Integration of perinatal mental health care into district health services in Uganda: Why is it not happening? The Four Domain Integrated Health (4DIH) explanatory framework.

The Sustainable Development Goals recognise mental health and well-being as a target area, however, mobilizing funding and prioritisation of the same remains a challenge. Perinatal mental health care has the potential for incorporation and integration across the overall maternal health agenda, and can be especially relevant for low- and middle-income countries in their overall health systems strengthening strategies. This study aimed at qualitatively situating the extent to which integration of perinatal mental health care into maternal health care was considered desirable, possible and opportune within the existing policy and service-delivery environment in Uganda. A total of 81 in-depth interviews and nine focus group discussions (N = 64) were conducted with a variety of national, district, health system and community-level stakeholders. Data were analysed thematically using theory- and data-driven codebooks in NVivo 11. Analysis of the desirability, possibility and opportunity for integrating perinatal mental health care within the Ugandan district health system, highlights that concerned stakeholders perceive this as a worthwhile endeavour that would benefit the communities as well as the health system as a whole. Based on these current realities and ideal scenarios, a tentative explanatory framework that brings together various perspectives - that is, the perceived nature of the health problem, local and national health system issues, alternative systems of care and support, and international global perspectives - was constructed. The framework needs further validation but already hints at the need for global, national and local forces to concurrently rally behind the inclusion and integration of perinatal mental health care, especially at the primary care level in low- and middle-income contexts. If the global health community is poised to achieve high quality, women-centered care and people-centered health systems across the lifespan, then the sustainable integration of mental health care into general health care, is a commitment that can no longer be delayed.
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