South Africa does not have enough psychologists and psychiatrists to meet the mental health needs of everyone in the country. One solution is to train community healthcare workers to provide some basic mental health support. We explore how one such a task-sharing project is being scaled up in KwaZulu-Natal.
It’s a Wednesday morning in the Amajuba district near Newcastle in KwaZulu-Natal. A community healthcare worker walks into a brick government-subsidised house for her routine visit to the family living there. This is the picture painted by Professor Inge Petersen, Director of the Centre for Research in Health systems at the University of KwaZulu-Natal.
Anna, the community healthcare worker in this hypothetical example, is familiar with the households she visits, and is aware things are not going well in this home. She knows that one woman in particular is struggling with her mental health and may have depression. In addition to her basic healthcare training, Anna’s also been trained to use a special guide that helps families better understand mental health and spot when someone might need extra support or care.
Anna may have been made up to illustrate a point, but the guide, called the Community Mental Health Education and Detection (CMED) tool, is real and has been adopted by the KwaZulu-Natal health department and is currently being used in parts of the province.
The initiative is part of a growing trend where different health tasks are shared among a wider range of trained workers, not just doctors or specialists. This so-called task-sharing idea is that, since South Africa has far too few psychologists and psychiatrists to meet the needs of everyone in the country, other types of healthcare workers can share the load. Though community healthcare workers aren’t qualified to prescribe scheduled medicines or treat serious mental health issues, they can provide some support and refer more complicated cases on to others.
“It’s no secret that our health services are under enormous strain,” says Professor Dan Stein, Head of the Department of Psychiatry and Mental Health at the University of Cape Town. “Given the resources, in psychiatry, we largely focus on serious mental disorders and we’re not able to address fully the common mental disorders – depression, anxiety, and substance use disorders.”
Even though reliable data on mental health in South Africa is sparse, available data suggests that the burden is substantial. A landmark epidemiological survey published in 2009 – the first large-scale population-based study of common mental disorders in South Africa – found that around one in six people had a mental health disorder in the preceding 12 months. Around three in 10 of the over 4 300 people surveyed had at some point in their lives had a mental health disorder, and it was estimated that close to half of people would at some point in their lives experience one. In a more recent survey published in 2022, one in four people reported symptoms of moderate or severe depression and around 18% reported symptoms of anxiety.
In a study published in 2019, researchers estimate that less than 10% of people in South Africa are receiving the mental health services they need. They found that in the public sector, there were 0.31 psychiatrists and 0.97 psychologists per 100 000 people, though there were large variations between provinces and between urban and rural areas. The researchers found that around 4.6% of the state’s health spending goes to mental health and that around 86% of that goes to in-patient care.
Green, orange, or red
Back with our hypothetical example in Amajuba, Anna greets the members of the household. In the room is Ma Mkhize, who lost her daughter recently. Apart from still grieving, she’s also very stressed about how she will manage to support her daughter’s three children. Ma Mkhize’s sister and two young adult male family members are also present.
“While talking to the family, Anna likens mental health to a thermometer with a green, an orange and a red zone,” says Petersen. “Anna explains that when people are in the green zone mentally, they’re healthy; in the orange zone, they feel a bit stressed; and in the red zone, everything’s becoming too much. Doing her best to normalise mental health conditions, she explains how people shift along this emotional health ‘thermometer’.”
Anna would then have read the story of Nontobeko – a woman whose husband lost his job three months ago, and who is constantly worrying about how she’ll feed her children, is always tired, has a low appetite and struggles to sleep.
“Once she’s read the story about Nontobeko, Anna asks the family if the story reminds them of someone in the household. If they say yes, she uses an algorithm – developed to describe the symptoms – to determine whether Ma Mkhize should be further screened for depression at the local clinic,” says Petersen.
The next step
One of the keys to this approach is that community healthcare workers like Anna can provide support up to a certain level. It might be that no referral is needed and that that support from someone like Anna is enough to help someone through a difficult period.
But in Ma Mkhize’s case, Anna has to refer. At the clinic, Ma Mkhize would see an enrolled nurse, who, besides, checking her vital signs, like her blood pressure, also does a more in-depth mental health screening.
The next step for Ma Mkhize would be to attend a consultation with a professional nurse at the clinic who assesses her for depression, using Adult Primary Care guidelines that include mental health conditions.
“If she’s diagnosed as having a mental health condition, she will be referred to a psychological counsellor at the nearest community health centre for counselling; and/or to a primary healthcare doctor on the doctor’s next visit to the clinic; or to a district hospital if symptoms are severe,” says Petersen.
‘Layering mental health into the system’
Signs are that government, at least in KwaZulu-Natal, are buying into the idea of this type of task-sharing.
“Task-sharing assists us as a province with early detection and management of common mental health conditions,” says Dr Nikiwe Hongo, Director for Mental Health in the KwaZulu-Natal Department of Health. “Early interventions are then provided to avoid catastrophic manifestations much later. We have employed mid-level registered psychological counsellors within primary healthcare facilities to assist with this. It helps avoid unnecessary referrals to higher levels of care with few specialist resources available. We continue to roll out capacity building for early detection by household community health workers and intensive screening and assessment by nurses at the clinic level.”
These programmes are the culmination of much previous work. For the past seven years, Petersen says she and her colleagues have been working closely with the provincial health department to increase access to mental health services for adults by integrating mental health into primary care. “Together with the department, we have developed and refined the way we are layering mental health into the system along the care cascade. Innovations have been introduced along the patient pathway, so that mental health is part of every contact a person might have with the healthcare system,” she says.
“Task-sharing as a policy is strongly supported by the World Health Organisation and South Africa has adopted it into our national policy framework and action plan, but the implementation has been a challenge,” says Petersen.
She explains that while it’s challenging to provide exact numbers of healthcare workers trained in KwaZulu-Natal, since trainers are equipped to train others within their own districts, the available figures suggest that several hundred have already been reached. The initiative has also expanded beyond KwaZulu-Natal, with healthcare workers in one district in Limpopo and another in the Northern Cape currently undergoing training.
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‘A huge dilemma’
Dr Ingrid Daniels, Chief Executive Officer of Cape Mental Health and a past president of the World Federation for Mental Health, agreed the gap between need and resources in mental health services is dire.
“A huge dilemma South Africa faces is the fact that social determinants such as poverty, unemployment, and gender-based violence exacerbate mental health problems.
“This is further complicated by substance use, which is highly prevalent contributing to the burden of disease. On one hand, we have increasing prevalence of mental health issues among our population, and on the other, government-funded, state-run mental health services for 84 percent of our population, which are under resourced and often working among communities in dire circumstances,” she says.
Daniels says a burning question is how we can transform our mental health services to make them more accessible.
“Task-sharing is one of the best evidence-based interventions that have been very successful. It’s successful because we have a serious human resource shortage for mental health in South Africa. On top of that, we have insufficient social workers, as well as insufficient psychiatrists.
“We’re not going to narrow the treatment gap any time soon within the next decade or two, so task-sharing is critical because basically … you are providing the necessary knowledge and education to a community health worker,” she says.
Ultimately, in the context of scarce mental health resources, Petersen says “integrating mental health into existing health services provided by general healthcare workers through task-sharing is the only viable solution to closing the mental health treatment gap”.
While all the experts Spotlight interviewed for this article seem to agree with that view, the details of how to go about implementing the ‘solution’ are less clear-cut. It is in helping map this out that the work in KwaZulu-Natal is taking the field forward.
(Except for the headline, this story has not been edited by PostX News and is published from a syndicated feed.)
