Mental health is a cornerstone of personal well-being, social stability, and national development. Yet in South Africa, mental health promotion and care continue to face profound systemic neglect characterised by chronic under-investment, fragmented services, and a mismatch between policy priorities for mental health and the support needed for implementation of these policy imperatives to match the realities of those most affected. The burden of mental illness is rising, exacerbated by the interwoven effects of social determinants like poverty, deepening inequality, unemployment, exposure to trauma, and the lingering psychological toll of the COVID-19 pandemic.
This special edition of the South African Health Review 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 health care.
Our collective conscience bears the weight of the Life Esidimeni tragedy, where over 140 mental healthcare users died due to gross negligence – a crisis that remains a painful reminder of institutional and systemic failures. Most recently, the report of the Health Ombud into conditions at the Northern Cape Mental Health Hospital and Robert Mangaliso Sobukwe Hospital has again underscored the urgency of reform. These events expose the deep structural barriers within our mental healthcare system and the need to shift the focus to implementation capacity, effective governance, and the strategic delivery of high-quality, accessible services.
The papers in this special issue engage critically with the current state of mental health in South Africa. Through multidisciplinary perspectives, contributors reflect on systemic challenges, highlight innovative responses, and explore actionable pathways to bridge the gap between policy and implementation. Together, they call for a bold re-imagining of mental health care, one that places the dignity, rights, and lived experiences of individuals at its core.
This edition opens with an integrative review by Janse van Rensburg and Brooke-Sumner, who review South Africa’s public mental health research and reforms from 2011 to 2024 through the lens of people-centred care. Their analysis of 126 peer-reviewed studies finds encouraging trends such as shifts toward decentralised, community-based models and greater psychosocial focus, but also reveals enduring gaps: weak governance, failure to sufficiently invest in community mental health care, insufficient early intervention, pervasive stigma, poor intersectoral coordination, and a lack of cultural responsiveness. Implementation remains uneven across provinces, limiting accountability and impact. 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 South Africa’s Mental Health Investment Case (MHIC), a collaborative effort with the World Health Organization and United Nations 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. The MHIC strengthens the economic rationale for mental health investment, positioning it not only as a moral imperative but also as a fiscally sound strategy. 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. However, the paper underscores a crucial point: evidence alone is not enough. The impact of the MHIC will depend on its integration into budgeting systems, improved financial governance, and meaningful collaboration between the Ministries of Health and Finance.
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 such as diagnostics patterns, re-admission rates, bed occupancy, and length of stay. Presented through a user-friendly interface, it enables facility and provincial managers to monitor trends across different regions and priority populations, including adolescents, people with substance use disorders, and individuals at risk of suicide. This initiative represents a critical step towards more responsive, evidence-informed service planning. It demonstrates how digital innovation, when grounded in existing systems, can enhance transparency, identify gaps, and support more equitable resource allocation in a constrained and overburdened health 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 health care.
Robertson and colleagues turn attention to a critical but often overlooked component of mental health care: 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 mental health treatments. They note that while the Essential Medicines List has enhanced access to cost-effective treatment guidelines, systemic bottlenecks persist. Regulatory constraints, particularly those that limit prescribing authority for primary care nurses and clinical associates, exacerbate service delivery challenges in a health system already stretched by workforce shortages. The authors call for 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 across all regions.
Wolvaardt, et al. examine the severe shortage of mental health professionals ─ particularly psychiatrists – in South Africa’s public sector. The paper calls for investment in mid-level providers, such as registered counsellors and community mental health workers, supported by clear scopes of practice and incentives for rural retention. Task-sharing and innovative training models are critical for expanding access and achieving universal coverage.
The following set of papers in this edition underscore a growing recognition that mental health recovery must be rooted in communities, not institutions, and centred on the lived experiences of those receiving care.
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. These workers, embedded within multidisciplinary teams, deliver basic rehabilitation and psychosocial support under supervision. The results have been tangible: reduced hospital re-admissions, improved district-level intersectoral coordination, 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 implemented in northern KwaZulu-Natal. Framed within the global and national shift from institutional to community-based care, the paper critiques 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. By documenting the model’s successes and challenges, the paper offers a scalable blueprint for expanding access in under-served areas, advancing the goals of equity, inclusion and community integration.
Complementing these innovations, Gamieldien, et al. explore how recovery from severe mental illness is understood and experienced by service users, caregivers, and practitioners. Their study draws a critical distinction between clinical recovery, defined by symptom reduction, and personal recovery, which is about reclaiming identity, connection and meaning. 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 from the Western Cape Department of Health and Wellness 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. Yet structural barriers such as poverty, stigma and discrimination often prevent this, compounding exclusion for people with mental health conditions.
Honikman, et al. describe the Maternal Support Service (MSS), a stepped-care model integrated within antenatal services. With over 3 000 women reached in 2024 and hundreds receiving psychotherapeutic care, the MSS demonstrates the feasibility of early intervention within primary care. The programme’s success relies on screening, collaboration with maternity teams, and staff support, proving that integrated maternal mental health is achievable even in low-resource settings.
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. The authors advocate for decentralised, family-centred, school-based models supported by task-sharing and early intervention – arguing that this is not only a public health necessity but also a long-term developmental investment.
De Jong and colleagues explore why adolescent mental health remains under-prioritised despite growing need. Based on interviews with policy actors and youth advocates, they identify fragmented leadership, poor cross-sector co-ordination, and insufficient youth engagement. Yet, the post-COVID-19 context and NHI roll-out offer renewed momentum. 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 highly vulnerable adolescent girls and young women (AGYW). 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. The intervention, which was rolled out across five high HIV-prevalence districts in the Eastern Cape and KwaZulu-Natal, targeting AGYW aged 10–24 years, demonstrates the feasibility of integrating mental health services into existing HIV prevention programmes. Using a customised electronic screening tool, the team developed comprehensive mental health risk profiles, enabling timely referrals to appropriate support services. The authors advocate for the adoption of a similar model for mental health screening, referral and treatment within the Primary Health Care system.
Writing about integrated approaches to adolescent health, Lee, et al. demonstrate how mental health can be effectively integrated into broader public health initiatives. The authors spotlight Grassroot Soccer’s innovative integration of mental health into its sport-based sexual and reproductive health and rights (SRHR) programmes in Alexandra. This non-profit entity 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: co-design revealed key mental health challenges, while monitoring data showed improved knowledge in both mental health and SRHR. Facilitators emphasised the need for referral pathways and support systems for their own well-being. Other lessons include the importance of co-creation and better tools for measuring mental health outcomes.
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.
Together, these papers offer a compelling case for community-based, person-centred models of care that go beyond managing illness to supporting full participation in society. They call for integrated pathways that link health and social services, value local knowledge, and elevate the voices of those most affected. If scaled and sustained, these approaches can help in manifesting a mental health system grounded not only in clinical efficacy but also in dignity and inclusion.
This edition of the South African Health Review provides both a sobering reflection and a hopeful vision. It charts a path toward a more inclusive, equitable, and people-centred mental health system. 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 to one that centres lived experience, values community, and sees mental health care as foundational to justice and wellbeing.
South Africa stands at a critical juncture. As the country advances towards universal health coverage, the opportunity is ripe to reframe mental health not as a peripheral concern, but as central to human development and national progress. This Review offers a roadmap grounded in evidence, informed by practice, and inspired by possibility.