Table 1 summarises the information available for each indicator, sources of information from the data mapping or as recommended by the participants, and relevant quotes from the KIIs on the indicator's status in Nepal’s healthcare system. Similarly, the level of structural stigma, as indicated by the percentage endorsement using RAG rating, including the non-response and indecisiveness, is visually illustrated in Fig. 2.
Domain 1: Discriminatory legal framework and policy environment
This domain includes five indicators focused on structural stigma and discrimination within the policies and legal environment, such as the existence of mental health policies and acts, exclusion from universal health coverage and national health policies and programs, lack of coverage in insurance policies, and discriminatory language and provisions in policies.
The indicator ‘exclusion of mental health from universal health coverage’ had the most consistent rating (100% rated as amber). All participants indicated that the inclusion of mental healthcare services within the basic healthcare package and the government’s health insurance scheme clearly showed attempts made at inclusion. However, they mentioned substantial work was still necessary for the indicator to turn green due to the lack of scheme coverage, geographically limited implementation of mental health programs within primary healthcare services, and the lack of comprehensive mental health services (e.g. psychosocial counselling, evidence-based therapies) within basic health and insurance packages.
Indicators such as ‘unavailability of mental health act and policies’ and ‘discriminatory language and provisions in mental health policies’ also had a higher percentage of amber rating, indicating some levels of discrimination but also attempts made to address them. For example, almost all participants mentioned the drafting of national mental health strategies and action plans as a huge step forward. Still, without a mental health law that impacts PWLE’s services and rights, the indicator has yet to turn green. Participants undecided between red and amber ratings cited a lack of province-level legal documents and policies for mental health and a lack of implementation of the national action plan at local levels, indicating stigma at the province and local levels.
Domain 2: Stigmatizing system infrastructure and resources
This domain contains indicators related to measuring stigmatising system infrastructure and resources such as insufficient funding, unavailability of human resources, indicators not included in Health Management Information Systems (HMIS), unaffordable services compared to other chronic conditions, differential quality of space/infrastructure for mental health services, and unavailability of medications at health facilities.
Most participants rated “unavailability of trained human resources for mental health” (75%) and “mental health indicators not included in national health information systems” (83%) as amber, as in these areas, the government had realised potential gaps and initiated mechanisms such as prioritising the mental health training for primary healthcare workers, initiating health administrators training for the implementation of mental health programs, and incorporating additional indicators for better understanding national-level mental health data. Nevertheless, they raised concerns that much was needed to turn the indicator green, such as increasing the number of trained health workers at health facilities and creating specialist positions at district hospitals, ensuring not just clinical team availability but also the therapists/counsellor and nurses’ availability to provide holistic psychosocial support, and implementing the newly adapted mental health indicators in all tiers of healthcare.
The ‘differential quality of spare/infrastructure’ indicator had a higher rating of red (75%). In comparison, some participants (17%) rated it between red and amber, given the unavailability of specified beds or in-patient units within the larger provincial and district hospitals. Similarly, participants highlighted that although there were infrastructural limitations at the primary healthcare facilities, some municipalities and health facilities with motivated health professionals and administrations had created ad hoc confidential spaces within their limited infrastructure for the provision of mental health services (e.g. meeting rooms within ward administrative offices or medication dispensary room), highlighting the lack of space as a stigma issue.
Participants seemed ambivalent towards indicators such as ‘insufficient funding for mental health’ and ‘unavailability of medications’, with ratings split between red and amber. In terms of funding, all participants agreed that the budget was insufficient to implement mental health policies and programs.
However, some participants highlighted that the government has started allocating separate budgets for community mental health programs (e.g. mental health training and medication procurement). In contrast, mental health-specific budgets were previously channelled only towards hospitals providing mental health services. Alternatively, some participants emphasised that mental health program funding mostly came from development partners, leading to drastic changes (increases or decreases) in mental health expenses from one year to another, as such funding is short-term and unsustainable.
Ratings for ‘unavailability of medications at health facilities’ were distributed between red and amber, mainly due to limited clarity on whether it was a supply chain problem (if so, are there supply issues also for medications for other health conditions) or is restricted supply chain management caused by issues with mental health-specific policies. While most agreed that including psychotropic medications in the free drug list was a huge step forward, its implementation was lacking as the medicines could only be supplied to health facilities with trained health workers. Even then, the supply of medicines was ad hoc, without proper evaluation of prevalence, catchment population, or need (due to problems in recording mental health indicators), resulting in either an over or undersupply of medications. A highlighted structural stigma issue was a policy on authorising the purchase of psychotropic medications. While most drugs on the free drug list could be authorised for purchase by local government (municipalities), purchasing psychotropic drugs was only permitted by the provincial and federal government bodies, leading to lengthy procurement and supply time.
Participants also seemed unsure about ‘unaffordable services compared to other chronic conditions,’ with ratings distributed between red (58%), amber (16%), green (8%), and undecided (18%). Some participants opined that mental health services in Nepal’s health system were generally affordable compared to many other chronic conditions with much lower costs for medications and hospitalisations, hence rating it green. However, other participants rated it red, highlighting larger travel and caretaker costs given the lack of easily accessible community-based mental health services. Nevertheless, participants found the indicator difficult to rate due to a lack of aggregated representative data on out-of-pocket (OOP) costs for mental health compared with other physical health conditions.
Domain 3: Stigmatizing Knowledge, Attitude, and Practices of individuals affiliated with the health systems (health workers and administrators)
This domain consists of indicators reflecting negative aggregate attitudes of health system staff, health workers unaware of the rights of PWLEs, lack of competency of health workers when dealing with PWLEs, the culture of not involving PWLEs in decision-making, and the culture of stigmatising mental health staffs by other professionals in healthcare systems.
These indicators had the most variable ratings compared to other domains, although most ratings were between red and amber. The ‘culture of not involving PWLEs in decision-making’ had a higher red rating (57% vs 43% amber). In comparison, ‘negative aggregate attitude/behaviour of health systems staff’ (57% amber, 29% red, 14% green), ‘culture of stigmatising mental health staff’ (58% amber, 14% red, green, and undecided each), and ‘less competency of health workers’ (42% amber, 29% for both red and undecided) had a higher proportion of amber rating compared to red and green. As most indicators in this domain had no aggregate data or information that could be mapped, the ratings were based on personal experiences, which varied between participants.
The ‘health systems staff is not aware/knowledgeable about human rights of PWLEs’ indicator had comparable ratings for red and amber (42%), while 16% were undecided between red and amber. The varying opinions reflect the participants' experiences. For example, a health coordinator thought the indicator was irrelevant because health professionals were not lawyers and did not need to know the human and legal rights of PWLEs. Some participants, however, believed that the indicator was very relevant and necessary and rated it amber as some development partners had conducted WHO Quality Rights training [23]. Some participants rated it red, as the lack of data or information for the indicator in mental health was considered to reflect structural stigma, and a lot was needed to turn the indicator green.
Domain 4: Inequitable and poor quality of care
This domain contains five indicators reflecting ‘involuntary/compulsory treatment,’ ‘unavailability of evidence-based services,’ ‘separation of mental health from primary healthcare,’ ‘lack of multisectoral collaboration for mental health services,’ and ‘lack of clear referral pathways.’
Like the indicators in domain 3, these indicators had limited data from published literature, so the information was mainly derived from qualitative studies conducted in specific geographic or healthcare settings. As such, indicators like ‘involuntary/compulsory treatments’, ‘separation of mental health from primary healthcare,’ and ‘lack of collaborations’ had higher non-response rates compared to other indicators. Nevertheless, all indicators within this domain except ‘separation of mental health from primary healthcare’ were rated mainly as red, implying higher manifestations of structural stigma in this domain.
For example, 50% of participants rated ‘involuntary/compulsory treatment of PWLEs’ as red. In contrast, 29% rated it amber, and 21% had no response due to lack of information. Those with amber ratings were mainly mental health practitioners and administrators. They mentioned improved restraining or compulsory admittance practices over time, occurring only when justified by the nature of the condition. This was corroborated by a mental health specialist rating the indicator red due to unnecessary sedation and overprescription, even by specialist practitioners.
Most participants also rated the ‘unavailability of evidence-based mental health services’ red, given the government not prioritising evidence generation (evidenced by no mental health data for use in resource allocation), using a political agenda rather than evidence to inform policies, and the information lacking for most indicators within the framework. Some participants, however, highlighted the adaptation and implementation of WHO’s mhGAP program [24] as a noteworthy government step and therefore rated it yellow.
The ‘lack of multi-sectoral and inter-disciplinary team collaboration for mental health services’ had more varied ratings, with 50% red, 36% amber, 7% green, and 7% undecided/no response. Those with amber or green ratings highlighted government attempts to bring together different stakeholders for policy and planning, such as development partners from various mental health non-profit organisations, service user advocates, and mental health specialists. They also highlighted that such collaborations were more common in mental health than other health conditions, making it a comparatively lesser structural issue for mental health. Nevertheless, some participants considered collaboration and communication between different tiers of government – federal, provincial, and local –challenging for mental health and therefore rated this red. They mentioned no clear division of roles and responsibilities, resulting in duplicate program implementation, such as mental health training for the same health workers. Medication supply problems were also given as an example of lacking collaboration between different tiers of government bodies and institutions, such as the health directorate office, health training centre, and health logistics management centre.
The ‘lack of clear referral pathway’ indicator, too, had mostly red ratings (57%) compared to amber (29%) and green (7%). Participants highlighted lacking referral mechanisms between primary healthcare facilities and general or specialist hospitals, compared to safe motherhood programs.
Domain 5: Negative experiences of PWLEs
The final domain consists of indicators reflecting PWLEs’ experiences seeking services from the healthcare systems, namely ‘low satisfaction of mental healthcare received,’ ‘negative interaction with health workers/administrators,’ ‘high out-of-pocket expenditure for mental healthcare,’ ‘lack of ease of access to mental healthcare,’ and ‘insufficiently informed about their condition or treatment.’
Most information mapped to these indicators came from either FGDs, expert consultations with PWLEs during the framework's development, or qualitative studies on barriers to care in Nepal. Most participants (55%) rated ‘low satisfaction of mental health care received’ as red, while the rest rated it as amber. PWLE participants especially resonated with the information mapped on the indicator and shared their own experiences of dissatisfaction with the care received. This ranged from the unavailability of medications resulting in having to purchase medicines from private pharmacies, health workers not listening and communicating like a ‘robot’, lack of freedom during hospitalisations and being treated as prisoners, and the troublesome/annoying process of using services like insurance schemes.
Most participants (55%) rated ‘negative interaction with health system staff’ as amber, indicating some progress in this area. However, several initiatives were needed to turn the indicator green, given issues like the use of stigmatising words towards patients, teasing patients, making snide comments about the patient while talking amongst themselves, commenting on them looking fine when trying to access disability services, being ignored or not taken seriously, and being judged. Nevertheless, participants mentioned that this was improving, as public attitudes towards PWLEs, in general, were improving because of government-provided mental health training. The government initiatives to integrate mental health into essential healthcare services, with primary healthcare workers trained to provide free basic mental health treatment, was the reason behind most participants’ amber ratings for ‘high OOP expenses for services’ (55%) and ‘lack of ease of access to mental health services’ (64%). However, some PWLEs rated these indicators ‘amber’ due to experiencing difficulties in accessing care, such as accessing services from multiple providers and spending lots of money before receiving a diagnosis or treatment.
The final indicator, ‘PWLEs insufficiently informed about their conditions and treatment,’ was rated red by most (73%). PWLEs shared instances where they observed no two-way communication between service providers and patients in a government hospital’s psychiatric outpatient ward, where service providers prescribed medications and asked patients to attend follow-up without considering the patient's or their caregiver's opinions. In comparison, some rated it amber (18%), and 9% of the participants were undecided between red and amber.
Table 1
Summary of mapped information, its sources, and relevant quotes from KIIs
| Domains/Indicators | Information from the mapping exercise and KIIs used for rating | Information sources identified or suggested | Relevant quotes from participants on indicators and their rating |
| Domain 1 | Poor and discriminatory legal framework and policy environment |
| Unavailability of Mental Health Act, policy/action plan | The government of Nepal drafted a national mental health policy in 2017, but the cabinet minister did not approve it, and hence, it never came into existence. Later, the National Mental Health Strategy and Action Plan 2077 was formulated to provide easy, accessible, and quality mental health services to the people. There isn't any mental health act formulated in Nepal to date. Although the draft for the Mental Health Act was developed in 2006, it never existed. Besides that, the Gandaki province has included mental health in its own provincial policy, and Karnali province has endorsed its own mental health strategy and action plan. | - Policy review - WHO Mental Health Atlas indicators - Survey/interviews with policy stakeholders | A participant highlighted what should be present for the indicator “exclusion of mental health from universal health coverage” to turn green: “Service availability should be maintained. Right now, only 23% of the population receives mental services- even if we go by the best estimate. In all of primary healthcare, there needs to be at least two trained human resources available in the primary healthcare facilities at all times, medicines should not be disrupted for more than seven days in a year, and district hospitals should be the first level of referral with at least one psychiatrist to be available as a trainer/supervisor and also provide tele-mental health.” (Male, development partner/mental health specialist) A participant on why they were undecided between red and yellow for the indicator “unavailability of mental health act, policies/action plan: “The provincial and local governments should develop mental health strategies based on their provincial scenario. All levels of government should prioritize mental health and implement the strategies.” (Female, development partner) |
| Exclusion of mental health from universal health coverage | The government of Nepal has included mental health in the Basic Healthcare Service, 2075, to ensure that health services are easily accessible and available free of cost. The Basic Health Service (BHS) package provides essential medicines for mental health and some psychosocial support services for common neurotic and psychotic disorders (depression, anxiety, and psychosis) and idiopathic epilepsy. These services are available from primary healthcare facilities such as HPs, PHCs, and hospitals. In the Social Health Security Scheme, the medical management of conversion disorder, severe depression, bipolar disorder, epilepsy, and schizophrenia are only included in the insurance package. However, psychosocial management/therapies are not listed in the scheme. The government of Nepal developed the national health insurance program in 2017 based on the Health Insurance Act, and ensured its implementation in all 77 districts by the year 2022. However, this is yet to be achieved. | - Policy review - In-depth review of insurance policy documents |
| Exclusion of mental health from national health policies/programs | The Public Health Service Act of 2018 includes the services related to mental health as free basic health services. Mental health agenda is included sparsely in national health policies and acts. Similarly, the National Health Policy 2019 addresses mental health as a concern and ensures access to mental health and psychosocial services from local health facilities by promoting knowledge and skills transfer in primary hospitals. Mental health is included in provincial health policies (Gandaki and Karnali), focusing on services at district hospitals and mental health camps. However, mental health is rarely included in wider national public health programs such as maternal/child health and HIV/NCD programs. | - Policy review - Survey/interviews with stakeholders |
| Lack of involvement of PWLEs in policy and program development, implementations, and evaluations | A qualitative study conducted among service users and caregivers in Nepal stated that PWLEs and advocates are rarely involved in policy and program development/implementation/evaluation phases. Any involvement is only tokenistic, with feedback rarely sought or considered. | - Qualitative interviews with PWLEs/advocates - Observations of stakeholders narrated during KIIs |
| Discriminatory language or provision in mental health policy | A scoping review of health and social policies of Nepal showed some progress had been made in revising stigmatising language, labelling terms such as “baulaaeko” (insane), imprecise language (mental disease, drug abuse), devaluing terms (mentally incapable/handicapped, mentally incapacitated), and dated terminology (mental asylum) persists in several policies. Similarly, some amended policies have replaced the previous stigmatising words ‘mentally unstable/insane’ with ‘of unsound mind’. Although this terminology and its definition encompass both mental and physical incapacity, the policy and strategies formed on its basis primarily affect those with mental health conditions, reinforcing negative attitudes and behaviours. | - Policy review |
| Domain 2 | Stigmatising system infrastructure and resource allocations |
| Insufficient funding for mental health services and programs | A study from 2020 reflected only 0.2% of the budget allocated to mental health out of 6.15 for the overall health budget. The government has allocated less than 1% of total national health expenditure, with a significant proportion directed towards mental hospitals. As per the WHO Report 2022, the estimated annual budget for mental health intervention (excluding human resources and hospital operations) is USD 1.5 million, i.e. NRS 199,955,421 (approx 20 Cr.). The per capita public funds allocated for mental health is approximately 0.05 USD i.e. NRs 6.67. | - National health accounts - WHO report - EDCD - Line Ministry Budget Information System (LMBIS) | A participant from a development partner agency highlighted how the differential quality exists explicitly at the hospitals that provide both physical and mental health services: “Where it does differ is in the hospitals where there are in/outpatient mental health services. Usually, the OPD (Outpatient Department) for mental health is allocated in a far-off corner where no one wants to go. The psychiatric wards are typically underground or far from the main facilities, with limited lights and mouldy rooms. Suitable buildings with good infrastructures are not reserved for mental health wards; they are reserved for other conditions. In addition, if new beds are bought, they are handed over to other wards, and the older beds are allocated to psychiatric wards. We have observed infrastructural discrimination in such ways.” (male, development partner/mental health specialist) A government official discussed the competing needs within the healthcare system, resulting in a limited mental health budget: “We are still struggling with infectious diseases such as malaria and leprosy elimination. Our targets and activities are focused on this. If you look at the Ministry of Health- it has a Department of Health Services, and the department has ten divisions, one of which is the NCD and mental health unit. The NCD and mental health are put together even in that one division. So, you can imagine how much of our budget is for mental health.” (Female, policy maker/health system leader) A participant on cut down of mental health program budget: “When the government goes into crisis, they target to cut down the mental health budget rather than from budget allocated to physical health conditions. I don’t think the gov understands the importance of mental health.” (Male, development partner) A participant at the government level outlining issues in the procurement process of psychotropic drugs: For basic healthcare, we have classified the medicines out of the 98 essential healthcare medicines, ones that the federal government can purchase, ones that the province level can purchase, and ones that the local level can purchase. So, what happened was that the purchase of mental health medications is listed under the province's government. The challenge is that the provincial government says that they don't receive enough budget. However, they don't have data on quantification- how many cases are there and how many medications are required- they don't have this information. It would be easy if the local government could inform the province that they need these medications of these dosages. Because the medications are not that expensive, the federal government tells them that the budget they have sent them is enough. Another issue is that the local level cannot purchase psychotropic medications (I don’t know if it is due to legal issues surrounding psychotropic drugs). Because they cannot purchase it themselves, the problem is that they must depend on the quantities sent by the province. But then the province doesn't know what quantities it is required for. A lot of local government bodies are lobbying for them to be able to purchase mental health medications. However, the basic health care package is like a law, so we haven't been able to amend it quickly. That's our gap. (Female, policy maker/health system leader) |
| Unavailability of trained human resources for mental health | The trained healthcare providers as of the year 2022 are psychiatrists (200), psychologists (30), psychiatric nurses (75), psychosocial counsellors (1300), prescribers trained at local health facilities (more than 1700), female community health volunteers (938). The accurate number of trained healthcare providers for mental health isn't made accessible to the general public through the official government website; hence, the data mentioned from different studies or WHO may be inaccurate as compared to the current scenario. | - WHO report - National Health Training Center (NHTC) - MoHP -Psychiatric association data log -Nursing association data log |
| Mental health indicators not included in national health information system | The Health Management Information System (HMIS) reports and records all the delivered health services from all levels of the health system of Nepal. In the case of mental health, the indicators related to mental health in HMIS are included with archaic indicators in HMIS 9.3. Recently, new NCD and mental health indicators have been developed that logs information on diagnosis and treatment of priority mental health conditions and disaggregates gender and age. However, training and implementation of these new indicators are pending. | -HMIS 2070 - Revised HMIS indicator 2078 |
| Unaffordable services compared to other chronic conditions | The findings from the NHRC national survey 2020 found the average expenditure on treatment of mental disorders in the past 12 months was found to be NRs 16,053; expense on transport and other costs associated with seeking treatment was NRs 4,146 and NRs 3,460 respectively. A study conducted on out-of-pocket expenditure associated with depression found a total mean expenditure of $118 USD (NRs 15,730) per year out-of-pocket on healthcare. This amount represents a substantial proportion of household budgets, especially considering that the median annual income for adults with depression in the area is estimated to be $501 USD (NRs 66,785). | - National Mental Health Survey - Costing and Cost-effectiveness studies |
| Differential quality of space/infrastructure for mental health services | Studies have found the lack of separate/private space for counselling as a barrier to mental health services. The ongoing study on mental health (RESHAPE) [25] in the three districts of Gandaki Province has the data of 21/30 Health facilities in 8 municipalities did not have the OPD or counselling space required to deliver mental health services. | - Findings from WHO Quality Rights toolkit - Qualitative studies and site observations - Health facilities observation |
| Unavailability of medications at health facilities | The data from the RESHAPE study found that essential medicines like antidepressants/SSRIs, antipsychotic medications, and benzodiazepines were continuously available for more than 4 months in 22,15 and 8 health facilities out of 24, respectively. However, certain medicines were continuously unavailable at many health facilities. Additionally, 24HFs rated ease of procurement of psychotropic medications on average 3.7 compared to procurement of other drugs (average 6.9) on a scale of 1–10 where 10 was very easy to procure while 1 was very difficult to procure. | - Governments Logistic management data system - Observation - Health facility store logs |
| Domain 3 | Aggregate stigmatising attitudes and practices of healthcare system personnel |
| Negative aggregate attitude/behaviour of health and other staffs towards PWLEs | Studies conducted on stigma and barriers to mental health services in Nepal have identified stigma among health workers as a significant barrier to service delivery. Health workers often perceive a risk of personal harm and violence and fear of losing social prestige in the community when treating people with lived experiences (PWLE). However, there is a lack of data addressing the stigma of healthcare staff within hospitals/healthcare settings. | - Use of stigma attitude tools during trainings - In-depth interviews with PWLEs | A health coordinator from a rural municipality reflects on the indicator “culture of not involving PWLEs in the decision-making process”: “The patient who recovered from the physical health problem is trusted fully as compared to those who have mental health conditions. There is still a huge stigma towards people who are recovering from mental health conditions, that they aren't capable enough to make the decision.” (Male, Health coordinator from rural municipality) A health worker on rating the indicator ‘negative attitude of health systems staff’ as red based on their experience with other health workers in their facility: “When the Alcohol Use Disorder (AUD) patient comes to our health facilities, my colleague stays away from them or tells the patient to stay outside. If the psychosis patient visits health facilities, they don't want to handle that case. The Health Workers used to give less time to that patient, but it may have been due to a fear of harm to them.” (Male, Health facility Incharge/health worker) Reflection by a participant on the indicator “Health system professionals not aware about human rights of PWLEs”: “There is a huge gap as these are not researched, but based on my observations, I would give a red rating to this. There aren't many initiatives to address this issue, and we need to do quite a lot about this. Even as part of the mental health training, where have we talked about human rights? Even in module 1 and module 2 training of health workers, human rights issues are not addressed. We train them on basic communication skills, therapeutic skills, and medications, but we haven't incorporated human rights topics in these trainings for health workers.” (Male, Development partner) |
| Health workers not aware or knowledgeable about the human rights of PWLEs | There isn't any reported data on health workers knowledge or awareness level about the human rights of PWLEs. Limited trainings for health workers or administrators on rights of PWLEs. Few Quality Rights trainings organised by I/NGOs. | -No identified sources for data |
| Less competency of health workers in dealing with PWLEs | The competency measure of health workers in dealing with PWLEs was shown by a study conducted in Nepal along with two other countries that found health workers incompetency in diagnosis, addressing confidentiality, involving family members in care, and assessing suicide risk. Similarly, the ENACT (Enhancing Assessment of Common Therapeutic Factors) tool that assesses the diagnostic accuracy of mental illness, showed the result of only 10 of 29 accurately diagnosed by the PCPs. However, there wasn't any data available on the competency measures of other health staff (nurses, assistants, administrators) in the healthcare setting. | -Use of ENACT or other competency based tools - PWLE observations and interviews |
| Culture of not involving PWLEs decision-making | A qualitative study with PWLEs from Nepal found that they were not involved in major decision-making processes. Similar outcomes were found in qualitative interviews from the RESHAPE and INDIGO studies, ongoing in Gandaki Province, where healthcare providers did not include PWLEs in discussions about medication and treatment options. | - Qualitative interviews with PWLEs |
| Culture of stigmatizing mental health staffs by other professionals in healthcare systems | Health Professionals said they often have to face the stigma from their colleagues whenever they used to work in the psychiatric ward. They were given names as psycho doctors just because they treated the MH patients. These are the findings from qualitative interviews of the INDIGO study. | -Qualitative interviews with health professionals |
| Domain 4 | Inequitable and poor quality of care |
| Involuntary/compulsory treatment of PWLEs | The PWLEs shared they were prescribed unnecessary medicine for their conditions because the doctor would often get profit from the pharmaceutical company for prescribing those medicines. Some PWLEs mentioned they were subjected to involuntary confinements and hospitalisations for their conditions even though they asked to be released. They were confined along with the patient having severe mental health conditions. | -Focus group discussion among PWLEs -In-depth interviews with PWLEs | A health coordinator on “involuntary/compulsory treatment” yellow mentioned: “I think it depends on the case. The health workers want the patient to get better, and it depends on how the patient is. If the patient is violent, causing harm to others and destroying property, then they should even be locked up. (Interviewer: So, the patient can be treated involuntarily and even imprisoned for their safety?) Yes, that's why doctors make those decisions.” (Male, Municipality health coordinator) A mental health specialist rating the same indicator “involuntary/compulsory treatment” red: “In most cases, family members of PWLEs are not involved by clinicians in decision-making- there isn't a practice for that, even from qualified practitioners. Prescribing a lot of unnecessary drugs and over-sedation- are the issues. This is even true for who we call mental health specialists. This is a big area that we can work on. If you sell many drugs, you make a lot of profits, which is true in many profit-making institutions. This is one aspect. The other aspect is that if the patient is sedated- it's much easier for ward staff on duty. These are some of the malpractices I have observed as an insider”. (Male, mental health specialist) A participant on why they rated the indicator “lack of clear referral pathway “ as red: “In the case of maternal health, Skilled Birth Attendant has a separate slip with them if they cannot manage the case. The referred hospital will know where the case came from and what the patient's situation is. The HMIS also has reporting of referred cases for maternal health. But in the case of mental health, there aren't any referral slips available, and there isn't any system to track whether the referred patient has received treatment. There are many losses to follow-up cases because of the weak referral mechanism. People are forced to visit private hospitals because of the government's weak referral mechanism. Let's not even talk about the reversed referral; after the treatment from the referred hospital, they can still take medicine for conditions like depression or epilepsy from the nearby health facilities, but that’s not the case at all.” (Female, development partner) |
| Unavailability of evidence-based MH services | The integration of mental health into basic healthcare programs was based on evidence from PRIME project adapted the WHO’s mhGAP intervention to Nepal’s context. WHO looking at evidence of tele-psychiatry to inform government. No other information on whether mental health and psychosocial programs are evidence based. Mental health research and data quality from HMIS is limited and so less likely to have evidence based mental health programs. | -Government policy introductions NGO reports |
| Separation of mental health services from Primary health or basic health services | Public Health Act,2075, has included mental health in basic healthcare services. Looking at the current scenario, the integration of mental health is in the scale-up process. As per the WHO report 2022, the GoN- MoHP has now integrated the mental health service in 35 of the country's 77 districts through PHC and district hospitals. Primary health care (PHC) providers were taught to diagnose, identify, and manage basic mental health issues. At least one medical doctor in Nepal’s 35 district hospitals were trained in mental health. | -WHO report -Policy review |
| Lack of multi-sectoral and multidisciplinary team collaboration within health systems for mental health compared to other services | There isn't any reported information available on how the different levels of government healthcare systems collaborate within different departments or institutions for mental health programs. | -Observations and qualitative interviews with stakeholders |
| Lack of clear referral pathway system | A study from Nepal [26]highlights the lack of clear referral mechanisms from primary to tertiary care, which is one of the barriers to the identification and treatment of mental health patients. Besides that, there isn't any information available about the two-way referral pathways. | -Research study |
| Domain 5 | Negative experiences of PWLEs |
| PWLE low satisfaction of mental healthcare received | The PWLEs mentioned they had low satisfaction of care received from health facilities and hospitals due to the lack of medicines, health workers rude behaviours towards them, and lack of privacy (no separate space to share their problems openly). | -FGD with the PWLE - PWLE service satisfaction surveys | PWLEs reflecting on the difficulties in accessing mental health care: “If the doctor gives more time and asks the patient questions, they could identify mental health problems. If not, the patient must go to many places for their diagnosis, ultimately increasing expenses. People visit Dhami chakra (traditional healers) and spend money; they go to the district hospital, but the GP cannot identify the mental health problems. In this process, they spend a lot of money.” (Female, PWLE) A PWLE shared his negative experience of hospitalisation: “In the hospital where I was admitted, I remember this lady who told us we were prisoners there. They never told us why we were there, for how long, why we were imprisoned there without our choice. I used to think about it and felt very bad at that time. I have talked to many people who have faced similar experiences”. (Male, PWLE) A PWLE on ease of access to services: “There was a person in our community who ran away from home- he was naked, had no slippers, was vulnerable to himself, and was aggressive to others. We took him to the government hospital but they said that there's no bed for people having a mental health problem and asked us to leave after a day of admission. They would have treated him if he had been taken to a private hospital, but they couldn’t afford it. At the government hospital, we somehow managed to keep him there for a night, but they kept him tied up the whole night, and the next day, the hospital didn't want to keep him there. So, we had to send him to Kathmandu the next day by making him unconscious. What can we say now? (laugh). The access to services is zero.” (Male, PWLE) A PWLE on lack of communication and sufficient information by service providers: “They have 4/5 doctors in the same room and just write the medicines without listening to patients. They ask them to come again after one week or 15 days. That's all based on their (doctor’s) assumptions, not what patients told them. It’s like they can do whatever they want” (Male, PWLE) |
| PWLE negative interaction with health workers/administrators | Some PWLEs shared that the doctors and other staff tease them while visiting for check-ups. A few of the AUD patients shared the doctor made inappropriate jokes like how many bottles of alcohol they consumed during consultation. Furthermore, they added the doctors wouldn't listen to them properly while sharing their problems. | -Qualitative interviews with PWLEs - PWLE quality of service surveys |
| PWLE out-of-pocket expenses for mental health services | PWLEs have shared they have to travel and buy medicine from the city with their own money because of the medicine's unavailability at the health facility. | -FGD and qualitative interviews with PWLEs - Costing and cost-effectiveness studies |
| PWLE lack of ease of access to mental health services | PWLEs shared they were unable to find medicine when prescribed by the doctor and had to go to multiple places in search of medicine for mental health problems. They shared that medicines aren't as easily available for mental health conditions as compared to physical health conditions. | -FGD and qualitative interviews with PWLEs |
| PWLE insufficiently informed about their condition or treatment | PWLEs mentioned that health workers do not give enough time to listen to their problems nor inform them properly about their problem. | -Qualitative interviews and FGDs with PWLEs |