Breaking down barriers: A qualitative study of demand- and supply-side barriers to depression care in Nepal

Despite global initiatives like WHO's mhGAP, mental health treatment gaps remain substantial, especially in LMICs. Barriers are often presented collectively, with an emphasis on supply-side solutions, while demand-side factors are frequently overlooked. Distinguishing these barriers and implementing tailored strategies is critical for improving access and utilization. This study explores stakeholders' perceptions and experiences of demand- and supply-side barriers to mental healthcare in Nepal. Qualitative interviews were conducted with 65 community stakeholders, including people with lived experience, using vignettes and the McGill Illness Narrative Interview (MINI) guide. Data were analyzed thematically in NVivo and interpreted through Levesque et al.'s access framework, which examines health system characteristics and individual capabilities. Demand-side barriers included spiritual attributions of mental illness, stigma, low perceived need, financial hardship, lack of family support and limited awareness of conditions and available services. These factors hindered recognition, help-seeking, affordability and engagement. Supply-side barriers involved frequent staff transfers, inadequate training, lack of privacy, poor infrastructure and irregular psychotropic medicine supply, affecting service acceptability, availability and appropriateness. Access to mental healthcare in Nepal is shaped by interconnected demand- and supply-side barriers. Addressing these requires culturally sensitive stigma-reduction, mental health literacy programs, workforce stabilization, reliable medication supply, privacy-friendly facilities and financial protection.