Mental health has become one of the most pressing public health challenges in South Africa and worldwide. Within our national context, entrenched socio-economic disparities, cultural dynamics, and systemic service delivery constraints continue to drive inequities, particularly among vulnerable and underserved populations.
Although progressive mental health legislation and strategic frameworks have been developed, their implementation remains inconsistent. Most health facilities lack adequate resources, and there is a critical shortage of trained mental health professionals, especially in rural and under-resourced areas.
The 27th edition of the South African Health Review, devoted entirely to the advancement of mental health services in this country, seeks to raise awareness, inspire action uand galvanise investment in a sector urgently requiring transformation.
It underscores a growing recognition that mental health recovery must be rooted in communities, not institutions, and centred on the lived experiences of those receiving care. It calls for a bold re-imagining of mental healthcare, one placing the dignity, rights and lived experiences of individuals at its core.
The mental illness burden is rising, and this special edition comes at a pivotal time: with the new 2023–2030 National Mental Health Policy Framework and Strategic Plan (NMHPFSP), the phased roll-out of National Health Insurance (NHI), and a growing national recognition of the human cost of inadequate mental healthcare.
The papers engage critically with the current state of mental health in South Africa, and through multi-disciplinary perspectives, contributors reflect on systemic challenges, highlight innovative responses, and explore actionable pathways to bridge the gap between policy and implementation.
Reforms, political will
An integrative review by Janse van Rensburg and Brooke-Sumner looks at research and reforms from 2011 to 2024, their analysis of 126 peer-reviewed studies finding encouraging trends like shifts toward decentralised, community-based models and greater psychosocial focus, but also revealing enduring gaps: weak governance, failure to sufficiently invest in community mental healthcare, insufficient early intervention, pervasive stigma, poor intersectoral co-ordination, and a lack of cultural responsiveness.
The authors argue that meaningful reform demands more than policy and must be accompanied by political will, investment, and a re-imagining of care systems grounded in the realities of those they serve.
Besada and colleagues present SA Mental Health Investment Case (MHIC), a collaborative effort with the WHO and UN Development Programme that quantifies the economic and social returns of scaling up 10 evidence-based interventions.
These range from maternal mental health and depression treatment to school-based psychosocial support. Importantly, the MHIC seeks to address two persistent challenges: considerations of lessons learnt from the under-implementation of the 2013-2020 National Mental Health Policy Framework in efforts to realise the targets set by the new NMHPFSP, and the need for informed planning as mental health is considered for inclusion in the NHI benefits package.
By offering policymakers robust cost-benefit data, the MHIC provides a valuable tool for prioritising and allocating resources more effectively.
Mountford and colleagues present an example of leveraging routine information for real-time insight. They showcase a significant innovation in mental health surveillance: the development of a real-time admissions dashboard built from routinely collected data across 40 public hospitals in the Western Cape.
The dashboard tracks key indicators like diagnostics patterns, re-admission rates, bed occupancy, and length of stay.
This initiative represents a critical step towards more responsive, evidence-informed service planning, demonstrating how digital innovation can enhance transparency, identify gaps, and support more equitable resource allocation in a constrained and overburdened system.
Already in use at provincial surveillance forums, the dashboard offers a replicable model for other provinces aiming to build capacity for real-time decision-making in mental healthcare.
Medication and access
Robertson and colleagues focus on a critical but often overlooked component of mental healthcare: access to essential psychotropic medicines. Their analysis of public-sector procurement data from 2019 to 2023 reveals stark disparities in medicine availability across provinces, highlighting deep-rooted inequities in the distribution and regulation of treatments.
They note that while the Essential Medicines List has enhanced access to cost-effective treatment guidelines, systemic bottlenecks persist. Regulatory constraints, particularly those limiting prescribing authority for primary care nurses and clinical associates, exacerbating service delivery challenges in a system already stretched by workforce shortages.
They urge decisive reforms, including a decentralised prescribing authority, improved patient-level monitoring, and equity-oriented planning tools to ensure more consistent and fair access to medicines.
Wolvaardt, et al, examine the severe shortage of mental health professionals – particularly psychiatrists – calling for investment in mid-level providers, like registered counsellors and community mental health workers, supported by clear scopes of practice and incentives for rural retention.
Peters and colleagues detail an innovative initiative piloted in the Klipfontein/Mitchells Plain substructure, where Rehabilitation Care Workers (RCWs) were trained through a one-year Higher Certificate in Disability Practice.
The results have been tangible: reduced hospital re-admissions, improved district-level intersectoral co-ordination, and early steps toward provincial policy endorsement for broader implementation. This model shows how task-sharing and community-grounded care can extend the reach of services and enable more inclusive, continuous support for the psychosocial needs of people with disabilities.
Brooker and colleagues detail a rural mental health outreach model in northern KwaZulu-Natal, and critique the country’s ongoing over-reliance on hospital-based services and chronic underinvestment in prevention, quality treatment, and culturally aligned care, especially in rural and low-income communities.
The model responds directly to the National Mental Health Policy Framework and Strategic Plan (2023–2030) by demonstrating how decentralised, collaborative care can be delivered in resource-constrained settings.
Through specialist outreach, integration with general health services, partnerships with traditional and faith-based healers, and local capacity-building, the initiative reflects a pragmatic, context-sensitive response to systemic barriers.
The paper offers a scalable blueprint for expanding access in under-served areas, advancing the goals of equity, inclusion and community integration.
Recovery and rights
Gamieldien, et al, explore how recovery from severe mental illness is understood and experienced by service users, caregivers, and practitioners. The authors argue for a paradigm shift: away from narrow biomedical approaches and towards rights-based, recovery-orientated services that integrate lived experience, social support, and cultural context.
Firfirey-Brijlal and colleagues present a vision for mental health reform grounded in the principles of occupational justice.
Their paper outlines the development of a new Psychosocial Rehabilitation framework, designed to expand access to person-centred support across the care continuum from individuals with severe mental disorders to those seeking broader mental well-being.
At its core, occupational justice holds that everyone should have the opportunity to engage in meaningful daily activities such as work, learning, and social participation that contribute to identity, health and purpose.
Honikman, et al, describe the Maternal Support Service (MSS), a stepped-care model integrated within antenatal services. With more than 3 000 women reached in 2024 and hundreds receiving psychotherapeutic care, the MSS demonstrates the feasibility of early intervention within primary care.
Simelane and colleagues spotlight child and adolescent mental health, noting that half of all mental disorders begin before age 14. Specialised services, however, remain concentrated in urban areas, and the authors advocate for decentralised, family-centred, school-based models supported by task-sharing and early intervention, arguing that this is a long-term developmental investment.
Poor leadership
De Jong and colleagues explore why adolescent mental health remains under-prioritised, and identify fragmented leadership, poor cross-sector co-ordination, and insufficient youth engagement. The paper calls for co-ordinated advocacy, youth-led initiatives, and tighter alignment between research, policy, and implementation.
Hartnack and colleagues present insights from the South African implementation of the multi-country DREAMS programme, which aims to reduce HIV incidence among vulnerable adolescent girls and young women.
They describe how one of the programme’s implementing partners adapted the standard DREAMS intervention to include a structured mental health screening and referral component, resulting in a mental health support cascade. It was rolled out across five high HIV-prevalence districts in the Eastern Cape and KZN.
The authors advocate for the adoption of a similar model for mental health screening, referral and treatment within the primary healthcare system.
Writing about integrated approaches to adolescent health, Lee, et al. demonstrate how mental health can be effectively integrated into broader public health initiatives, spotlighting Grassroot Soccer’s integration of mental health into its sport-based sexual and reproductive health and rights (SRHR) programmes in Alexandra.
This NPO redesigned two evidence-based curricula through a participatory process involving stakeholders and adolescents, resulting in targeted mental health content tailored to young people’s needs: early results are promising.
Gaps in data capture
Ndlovu and team note that mental health data assets are expanding with improvements in the routine indicator set and the inclusion of mental health metrics in longitudinal cohorts. However, significant gaps remain concerning community-level data capture, disaggregation by age, gender and geography, standardisation of indicators, and governance structures.
These limitations hinder the full integration of mental health into national health surveillance systems.
These papers all offer a compelling case for community-based, person-centred models of care that go beyond managing illness to supporting full participation in society.
This edition of the Review provides both a sobering reflection and a hopeful vision, and the message is clear: policy alone is insufficient. Achieving real change will require sustained investment in the resources and systems needed to support strategy and policy implementation, collaborative leadership, monitoring and evaluation, and a radical shift in mindset.
See more from MedicalBrief archives:
Increasing need for mental healthcare for ageing South Africans
Chronic staff shortages add to growing mental healthcare burden
Heads to roll after mental patients froze to death in Northern Cape hospitals
Mental healthcare resources dire in some provinces, says Phaahla
Child and adolescent mental health services in crisis, report finds