In South Africa, up to nine out of ten patients with mental health disorders do not receive treatment or have access to mental healthcare programmes. Primary healthcare (PHC) practitioners are working to fill this gap, but they are not getting the support they need.

This according to researchers from the Department of Family and Emergency Medicine at Stellenbosch University.

They explored the perceptions and experiences of PHC practitioners in managing common mental health disordersat clinics, community day centres (CDCs) and district hospital out-patient departments in the Garden Route District in the Western Cape – the province with the highest rate of mental health conditions in South Africa. They focused on nurse practitioners, lay and registered counsellors, medical doctors – sessional and permanent medical officers (MOs), community service MOs, medical intern doctors and registrars in family medicine – and social workers. 

Their findings were published recently in the African Journal of Primary Health Care & Family Medicine.

The researchers say that even though PHC practitioners play an important role in identifying, diagnosing and managing patients with common mental health disorders, they often lack the required resources and available support structures remain underutilised. “Part of the problem is that less than 3% of the national health budget goes to mental health services and only 7,9% of the mental healthcare budget is allocated to primary healthcare.” 

The researchers add that becausespecialist practitioners were scarce, PHC practitioners had heavy workloads, which made referrals difficult.They point out that there are just 0,31 public service psychiatrists for every 100 000 people – far below the recommended 1,03 psychiatrists and 10,36 nurses needed per 100 000 people to provide adequate mental health services.

“This workload shift to PHC is not supported by sufficient resources, particularly in the public health sector and especially in rural areas, resulting in overworked and insufficiently trained staff to manage both the high burden of disease and patients requiring specialist care.

“Just under half of participants (46,9%) said the workload was too heavy to allow effective mental health screening.”

According to the researchers, insufficient training, negative perceptions and beliefs about mental health screening and interventions prevented the integration of mental health services. 

“Although nearly nine in 10 participants (88,5%) said they received some mental health training as undergraduates, more than two-thirds (68,5%) felt only average or less confident in managing mental health conditions. 

“Just over a third admitted avoiding mental health-related complaints during consultations and that almost a half reported neutral opinions or insufficient mental health awareness at their facilities.

“However, participants at CDCs tended to view mental health disorders more positively when they had personal experience with one, or when they had a supportive referral experience. The presence of a dedicated mental health practitioner at a facility also had a direct influence on the experience of the staff in managing these disorders.”

The researchers say that while the Western Cape has introduced the Practical Approach to Care Kit (PACK) to help PHC practitioners manage common mental health conditions, it has yet to be used effectively.

“Various barriers – including widespread mental health stigma, understaffing, a high disease burden and limited specialist support – have prevented the PACK-guidelines from being applied effectively.

“The guidelines are only helpful if practitioners can spot a mental health disorder and follow the recommended steps. They need to recognise signs of potential problems and feel confident addressing them during a consultation. They also need to have the capability, motivation and supportive environment required to provide this service.”

The researchers call on policy makers and managers to motivate for training in mental health and to empower the PHC system to offer acceptable mental health services, in accordance with national and international guidelines.

They also highlight the importance of strengthening undergraduate programmes to better prepare practitioners to identify and manage mental health disorders effectively.

“Staff require additional training in mental health disorders, and managers need to emphasise and monitor the use of guidelines provided to assist in managing mental health disorders. There is a need to increase the number of mental health nursing practitioners, especially to support PHC clinics.

“It is crucial that we see primary health care as a priority, measure and improve quality, and make specialist support accessible and available. If primary mental health care is part of the model of PHC, then it needs to be supported by appropriate infrastructure, medication, workforce and information.”

• Source: Bouwer PJ, Jenkins LS, Schoevers J. Managing mental health disorders: Experiences of primary care providers in rural South Africa. Afr J Prm Health Care Fam Med. 2025;17(1), a4979. doi:10.4102/phcfm.v17i1.4979