By Stephan Rabie, Alice Nuttall, Nina Skinner, Kholeka Vezi, Lucy Wagner & John Joska

The burden of mental disorders remains critically unaddressed in South Africa. We have high rates of common mental disorders, such as depression, anxiety, and substance use disorders – nearly a third of South African adults will experience a mental disorder in their lifetime. Despite this significant burden, there continues to be low detection of mental disorders, access to and delivery of treatment, and good response outcomes – known as the mental health treatment gap.

This is the story we see every day in South Africa: In a rural village in the Eastern Cape, Mr. Ndlovu has spent more than a year searching for work, unable to provide for his family. The weight of hopelessness, anxiety, and the fear that nothing will ever improve has pressed heavily on him for some time. He is drinking more each day, and has considered taking his own life. Yet, seeking help feels shameful for a man expected to be “strong.” After walking more than three hours to the nearest clinic, he waits another five to see a nurse. Overwhelmed with “more urgent” cases, she sees him for five minutes and tells him to stop drinking. Mr. Ndlovu leaves feeling humiliated and unseen – his courage to ask for help met with insufficient care to recover from his illness.

The story of Mr. Ndlovu is not unique, and affect a large proportion of the South African population. In the South African public sector, approximately nine out of ten people with a mental disorder exist inside of the mental health treatment gap, with catastrophic effects on individuals, communities, and the economy. We propose five ways to address this gap, starting with (1) improved funding and (2) strategic allocation of the increased resources, but also strengthening mental health services in primary care by (3) staffing district mental health services, (4) sharing mental health service tasks with non-specialists in supported fashion, and (5) improving case management of individuals living with mental disorders.

Spending the Money Wisely Means Strategic Allocation

South Africa has a robust mental health policy, fortified by the National Mental Health Policy Framework and Strategic Plan 2013–2020. The strategic plan aims to integrate mental health into public healthcare and to transform the healthcare system to provide mental health services that are accessible, equitable, and comprehensive to reduce the burden of untreated mental disorders in South Africa. Yet, despite robust policies and strategic plans, our country spends approximately 5% of the total health budget on services for mental health, comparing to the lower end of international benchmarks of recommended spending on mental health. There are also increasing disparities in how province allocate mental health resources. Provincial spending on mental health ranged widely across all levels of the health system. For example, in Mpumalanga, mental health spending per uninsured individual is reported to be R58.50 compared to R307.40 in the Western Cape. South Africa’s mental healthcare system reflects these inequities starkly. Those with medical aid may access private care, but the majority depend on an overstretched public sector. Long queues, overburdened facilities, and a severe shortage of professionals trained in mental health mean that many are overlooked or deprioritised. Primary and community-based services - where the majority of South Africans could realistically access care - remain underfunded. This neglect means mental health remains isolated, difficult to reach, and especially scarce in rural areas.

Mental Health Is Everyone’s Business: Sharing Tasks With Non Specialists

A key solution may lie in expanding care beyond hospitals and private practices. Integrating mental health into primary and community health settings is both cost-effective and sustainable. One promising approach is task-sharing, where community health workers, nurses, and lay providers are trained to deliver counselling and basic mental health interventions, while being supervised by mental health professionals, such as registered counsellors or clinical psychologists. As task shared providers are often trusted members of their community, they make care more accessible, less intimidating, and culturally relevant. Integration of mental health services with chronic disease care also offers opportunities. In HIV clinics, nurses trained in basic counselling can provide antiretroviral treatment while addressing depression, anxiety, substance use, and other common mental disorders. This dual model not only strengthens mental health support but improves adherence to HIV treatment and other chronic disease management. In South Africa, Project MIND is a research intervention that integrates brief psychological interventions into existing primary health care structures. Trained lay counsellors and nurses provide group and individual counselling sessions for people attending HIV and chronic disease clinics, making mental health care both accessible and sustainable within community health systems. Task-sharing, while potentially effective to address the treatment gap, is not a zero-risk strategy. Task-shared mental health workers are at increased risk for experiencing burnout and vicarious trauma, especially working in high-burden settings. For this approach to be effective, task-shared workers need receive proper training, continuous supervision, and debriefing support from mental health professionals. There are several models of supervision for non-specialist workers, and these models should be implemented in public mental health care.

A similar strategy to improve mental healthcare access and treatment is the adoption of a case management strategy in public healthcare. Case management involves coordination of community and health services for people with mental disorders. For example, it can involve coordinating referral to a place of safety or shelter, linking patients with social support services, referral for additional psychiatric care, or to a community-based organisation that provides specialist services. A case management approach can ultimately mitigate the anxiety and stress associated with navigate multiple mental and health services, while improving mental and physical health and social wellbeing.

Towards an Inclusive Future

For mental health care to be truly effective, it must speak to people in ways that resonate with their cultural values, languages, and lived realities. Services that ignore sociocultural dimensions of distress, risk alienating those they intend to help. In many South African communities, people turn first to family, faith leaders, or traditional healers before visiting a clinic. Mental health care that collaborates with these trusted figures, rather than replacing them, builds trust and relevance. A well-known example is The Friendship Bench intervention in Zimbabwe, which trains community grandmothers to deliver problem-solving therapy in public spaces, such as park benches. By drawing on trusted community figures, the program bridges the gap between biomedical and local understandings of distress. It has since been adapted in several African contexts, showing how mental health care can be both evidence-based and culturally resonant. Equally important is language. If counselling is not available in a person’s home language, they may feel misunderstood or excluded, reducing adherence and impact. Additionally, research shows that people feel more comfortable receiving counselling from those from a similar cultural backgrounds. Language goes beyond words, it includes gendered communication patterns, societal expectations, and cultural expressions of distress, all of which need to be considered when designing effective ways to close the treatment gap in South Africa.

In collectivist societies, where community is the primary unit of support, group-based and community-driven interventions often prove far more effective than individual therapy. A Western-style therapy that focuses on individual talk therapy might alienate people from collectivist cultures who prefer community-based or spiritual approaches to healing. For example, the Institute for Healing of Memories provides a programme known as Community Healing Dialogues wherein youth come together in a safe space to discuss their experiences of alienation and suffering. Through fostering individual healing and collective understanding, these workshops equip participants with the emotional tools to understand and recover from trauma.

Mental health care in South Africa is at a crossroads. On one hand, the gaps are vast: underfunded services, inaccessible clinics, and widespread stigma. On the other hand, innovative strategies – community integration, task-sharing, cultural adaptation – offer real hope. Mental Illness Awareness Month reminds us that the courage shown by individuals like Mr. X must be matched by a collective response. By investing in community-based, culturally sensitive, and equitable mental health care, South Africa can move towards a future where mental health is everyone’s business.