Use of the consolidated framework for implementation research to understand the barriers and facilitators for mental health service delivery during health system restructuring and COVID-19 in low-resource settings

Despite the growing availability of evidence-based mental health interventions, access remains limited in low- and middle-income countries (LMICs). Identifying facilitators and barriers to mental health service delivery, particularly in fragile transitioning healthcare systems during crises like Coronavirus Disease 2019 (COVID-19) pandemic is crucial for effective implementation. This study uses the Consolidated Framework for Implementation Research (CFIR) to examine barriers and facilitators influencing implementation of a mental health study within the government health system in Nepal. In Syangja District in Western Nepal, 279 primary care and community health workers in 41 rural health facilities were trained to deliver mental health services from 2019 to 2023 through a study called Reducing Stigma among Healthcare Providers (RESHAPE). We collected training and supervision reports, notes from stakeholder consultations, field observations, dissemination meeting summaries, and process notes on study implementation. Using a deductive qualitative thematic analytical approach, this data was organized across CFIR’s three domains: outer settings, inner settings and individual characteristics to identify barriers and facilitators of implementing the RESHAPE study. Facilitators of implementing the RESHAPE study included strong partnerships between the implementing organization and government stakeholders, alignment with mental health policies, the development of an integrated service delivery model, and structured supervision. Implementation barriers at the health system level included disruptions due to the COVID-19 pandemic, poor coordination across government tiers, limited prioritization of mental health, funding constraints, medication shortages, and inadequate infrastructure. At the provider level, challenges included high staff turnover, limited availability of trained supervisors, and persistent stigma toward mental health conditions. At the patient level, a key barrier was distrust in the capacity of primary care facilities to deliver quality mental health services. Using CFIR, this study highlights the critical role of strong partnerships, policy alignment, and supervision in implementing mental health services during system transitions and public health crises. Addressing structural, provider, and patient-level barriers—such as coordination and policy gaps, stigma, and distrust—is essential to strengthen sustainable, community-based mental health care in low-resource settings.