EMERALD: Emerging mental health systems in low- and middle-income countries

Visit by the late Dr Sheila Ndyanabangi from the Ministry of Health to Emerald study site in Uganda (Picture credit: Sir Graham Thornicroft)

Health systems the world over are facing ever greater demands and challenges. The health systems of low- and middle-income countries (LMICs) are particularly strained due to the lower availability of resources and the higher overall burden of disease in these populations compared to high-income countries.

The Emerald project was a mental health service system strengthening research programme with sites in six LMICs, which aimed to identify key health system barriers to, and solutions for, the scaled-up delivery of mental health services in LMICs, and by doing so improve mental health outcomes in a fair and efficient way. This research project studied the element of the WHO Health Systems Strengthening approach in Ethiopia, India, Nepal, Nigeria, South Africa and Uganda, in relation to their mental health systems, aiming to improve mental health outcomes in the six countries by building capacity and generating evidence to enhance health system strengthening.


The Emerald 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. These recommendations are relevant not only to the six countries in which their evidential basis was generated, but also to other LMICs; they may also be generalizable to other non-communicable diseases beyond mental, neurological or substance use disorders.

Photo: Visit by the late Dr Sheila Ndyanabangi from the Ministry of Health to Emerald study site in Uganda (Picture credit: Sir Graham Thornicroft)

Additional materials

In 2018, The Lancet Commission on global mental health and sustainable development was published, presenting the future directions of global mental health. In 2007, a series of papers in The Lancet synthesised decades of interdisciplinary research and practice in diverse contexts and called the global community to action to scale up services for people affected by mental disorders (including substance use disorders, self-harm, and dementia), in particular in low-income and middle-income countries in which the attainment of human rights to care and dignity were most seriously compromised. 10 years on, this Commission reassesses the global mental health agenda in the context of the SDGs:

The Lancet: https://www.thelancet.com/commissions/global-mental-health