LMIC). This study aimed to estimate the incidence and intensity of catastrophic out-of-pocket (OOP) payments and coping strategies implemented by households with and without a person with SMD in a rural district of Ethiopia. Methods A comparative cross-sectional community household survey was carried out from January to November 2015 as part of the Emerald programme (emerging mental health systems in low- and middle-income countries). A sample of 290 households including a person with SMD and 289 comparison households without a person with SMD participated in the study. An adapted and abbreviated version of the World Health Organization SAGE (Study on global Ageing and adult health) survey instrument was used. Households were considered to have incurred catastrophic health expenditure if their annual OOP health expenditures exceeded 40% of their annual non-food expenditure. Multiple logistic regression was used to explore factors associated with catastrophic expenditure and types of coping strategies employed. Results The incidence of catastrophic OOP payments in the preceding 12 months was 32.2% for households of a person with SMD and 18.2% for comparison households (p = 0.006). In households containing a person with SMD, there was a significant increase in the odds of hardship financial coping strategies (p < 0.001): reducing medical visits, cutting down food consumption, and withdrawing children from school. Households of a person with SMD were also less satisfied with their financial status and perceived their household income to be insufficient to meet their livelihood needs (p < 0.001). Conclusions Catastrophic OOP health expenditures in households of a person with SMD are high and associated with hardship financial coping strategies which may lead to poorer health outcomes, entrenchment of poverty and intergenerational disadvantage. Policy interventions aimed at financial risk pooling mechanisms are crucial to reduce the intensity and impact of OOP payments among vulnerable households living with SMD and support the goal of universal health coverage.

Background There is a lack of high quality population-based studies from low- and middle-income countries examining the relative economic status of households with and without a member with a mental health problem. The aim of the study was to explore the socio-economic status of households with a person with severe mental disorder (SMD; psychosis or bipolar disorder) or depression compared to households without an affected person. Methods A population-based, comparative, cross-sectional household survey was conducted in Sodo district, south Ethiopia, between January and November 2015. Two samples were recruited, each with its own comparison group. Sample (1): households of 290 community-ascertained persons with a clinician-confirmed diagnosis of SMD and a comparison group of 289 households without a person with SMD. Sample (2): households of 128 people who attended the primary health care centre and who were identified by primary care staff as having a probable diagnosis of depressive disorder; and comparison households of 129 patients who attended for other reasons and who did not receive a diagnosis of depression. Household socioeconomic status (household income, consumption and asset-based wealth) was assessed using a contextualized version of theWorld Health Organization (WHO) Study on global Ageing and adult health (SAGE) questionnaire. Each disorder group (SMD and depression) was further divided into higher and lower disability groups on the basis of median score on the WHO Disability Assessment Schedule. Results Households of a person with SMD who had higher disability were more likely to have a poorer living standard (no toilet facility; p  < 0.001). Having a reliable source of regular income was significantly lower in households of a person with SMD ( p  = 0.008) or depression ( p  = 0.046) with higher disability than the comparison group. Households of persons with SMD with higher disability earned less ( p  = 0.005) and owned significantly fewer assets ( p  < 0.001) than households without SMD. Households including persons with depression who had higher disability had lower income ( p  = 0.042) and reduced consumption ( p  = 0.048). Conclusions Households with a member who had either SMD or depression were socioeconomically disadvantaged compared to the general population. Moreover, higher disability was associated with worse socio-economic disadvantage. Prospective studies are needed to determine the direction of association. This study indicates a need to consider households of people with SMD or depression as a vulnerable group requiring economic support alongside access to evidence-based mental healthcare.