Health gains and financial protection provided by the Ethiopian Mental Health Strategy: an extended cost-effectiveness analysis

Background: Mental and neurological (MN) health care has long been neglected in low-income settings. This paper estimates health and non-health impacts of fully publicly financed care for selected key interventions in the National Mental Health Strategy in Ethiopia for depression, bipolar disorder, schizophrenia and epilepsy. Methods: A methodology of extended cost-effectiveness analysis (ECEA) is applied to MN health care in Ethiopia. The impact of providing a package of selected MN interventions free of charge in Ethiopia is estimated for: epilepsy (75% coverage, phenobarbital), depression (30% coverage, fluoxetine, cognitive therapy and proactive case management), bipolar affective disorder (50% coverage, valproate and psychosocial therapy) and schizophrenia (75% coverage, haloperidol plus psychosocial treatment). Multiple outcomes are estimated and disaggregated across wealth quintiles: (1) healthy-life-years (HALYs) gained; (2) household out-of-pocket (OOP) expenditures averted; (3) expected financial risk protection (FRP); and (4) productivity impact. Results: The MN package is expected to cost USD 177 million and gain 155,000 HALYs (epilepsy USD 37m and 64,500 HALYs; depression USD 65m and 61,300 HALYs; bipolar disorder USD 44m and 20,300 HALYs; and schizophrenia USD 31m and 8,900 HALYs) annually. The health benefits would be concentrated among the poorest groups for all interventions. Universal public finance averts little household OOP expenditures and provides minimal FRP because of the low current utilization of these MN services in Ethiopia. In addition, economic benefits of USD 51 million annually are expected from depression treatment in Ethiopia as a result of productivity gains, equivalent to 78% of the investment cost. Conclusions: The total MN package in Ethiopia is estimated to cost equivalent to USD 1.8 per capita and yields large progressive health benefits. The expected productivity gain is substantially higher than the expected FRP. The ECEA approach seems to fit well with the current policy challenges and captures important equity concerns of scaling up MN programmes