A recent study has found that integrating psychiatric services into primary health-care (PHC) clinics in Sedibeng has improved access for people living with serious mental illness. However, progress is being undermined by various challenges, including inadequate infrastructure, high patient volumes, staff shortages and fragmented leadership.

The study — published in the online journal Cambridge Prisms: Global Mental Health, and led by Saira Abdulla, a PhD fellow at the Centre for Health Policy at Wits University — evaluated mental health services in nine clinics across Sedibeng in southern Gauteng.

“Sedibeng district has really high levels of unemployment, poverty and violence — all of which really worsen health inequalities,” said Abdulla. “The district has also implemented mental health screening programmes in primary health care [after] the Life Esidimeni tragedy.”

About 4,500 patients in Sedibeng had accessed these services, though the system had not undergone a formal evaluation.

The research compared two models of integration: physically integrated clinics, where psychiatric and PHC teams share space, records and management structures; and co-located clinics, where psychiatric services operate adjacent to PHC facilities, but function independently.

“In South Africa, we actually don’t have any standardised approaches to integrating that care,” said Abdulla. “In physically integrated clinics, mental health staff are part of the clinic. They share records, space and resources. In co-located clinics, they work in silos.”

While physically integrated models offered better collaboration, both settings were constrained by inadequate space, high caseloads and limited staff. In some clinics, psychiatric consultations were held in shared rooms, with no privacy.

“I just want you to imagine, as you are speaking to the psychiatric doctor, there’s another psychiatric doctor in the same room as you seeing another patient,” Abdulla said. “The patients can listen to each other’s consultation.”

The study also uncovered serious staffing challenges. Clinics typically operated with five psychiatric nurses and doctors rotated between sites for adult psychiatric consultations. With monthly caseloads ranging from 580 to 910 patients, the lack of consistent staff meant long queues and rushed consultations.

“You have people waiting outside in long lines for hours without any seating,” said Abdulla. “Providers [staff] have to decide; see what is more important and then deal with it the next time you come back.”

The research also found that some PHC doctors were reluctant to treat psychiatric patients, especially stable ones who could be managed at PHC level. Instead, they referred all cases to already stretched community psychiatry staff.

“They are already overburdened and might not feel confident enough to treat mental health conditions,” said Abdulla. “Primary health-care providers should be managing common mental health disorders or stable cases, which is not actually happening.”

Another finding was the importance of leadership.

The physically integrated clinic benefited from stronger management, resulting in better communication and less staff conflict. In contrast, the co-located clinic suffered from a “vacuum in power and in management”, which led to a toxic work environment.

Abdulla is calling for national and district-level reform.

“We need clearer guidance in terms of referrals,” she said. “We need mental health training for primary health-care staff. We need strong leadership at the clinic level as well as at the district level.”

She added that clinics would also benefit from having dedicated mental health champions to support day-to-day integration efforts.

Though the study focused solely on Sedibeng for Abdulla’s doctoral research, she hopes to continue this work beyond her PhD.

Her warning to health policymakers is stark.

“Integration needs to happen, but it can’t happen without leadership, without support and without accountability,” she said. “While we do have really great policies, they need to be backed by action on the ground if you want to prevent tragedies like the Life Esidimeni. We must invest in primary health care and in specific integrated care.”

The tragedy involved the deaths of more than 140 mental health patients who were relocated from the private institution to less expensive psychiatric facilities as part of a government cost-cutting exercise.