Barriers and Facilitators to Implementing Mental Health Services into the Ethiopian Health Extension Program: A Qualitative Study

Background: Mental health problem is the major health problem globally and nationally in Ethiopia. To address this problem the Ministry of health of Ethiopia integrated mental health services in to the community health service. However, the preliminary reports showed the service has not been implemented yet. Therefore, the aim of this study was to explore the barriers and facilitators of mental health service implementation in to the Ethiopian health extension program. Methods: A qualitative case study was conducted in the Ethiopian primary health care system from 12 August to 25 September 2019. We have conducted about ten purposively selected key informant interviews from the Ministry of Health and community level workers (i.e. health extension workers). All interviews were recorded using voice recorder and transcribed verbatim and translated for analysis. The data then analyzed manually in relevant themes. Results: Mental health problem currently is a major health issue in Ethiopia. However, the service is not ready to respond for the existing health service need. The recently designed integration of mental health services in to health extension program was not implemented so far. The basic identied barriers were, low political commitment, shortage of resources, non-functional referral system, lack of interest from private health service organizations, attitudinal problems from both the society and service providers, the lack of reporting system for mental health problems. On the contrary, there are also facilitators for the service like well-designed primary health care system, trained health extension workers, changing political commitment and attitude of the community. Conclusion: Although mental health problems are widely spread and increasing in alarming rate, in Ethiopia, the existing health system is not capable enough to respond. This problem is complex and intertwined. A series of activities to solve the major barriers are expected especially from the health system leaders to implement follow up and evaluate mental health services at the health extension programs.


Introduction
We live in a complex fast-moving and interconnected world in which the importance of physical, mental and social wellbeing cannot be overemphasized. In this interwoven situation of life, we could understand that mental health plays a vital role in the well-being of individuals, the community, countries and the entire world (1,2). Although mental health has no an agreed up on de nition, the world health organization (WHO) has given its own de nition, saying "a state of well-being enabling individuals to realize their abilities, cope with the normal stresses of life, work productively and fruitfully, and make a contribution to their communities (3)." According to the WHO's report, more than 450 million people in the world suffer from mental and behavioral disorders. It accounts for four of the six leading causes of years lived with disability. According to the report about 1 million people commit suicide as a result of one of the mental disorders (3). Globally each year it costs more than US$ 1 trillion in lost productivity time (4,5). Despite being a global health issue with economic repercussions, provision of services for mental health and mental disorders in the health care sector of many countries, has been sidelined (6).
The situation seems sever in low income countries. A report by the World Bank group and WHO indicates low and middle income countries contribute about 80% of people who have experienced mental disorder in their life time (7,8). Furthermore, the concern given to this serious problem is very little in developing countries (9,10).
This impose signi cant burden to the well-being of the society. Moreover, these mental health problems levy a huge economic burden in these countries. The productivity loss due to mental disorders, treatment costs to mentally ill people, and the exposure of these people to other co-morbidities forced countries to exert the huge proportion of their minimal and donor dependent economic capacity (7,(11)(12)(13).Therefore, the provision of cost effective and e cient measures to combat this disabling problem has become exigent for low income countries.. This makes a call for using the existing primary health care (PHC) structure to address the needs of the vast majority of the population (14).
Although it has not actually been implemented in most of the countries, promoting mental health was outlined as one of the essential element of primary health care during the Alma Ata declaration of 1978 (15,16).
Understanding the bene t of administering mental health services in the primary health care system, after many years countries have integrated mental health services (17,18). Ethiopia is one of the countries that integrated mental health service into the well-structured primary health care system (19). In Ethiopia, primary health care forms the rst tier of the country's three tiered health care structure. The service wing of the primary health care includes primary hospitals, primary health centers and satellite health posts. Health posts are the rst contact units for the patients and staffed with averagely two health extension workers (HEWs). Community health workers called health extension workers in Ethiopia are the nearest health workers to the community.
They give service, mostly preventive and promotive, to the community members either in house-to-house basis or based in a health post. In the country there are over 42 000 HEWs employed by the government. These HEWs give service in two approaches, 1) based in health posts and 2) in a community based house-to-hose visit. There are well-designed 18 health service packaged to be undertaken by HEWs. The packages are mostly preventive and promotive aspects of health care delivery. The whole process primary health care is overseen by a district health o ce (20,21).
Health extension program (HEP) helped the country to achieve in various health indicators. In the updated health extension program by Ethiopian Ministry of Health (MOH) in 2015, mental health was one of the 18 health services packages. However it was observed that mental health services had not been included in health posts and primary care services (22). Based on this initiative nearly 75% of HEWs have got refresher training on the newly added packages including mental health services. However, the actual situation in health posts and the primary health care system revealed the service was not started so far in the country. Based on these scenario, we questioned why mental health services were not still implemented in the health extension program of the country. Therefore the objective of this study was to identify barriers and facilitators of implementing mental health services in the Ethiopian health extension program.

Study Setting Design
Overall we did a case study to explore the Ethiopian primary health system, to see the possibilities so as to implement mental health services to health extension program. The entire chain of health extension program from the central ministry of health to health extension workers working in the community was taken as a case.
Ethiopia is the largest land locked country located in the horn of Africa. The country share border with Eritrea from the North, Djibouti and Somalia from the East, Sudan and South Sudan from the West and Kenya from the Southern direction. The second populous country in Africa have a total of 107.53 million population with equivalent proportion of male and female. The country's capital, Addis Ababa, is the home for the African Union's headquarter and the second diplomatic city in the world.
Ethiopia has a three tier health service delivery system. The system has also administrative and policy making wing, service delivery wing and community wing. Health extension program is a community based health service delivery at the primary health care level, mainly administered by health extension workers trained for the purpose. The policy making and administration of this program starts from the national ministry of health up to primary health care units (PHCU). We have conducted a qualitative study from 12 August to 25 September 2019.

Study Participants And Data Collection
We have conducted a total of 10 key informant interviews with purposively selected key informants. Working units and knowledge of the subject matter were considered when selecting respondents for the study. We also considered maximum variability when selecting HEWs. We also considered the main constituency the respondents represented when selecting key informants. The key informants comprise policy makers, decision makers, health system managers and health service practitioners (HEWs).
During selection of key informants and data collection, we have followed the Ethiopian HEP and mental health services administration system. 3 key informants were interviewed from the ministry of health noncommunicable diseases prevention and control directorate and PHC and HEP directorate. Following the chain, we then have gone to Oromia regional health bureau. Similarly we have got information from 3 key informants from non-communicable diseases prevention and control division and PHC division. Keeping the chain we directly gone to the service managing level. We have taken one district from Jimma zone, which is located in Oromia regional state. Two key informants (non-communicable diseases coordinator and HEWs coordinator) were interviewed in Seka Chekorsa health o ce which is located in Jimma zone. Eventually two additional interviews of HEWs in the Health Posts located in Seka Chekorsa district of Jimma zone were done.. While interviewing personnel from district health o ces and HEWs data saturation was reached.
We have used pre designed unstructured interview guide to lead the interview. Each of the interview were conducted by two interviewers. The data collectors were master's degree level mental health professional and health system professional. All the interviewers were conducted by Amharic language, a language both the interviewers and interviewees understand. All the interviews were tape recorded and important points were jot down in a note book.

Data Processing And Analysis
All the tape recorded data were transcribed verbatim into written transcripts and translated into English language. We then managed and analyzed the data manually. Two of the investigators KY and YT read the transcripts repeatedly and assigned codes manually using an excel spreadsheet tables. Rigorous discussion among the investigators was done on the initial codes to reach on consensus. Codes were then grouped in to sub-themes. We nally came up with sub themes like mental health problem in Ethiopia, mental health services in Ethiopia, integrating mental health services into health extension program, and barriers and facilitators of mental health services in Ethiopia. Eventually, both the investigators double checked the themes after analysis with the transcripts and the statements quoted in each of the sub-themes.

Description of study participants
We did a qualitative study on the Ethiopian primary health care system starting from the top level policy makers to the bottom level health care managers and health extension workers (HEWs). A total of 10 respondents participated in the study. The rst three were policy makers at national level from non-communicable diseases directorate and PHC and HEP directorate. Three of them were decision-makers at regional level and other two were from service management body, district health o ces. We nally took information from two health extension workers. Mental health problems are not well studied in Ethiopia. But recent ndings indicate that there is a high burden of mental health problem in the country. According to an expert from the MOH, non-communicable diseases directorate, the burden of mental health problems is increasing fast in the country recently. Referring a metaanalysis conducted in 2018 he said, the prevalence of mental health problem in the country is 28%. Other interviewee from PHC and HEP directorate supports this idea. He said "the burden of mental health problem is very high these days in our country [Ethiopia]". This idea was also supported by the interviewee from ORHB non-communicable diseases prevention and control division..
Respondents from Oromia regional state health bureau also mentioned some possible reasons of the increasing burden of mental health problems in the region. Economic condition of the people in the country contributed to the burden. According to the respondents the existing high unemployment rate, and extreme poverty are major reasons for the recent mental health problems. Furthermore they stressed on the use of drugs in many areas of the country could be the major reason. There are local drinks like "Areke", "Tela" and "Tej" and mostly used local leaf called Khat [amphetamine like stimulant drug commonly abused in the East, North Africa and Middle East regions] are common in most parts of the country. Especially the use of Khat is increasing fast.
Regarding this, one respondent from MOH said "…for example, Khat [a local stimulant leaf] use was more prevalent in the eastern part of Ethiopia than the north part, but nowadays the use is spreading fast to the northern parts of the country." The other major reason for recent high prevalence of mental health problem magnitude is the recurrent internal displacements in the country. Political disputes were here and there especially in the biggest regional states of Ethiopia, like Oromia, Somali, Amhara and South Nations, Nationalities and Peoples (SNNP) regions. The dispute ended up with signi cant number of death, property loss and displacement of inhabitants from their original living area. They have been forced to live in temporary camps. The displaced people have experienced terrible situations during the con icts and the current camps. For instance a mental health focal person from ORHB reported that: In recent times there is an increase of mental illness because of displacement of a signi cant amount of population in the region [Oromia region]. The burden is high among those displaced people living in settlement camps. Many of them lost their families and some saw their relatives killed in front of themselves. They were also under stressful condition. Therefore post-traumatic stress disorder, depression, anxiety and psychotic feature are prevalent among these population. The cases were more seen in camps around Sululta, and Bishan Guracha [Two of the camps for displaced people].
The mental health focal person in the MOH has seen the burden dividing into urban-rural residence. "…if you ask me the difference in the rural and urban areas, I can say, it [mental health problem] is more prevalent in urban areas" he said. The reasons for this difference could be factors like displacement, unemployment, psychoactive substance use are more common in urban areas of the country.
In an interview with these HEWs we recognized that, they have observed some people with signs and symptoms of mental health problem during their house-to-house visit in their catchment population. For instance one 32 years old HEW said: "…in my kebele [the smallest administrative division in Ethiopia where HEW serve], I have seen some mentally ill patients [according to her de nition] who insults everybody, throwing a stone, being physically aggressive. I also observed a boy who got into con ict and disagreement with family. Another guy also was highly suspicious to his mother and he kicked out all the family members from their house and started living alone. These can be examples of the mental health problem in my working area."

Mental health services in Ethiopia
The Ethiopian health service delivery system has three tiers. At the tertiary level, highly specialized medical services being given on a referral basis. At the secondary level still services given based on a referral basis but the level of specialty and the number of catchment population are lower than the tertiary level care. At the primary level on the other hand, mostly preventive, promotive and basic curative services are being given. This primary health care is currently administered at primary hospitals, health centers and satellite health posts.
Regarding mental health services the actual practice in Ethiopia tells us that, the services are administered only in tertiary level hospitals. There is only one specialty hospital for mental health service situated at the capital of the country, Addis Ababa. There is a framework to deliver the services at general hospitals [secondary level] and primary level hospitals. However, because of different reasons the activity remain into some of the health facilities. The vast majority of the population living in the rural setting who are in need of care were not bene ted. The mental health focal person in the ministry of health mention reasons for this limited health service access. The rst basic issue is shortage of trained professionals. According to him: "….the service [mental health service] is not well developed, imagine we do have only 60 psychiatrists in the country. There are also mental health professionals at bachelors, master's degree level. However, all these professionals are not actively working in psychiatry clinics. Some, especially those at masters level remain in o ce works in one of health administrative organ." The information we obtained from Oromia regional health bureau mental health focal person supports this argument. There is high turnover of mental health professionals because of transfer, and promotion. The promotion policy in the region supports the transfer of health professionals from health facilities to administrative o ces. Therefore, the region lost many mental health professionals from their actual working area.
Expert from HEP directorate of ministry of health sees the reason from other angle. The source of the problem is absence of clear policy document at national level according to him. For instance "the mental health strategy that was prepared and completes in 2015 hasn't been endorser until now [in 2019]" he said. The strategy document was prepared referring international good practices and based on the world health organization's (WHO) recommendation for low and middle income countries. The strategy clearly indicates mental health services have to be given up to the lower level of care.
Acceptance of the service from the users' side and from the community angle in general is still poor. In most parts of Ethiopia mental health problems are considered as punishment from God or some kind of evil spirit possession. They therefore prefer traditional healers, and religious organization avoiding orthodox health services.
According to expert from Oromia regional health bureau health extension program directorate, a best way to deal with this adverse attitude is changing the behavior of community members. The regional health bureau have implemented and achieved in many health indicators is through community health service activity by health extension workers. The community's health seeking behavior in relation to maternal and child health service, and communicable diseases control and treatment was signi cantly changed with health extension program. The expert said: "The best way is to form a link between HEW to primary hospitals and to specialized hospitals". Health extension workers can mainly participate in identifying and linking those suspected cases to mental health clinics at health facilities.
Integrating mental health services into health extension program The recently updated health extension program consists of eighteen health service packages. Among these packages mental health service is one. Based on these packages the ministry of health has developed a training manual to give a refresher training to already existing HEWs and full package training to newly recruited candidate HEWs. Their main role in mental health service is giving behavior change education, identifying suspected mental health cases with vital signs and symptoms, linking to health service keeping their referral chain and following up adherence to treatment. The integration of mental health services into health extension packages was rst started in urban health extension program. It was then expanded to the rural health extension program. Currently the services are integrated both the urban and rural health extension packages.
Barriers and facilitators of mental health services in Ethiopia As has been revealed in various indicators of health in Ethiopia, the implementation of HEP has signi cantly changed the health status of the community. Since the focus of HEP is on prevention and promotion, burden in health facilities was minimized. The health system saved a substantial amount of resource that could have been used for curative services. Similar bene ts are expected while implementing preventive and promotive mental health services with the HEP in Ethiopia. That is why the government has included mental health services in to health extension packages and trained HEWs with the necessary modules. However, as the information we obtained, the packages were not implemented so far.
Facilitators to implement metal health services with HEP

Health system
Ethiopian health care tier system has is well designed primary health care structure. Under the primary health care structure there is there is service management system called primary health care unit (PHCU). In this unit there are averagely ve health posts with a referral health center. The administrative organ of these units is district health o ce. All the services and the activities of health posts are overseen by the health center. Currently in this system there is also a referral primary hospital. Cases that could not been managed at health center level will be referred to primary hospitals. The overall service at the PHCU supervised by district health o ce. Our key informants from ministry of health and Oromia regional health bureau consider this established system and management as one good opportunity to implement mental health services.
There are also policy documents and strategies that help implementation of the services. The currently available health extension program guideline includes, mental health as one of the main component. The mental health focal person in the ministry of health said: "We are working collaboratively with PHC and HEP directorate, while they were preparing the guidelines [HEP guideline]. We also develop plans together in regarding the mental health services in the PHC system." Despite its delay in implementation, there is mental health strategy document in the ministry of health. This document has given due emphasis to management of mental health problems at the primary health care level.
Government o cials and the ministry of health are now giving concern to mental health and mental health services. Previously there was no even a focal person dealing about mental health in the ministry. However, recently a case team which is dedicated to mental health was established under non-communicable diseases directorate. The ministry is ful lling the case team with human resource. The same is true in Oromia regional state health bureau. The respondent from the bureau stated that: "…the government now is committed to expand the services…". On the contrary to this, a HEW interviewed in one of the districts of Jimma zone respond that she and her colleague have not got trained on mental health and mental health services. We then con rmed this information from the district non-communicable diseases focal person. He said that, he has no any information regarding mental health training given to HEWs so far.
Barriers to implement metal health services with HEP

Health system
The focus of the health systems managing body in Ethiopia is mostly on communicable health problems and maternal and child health issues. Not only has the managing body, much of policy and strategy documents also given priority to similar health issues. The mental health focal person in the ministry has a great concern on this. He said: "….look at the MOH mission and vison; its entire focus is on communicable diseases prevention, promotion and curative aspect but they have totally ignored the rehabilitative aspect." This concern does not remain a problem by itself. It then translated to shortage in the availability of medical supplies, lower budget, and absence of incentive packages and staff's retention strategies for mental health professionals.
From the responses of one of the respondents in the ministry, we could able to catch that, mental health services are not integrated well with the PHC system starting from the ministry of health. "We are not the one planning mental health services." a respondent said from PHC and HEP directorate. They perhaps support the planning and policy department during issues related to integrating mental health into HEP.
The private health care delivery system is also the other center of focus. According to the key informants in the ministry of health, engagement of private institutions in the service [mental health service] is very much minimal. "There are only some two or three facilities giving specialty mental health services in Addis Ababa, the capital of Ethiopia. In other big towns there are no such dedicated health facilities for mental health." [MCH and HEP expert]

Resource
Human resource The major di culty that all the respondents raised was shortage of resources for mental health services. The referral system does not look functional for mental health services. Despite the availability of HEWs trained with mental health packages, there are no mental health professionals at referral health center and primary hospital level. Even though HEWs are trained with identifying and linking suspected people with mental health problem, the referral health centers and primary hospitals does not give services to the patients. There is a short fall of human resource trained with mental health. According to informants from the ministry the total number of psychiatrists in the country doesn't exceed 60. Similarly the health system is in short of psychiatry nurses and other mental health professionals. Therefore, even if there is a demand for mental health services at each level of health system the ministry could not feel the gap.
Therefore "why the government does not train student in this eld of study and feel the shortage of professionals?" could be reasonable question. As has been described above the respondents agreed that, despite the prevailing mental health problems in the country, the focus of health system administrators and policy documents is on other issues like communicable diseases and maternity care. "…this is actually the main problem in the country…" respondent from the ministry said. Therefore, most education program are and signi cant number of students join education programs, directed to what the government outlined priority. This is the case in Ethiopia where most of health and medical schools owned by the government.
It is not only from the side of the government administration, students who join medical and health schools also sometimes have adverse perception about the eld of study. Regarding this the PHC and HEP focal person in the ministry said that "…up on my experience many people do not like the profession [mental health]. For instance if you see physicians, most of them do not prefer to specialize in psychiatry." When respondent from Oromia regional health bureau justify this issue, he said: "there is a wide spread poor attitude that that, a person who treat a person with mental health problem would be a mentally ill afterwards." The cumulative effect eventually left the country in short of mental health professionals.

Finance
The other major concern is nancial constraint. Ethiopia is among countries that have the lowest per capita health expenditure in the world. Moreover, more than two third of the country's health care nance is dependent on external funds and out of pocket payments from users. In this country the amount of budget planned and nance spent in mental health service is minimal. As one of the reasons for minimal allocation, we trace back to the reason that mental health has low policy and political concern in the country. Describing the budget allocated to mental health services is low in the country, the mental health focal person in the ministry uncovered that, there are improvements in the allocated amount of budget for the service currently. "Comparing to the past, currently more budgets are being allocated for mental health services" he said.
The other major source of nance in the Ethiopian health care is support from international organization and bilateral aids. In this regard also, mental health services do not bene t. Most of external aids spent for services like maternity care and communicable diseases control purposes. "for example" says the PHC and HEP focal person in the ministry, "…most of other programs in the ministry supported by international development organizations. As far as I know, mental health has no any support, except little amount of monitory and technical support from WHO." Therefore, it would be di cult to address the mental health need in the country with the sum of available amount of nance. Both Respondents from both Oromia regional health bureau and non-communicable diseases focal person in Jimma zone agree with this issue. They frequently look for additional funds from external organizations, but they left with nothing. "…we have requested [fund for mental health service], but I think they [external aid organizations] are not volunteer to support mental health services…" said mental health focal person in Oromia regional health bureau. There are no external collaborators at the regional and district levels.

Commitment of HEWs
For long HEWs have been serving in the Ethiopian health care system as a community health workers. There are averagely about two HEWs working in a health post. A single health post is supposed to give service averagely to 5000 population. That means two HEWs give the services to more than 1000 households living in a kebele. They serve the people both based in a health post and in house-to-hose visit. They have a signi cant impact in improving the health status of the community in the country according to respondents in the ministry.
However, their pay scale is the lowest in the public health system career structure. Therefore, there is a fear that HEWs may lose their commitment when a new service package is integrated and became add up to the existing.
"We are forced to cover a long distance in a foot walk to address all the households in a kebele. We are loaded with the existing health service packages. All the assigned HEWs do not always available on board for assignments. Some of them may be on maternity leave, some may absent from their work. On top of this I have not got any mental health training so far. Therefore, how can I supposed to do additional activities?" [28 years old level 3 HEW] It could be challenging to administer mental health services in the existing HEP arrangement and career level.
We have also got similar response from the ministry of health PHC and HEP directorate.

Other challenges
There are also some more challenges to the health system to implement mental health services in to the Ethiopian health extension program. The acceptability of the services from the community side and the health systems monitoring and evaluation system are the rst line.
In most parts of the country, people especially those living in the rural areas consider mental health problems as some evil spirit and look for some traditional healers or religious organizations. The problem is heavy in a country with more than 85% rural residents. Some community members are not willing to accept advice from health professional and HEWs. A HEW respondent in this regard said "…some of them [community members] are not willing to take our advices…" Respondents from Oromia regional health bureau have strengthened this view. According to their thought, there is adverse perception about the causes of mental health problems and negative attitude regarding mental health services. This would be challenge when implementing mental health services with HEP.
The Ethiopian health system monitoring and evaluation generally guided by a system called health management information system (HMIS). It is an electronic as well as manual platform that enables the smooth transfer of information from and/or to the bottom level of health service delivery to the ministry of health. The system has pre-de ned health related indicators. Therefore the reporting of health events directly adhere with these pre-de ned indicators. According to the information we have got from the Ministry of health and Oromia regional health bureau, there is no any indicator regarding mental health in the system. The mental health focal person has given stress to this point. He said "…the complaint before was this one. The service [mental health] had no indicator in HIMIS" However, the HMIS system currently is under the process of update.
The new system district health information system (DHIS2) consists some mental health indicators. "Starting from the current scal year mental health indicators are being included in DHIS 2" he said.

Discussion
The origin of community health workers' activity trace back to the Chinese bare foot doctors approach of service. Since then community health service has been practiced in many countries of the world and found effective. Ethiopia has started implementing a structured community health workers approach since 2003 to support the primary health care in the preventive and promotive aspects. The service used to have sixteen health service packages before being updated recently. Many countries achieved health related goals with this approach. Low and middle income countries like Zambia, Uganda and Bangladesh integrated their mental health services with community health approach and shown massive improvement in mental health and service use (18,23,24). Preventive, promotive and rehabilitative mental health service were integrated in the Ethiopian HEP in 2015 (25,26). However, the service has not been fully implemented yet in the country.
The ndings in this study indicate, there is a high burden of mental health problems in Ethiopia. Quantitative gures also indicate the mental illnesses especially like depression and anxiety are most common in various parts of the country (27). Relatively the same happen in other African country (28). Especially currently these cases are frequently happening because of some predisposing factors. Substance use is increasing in many parts of the country currently. Especially the young and adolescent age groups at the level of secondary schools and colleges are vulnerable for this situation (29,30). The internal displacement could also be one major reason for the current peak situation. Currently in Ethiopia there are more than three million internally displaced people because of political disputes. Some documents indicated Ethiopia recorded the third largest internal displacement in the world (31). Therefore, post traumatic syndromes, depression and anxiety disorders could be common because of the con icts and their current di cult living conditions.
The people in most cases use traditional and religious ways of treatment to treat mental health problems.
Mostly they associate the disease to an evil spirit possession or a punishment from God against their sins.
More severely, some families keep a member with mental illness in their house without any treatment. It is the cases in many African countries too. For instance a study conducted in South Africa indicated that, mentally ill people live in a dangerous situation (32). They mostly experience stigma, they do not get the necessary treatment, and they even do not get necessary treatments for other co-morbidities (32,33). All these problems indeed created a high unachieved need for mental health preventive, promotive, curative and rehabilitative services in Ethiopia and other countries with a similar situation. This is the reason that trigger the health system to avail health service as nearest as possible to the population. Various literature suggest giving service at the PHC level is a good initiative to enhance the health of the society at the grass root level, especially in low income countries (34)(35)(36). On top of this others also suggest continuing education and appropriate supervision for primary care workers would lead to success (37).
Although integrating mental health issues in the primary health care delivery system is a good approach, its practicality is di cult in a resource limited country. For instance, when we see the Ethiopian situation, there is a well-structured primary health care system and there are strategic documents supporting the integration of mental health service into the system (38). However, the practice has not been actually started yet. Health system and program people in the Ethiopian healthcare system list lots of reasons for this occurrence. Despite the fact that mental illness is a big problem in the country, leaders in the health care system and most policy documents have not made this issue a priority problem. Failures of various approaches of health service gives a lesson that (39,40), if there is no political commitment in the health care system it would be simply a result less effort.
Resource is at the heart of health care system. In a resource limited countries, it is really a headache to allocate the existing few resource into varieties of health service. For instance in Ethiopia, a country with more than 110 million population, there are only about 60 psychiatrists and not more than 500 other mental health professionals mostly accumulated in the capital of the country (38). Most of primary health care facilities like primary hospitals and health centers have no any mental health professionals (38,41). Likewise, nance is the other big problem to implement mental health services up to the household level (42). It would also be a big problem in countries dependent on external fund. More than one third of Ethiopia's health care nance is covered by the external world (43). Therefore, even decision makers have to stick with the plans of the funders, they will not have a full autonomy to allocate the nance to priority health problems.
On the other hand, some attitudinal and behavioral issue in the community and health care providers does really affect the implementation of mental health services in the community health service. In a country with about 85% rural residents and mostly uneducated (44), obtaining of the acceptability of mental health service is not as such easy. Not only the uneducated people, according to our ndings, even educated and health care workers have an adverse attitude on mentally ill people and the service itself. As part of the community, some HEWs have wrong attitude regarding mental illness and mentally ill people. We have also identi ed other barriers like; poor knowledge of community members, lack of indicators in the reporting system, lack of need from students to join mental health professions so and so forth. A systematic review has also revealed that the same barriers happen in other low income settings (42).
Our study on the other hand, has identi ed some major facilitators that help implementing mental health services at the community level. Implementing mental health services in the PHC system does not need an establishment cost in Ethiopia (19). Not only the ministry of health led health system, in the country there is also a community arrangement led by voluntary community health workers that supports the health care system (45). Using these system as a strategy, helps to implement mental health service with a minimal cost.
There are also more than 42 000 HEWs working in various parts of the country mostly trained with some basic mental health service. Experience in many countries indicated that, implementing mental health service in the community health workers' system has resulted improvements in many mental health indicators (46,47).

Conclusion
In conclusion, mental health problems are increasing in alarming rate and should be the major concerns in Ethiopia. The currently increasing substance use especially the youth and the huge amount of internal displacements fuel the problem. On top of that, the community's awareness, knowledge, attitude and health seeking behavior contributed to the low level of utilization even at the current health system status. Yet, the currently functioning size of mental health services is not capable enough to respond to the existing need. The preventive and promotive mental health was integrated in to the country's health extension program recently.
Our nding indicated that the service was not implemented yet.
We have identi ed barriers that tackled the implementation like, low concern for mental health service among health system leaders and policy documents, low level public-private partnership regarding mental health services, disastrous shortage and donor dependent resource, acceptability of the services from both the community and HEWs side, some problems in commitment of HEWs, absence and inadequate indicators in the Ethiopian health information system. On the other hand, there are also some facilitators that help the implementation of mental health services with the health extension program. There is a well-designed primary health care system, recently there are also improvements in valuing mental health from health system leaders, especially at the national level, there is also policy documents that states the integration of mental health in to health extension program, about 80% of HEWs are trained with some basic mental health services and the attitude of the people is currently changing.
In general, implementation of mental health promotive, preventive and identi cation and linkage service of patients with mental health problems at the community grass root level through HEWs would paramount importance for the mitigation and controlling devastating effect of the problems. The proposal of the study was reviewed and approved by the Institutional Review Board (IRB) of Jimma University institute of health. Before data collection, an o cial letter of support was written to Ministry of health of Ethiopia, Oromia Health bureau, Jimma zone health department, and subsequent support letter was given for Seka chekorsa woreda health o ce. Additionally, the interviewees were briefed on the study objectives and methodology and were assured of the anonymity of their participation, moreover oral informed consent was obtained from the study participants.

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Competing interests