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Table 4 Recommended strategies for adequate, fair and sustainable financing of mental health care in Ethiopia

From: Moving towards universal health coverage for mental disorders in Ethiopia

  Strategy elements Pros and cons
Strategy 1: improve efficiency (use of existing resources) Ensure that the revision of the National mental health strategy to integrate mental health into primary care is completed and that implementation is re-invigorated
Build capacity in mental health care planning and programme implementation at all system levels
Implement the new Ethiopia primary health care clinical guidelines (PHCG), which will ensure full horizontal integration of mental health care
Mobilise mental health stakeholders to advocate in a consistent and sustained manner for demand generation
Pros
Ethiopia Primary Health Care Guidelines are likely to have better uptake by regional health bureaus than vertical mental health programmes
Community-based mental health care is a wise investment because it reaches more people for less money than hospital-based care
Materials for building capacity in mental health care planning have been developed for Ethiopia via the Emerald programme
Leveraging existing cadres of health workers to deliver mental health care allows rapid and efficient expansion of human resources for mental health
Increasing demand helps to ensure that committed resources are utilised fully and wastage is minimised
Cons
Expanding mental health care, even when integrated into primary care, requires additional money for specialist expansion to provide supervision and training, as well as programme costs
Ethiopia PHCG will need to be supported by in-service mental health-specific training because of low level of existing health worker competence
Improving efficient use of existing resources does not address the longstanding neglect of mental health care and need for increased resources
Strategy 2: increasing domestic financing for mental health Inclusion of clearly specified mental, neurological and substance use disorders in the community-based health insurance (CBHI)/social health insurance (SHI) schemes can help to secure increased and more sustainable financing for mental health
Introduce a ‘sin tax’ on alcohol and khat and make the case that a proportion of the revenue should be reserved for health in general, and for substance use disorders and mental health specifically
Increase revenues by improving tax compliance and efficiency to solidify financing of CBHI/SHI in the longer-term
Pros
CBHI is equitable and popular at the community level
Overcomes key financial barriers to healthcare for people with chronic conditions
Cons
Social health insurance implementation has been delayed
The cost to the government of supporting CBHI may be unsustainable and threatened in the event of economic downturn
Poorly defined mental disorders within CBHI may undermine the long-term inclusion within insurance packages
The increasing burden of chronic disorders may result in unaffordable tariffs for the community and governmental underpinning of CBHI and SHI
Lobbying from special interest groups may lead to unfair distribution of domestic finances
Money from the ‘sin tax’ may not be equitably distributed
Strategy 3: increase external financing Demonstrate how mental health is relevant for the global agenda on NCDs, chronic communicable diseases (HIV and TB) and maternal health to strengthen the investment case for mental health care
Demonstrate how mental health is relevant for SDG target for UHC to leverage external funding for mental health care
External support for scale-up of Ethiopia PHCG will lead to increased external support for mental health care scale-up
Advocate for inclusion of financing for mental health care in core international development aid for low-income countries, building on World Bank commitments to mental health
Advocate for establishment of a global fund for mental health to focus on people with severe mental disorder
Pros
Focus on co-morbidity promotes a joining up of thinking of physical and mental health
Ethiopia-specific evidence exists for the relevance of mental health to public health and development priorities
Targeted advocacy can leverage big funds from changing global priorities
International funders can kick-start an agenda for inclusion of people with mental health problems in low-income countries
A global fund can address the chronic neglect of care for persons with severe mental disorder
Cons
Focus on depression co-morbidity runs the risk that severe mental illness is neglected because of low prevalence (1–2%) even though high disability and human rights burden
External funding of health in Ethiopia will decrease concomitantly with the transition to middle-income country status