Adverse sequelae of the COVID-19 pandemic on mental health care in seven low- and middle-income countries: MASC study

A WHO rapid assessment of early impact of the COVID-19 pandemic on mental health services worldwide found a consistent pattern of degradation. In this context the MASC study aimed to: (1) identify the consequences of the pandemic for mental health services and people with pre-existing mental health conditions (MHCs) in 7 low- and middle-income countries; and (2) identify good practice to mitigate these impacts. The study was conducted in Chile, Ethiopia, Georgia, Nigeria, South Africa, Sri Lanka and Ukraine. This was an observational study, using a mixed-methods convergent design, triangulating data from: (1) 144 key informants participating in semi-structured interviews or focus groups and/or a self-completed survey; (2) routine service utilization data; (3) local grey literature; and (4) expert consultation. We found clear evidence in all sites that the pandemic exacerbated pre-existing disadvantages experienced by people with MHCs and led to a deterioration in the availability and quality of care, especially for psychosocial care. Alongside increased vulnerability to COVID-19, people with MHCs faced additional barriers to accessing prevention and treatment interventions compared to the general population. To varying extents, sites showed accelerated implementation of digital technologies, but with evidence of worsening inequities in access. Where primary care-based mental health care was more developed or prioritised, systems seemed more resilient and adaptive. Our findings have the following implications. First, mental health service reductions are clear examples of ‘structural stigma’, namely policy level decisions in healthcare which place a low priority upon services for people with MHCs. Second, integration of mental health care into all general health care settings is key to ensuring accessibility and parity of physical and mental health care. Third, digital innovations should be designed to strengthen and not fragment systems. We discuss these findings in terms of anticipating such challenges in future and preparing layers of resilience.