Background: Ethiopia is embarking upon a ground-breaking plan to address the high levels of unmet need for mental health care by scaling up mental health care integrated within primary care. Health system governance is expected to impact critically upon the success or otherwise of this important initiative. The objective of the study was to explore the barriers, facilitators and potential strategies to promote good health system governance in relation to scale-up of mental health care in Ethiopia.

Methods: A qualitative study was conducted using in-depth interviews. Key informants were selected purposively from national and regional level policy-makers, planners and service developers (n = 7) and district health office administrators and facility heads (n = 10) from a district in southern Ethiopia where a demonstration project to integrate mental health into primary care is underway. Topic guide development and analysis of transcripts were guided by an established framework for assessing health system governance, adapted for the Ethiopian context.

Results: From the perspective of respondents, particular strengths of health system governance in Ethiopia included the presence of high level government support, the existence of a National Mental Health Strategy and the focus on integration of mental health care into primary care to improve the responsiveness of the health system. However, both national and district level respondents expressed concerns about low baseline awareness about mental health care planning, the presence of stigmatising attitudes, the level of transparency about planning decisions, limited leadership for mental health, lack of co-ordination of mental health planning, unreliable supplies of medication, inadequate health management information system indicators for monitoring implementation, unsustainable models for specialist mental health professional involvement in supervision and mentoring of primary care staff, lack of community mobilisation for mental health and low levels of empowerment and knowledge undermining meaningful involvement of stakeholders in local mental health care planning.

Conclusions: To support scale-up of mental health care in Ethiopia, there is a critical need to strengthen leadership and co-ordination at the national, regional, zonal and district levels, expand indicators for routine monitoring of mental healthcare, promote service user involvement and address widespread stigma and low mental health awareness.