In Africa investments in mental health care systems have been limited ( 1 ). A previous initiative in two regions of Tanzania in the early 1980s, although successful in the short term, did not continue and was not disseminated after the donor funding ended ( 2 ). Tanzania is one of the poorest countries in the world, with a per capita annual income in 2005 estimated to be about $340 (U.S.), which rose to $400 in 2008 ( 3 ). Poverty in Tanzania is a major barrier to development, and the 2003 Tanzania Participatory Poverty Assessment cited environmental challenges, macroeconomic conditions, poor governance, disease, and cultural beliefs and practices as the main causes of poverty. The proportion of the population living below the basic-needs poverty line in 2000–2001 was 36%, with 92% using firewood and charcoal for cooking, 89% using traditional pit latrines, and 43% using an unprotected water supply ( 3 ).

Key contextual factors include a large geographic area (946,799 km 2 ); poor communications infrastructure; and rapidly rising population, from 33.6 million in 2002 to an estimated 41.0 million in 2009 (75%–80% rural), with 55% under age 19 and a life expectancy of 51 years. Health expenditure per capita was only $6.80 in 2004, rising to $11 in 2008. For a long time, Tanzania hosted more refugees than any other country in sub-Saharan Africa, estimated at 800,000 as of 1999 and falling to 360,000 in 2008 ( 4 ), mostly from Rwanda, Burundi, and the Democratic Republic of Congo.