By Willemien Jansen (Copy and Content Editor)

It's been a tough few years for most South Africans. We have lived through a pandemic and now suffer from the ongoing electricity crisis. The WHO states that a large number of people have reported symptoms of depression, anxiety or post-traumatic stress following the emergence of Covid-19. There have also been worrying signs of suicidal thoughts and behaviours, also among healthcare workers. Cassey Chambers from the South African Depression and Anxiety Group, in a conversation with Bhekisisa's Mia Malan, explains that according to a recent survey, South Africans are experiencing higher levels of depression and anxiety due to load shedding. Other studies have revealed that South Africans suffer from higher rates of depression and anxiety than most other countries.
More and more South Africans are in need of public mental healthcare services. But what do these services look like? We spoke to members of the Valkenberg Hospital leadership team to get their insights into the state of mental health care in South Africa.
What is Valkenberg?
Ms Charlyn Goliath, CEO of Valkenberg Hospital, explains that the hospital is one of three acute psychiatric hospitals in the public health sector in the Western Cape and provides an acute psychiatric service that consists of an in-patient service, an out-patient service and an outreach services. They also offer a forensic service that involves observation cases as well as a state patient service.
Dr Qhama Cossie, Head of Acute Services says: "We primarily function as a referral hospital with the idea that mental health services are provided at each level of the health system and that people in need of a more specialised service may come to this service, but the bulk of mental health services don't actually sit at Valkenberg, but Valkenberg is part of a greater system."
How would someone with a mental health challenge go about getting treatment?
Cossie explains: "A person with a mental health need would first present themselves at a primary healthcare facility where they will be seen by a mental health nurse or a general practitioner. First line mental health problems are dealt with as an out-patient. At that level in the metros there will be support from a district psychiatrist who would support each facility."
According to Cossie people who need further assistance or in-patient assessment would then be referred to what is commonly known as a general hospital. "The idea is that at a general hospital people would be able to stay over for a short time whilst medical problems are being excluded. There is also a higher level of expertise at that level. This means that the bulk of mental health services happen at the clinic or general hospital level."
"The general hospitals will have small mental health units where they can look after people for relatively short periods of time. And at that level patients would not necessarily need specialised care. A small number would then need to be referred up to a specialist hospital like Valkenberg. So if you look at everyone with a mental health need, we see only about 20% to 30% of the people that go to the general hospital. The majority of people get taken care of and treated at a lower level."
The South African Government supplies information about how to access mental health care on their website.
What is the general state of mental health in the public sector?
"It depends" says Cossie. "South Africa is a low- to middle income country and when we talk about challenges we need to put them in the context of where we sit as a country."
According to Mr Mapitsi Photo, Head of Nursing at Valkenberg Hospital, a shortage of skills and infrastructure are major problems.
Cossies continues "We know that our biggest challenge is resources, and when we talk about resources we are talking about money being put into health, but specifically about money being put into mental health. The mental health budget is relatively under-resourced and that is the biggest challenge. That's not a 'now' problem, it's very much a historical problem that will take many, many years to overcome. Linked to the resources, what that impacts on is infrastructure. We struggle with infrastructure, having the right kinds of places. The other big challenge is around our skills. So we have this need, but do we have the right professionals, and enough of them in the right places? That's a big challenge."
According to Goliath people with less serious mental illnesses are also the cohort who are less likely to present themselves. "We only see those who really can't cope with their symptoms anymore and the families can't cope. E.g. those with post-partum depression don't present themselves. They are seen as 'normal', but it just builds up. If there is a shift in how we can actually better identify or more quickly identify and provide treatment and support to your common mental illnesses that will also make a difference because there is a gap in that service area. If you use a health systems framework approach, [it] is not only infrastructure at an institution level but also infrastructure for example in NPOs. With the Mental Health Act and the terms for licensing makes it very difficult for your NPOs to actually become licensed to house mental healthcare users. Even the mental healthcare act is not assisting us which makes it very difficult. So it is not only infrastructure at an institutional level but also community infrastructure that is lacking to support governmental health services. The same goes for skills."
Is there anything that the National Department of Health and NGOs can do to improve the state of current affairs?
Cossie says: "For mental health particularly the social determinants of health are important; housing, jobs, education; that link with other governmental departments and also the link with NPOs that work in those spaces is something that we could do better."
Photo explains that advocacy out in the communities if very important. "In many instances we find that our patients are not necessarily well received within those settings because of the stigma or the lack of understanding of mental health conditions. They are still fully functional and capable of doing certain things for themselves where they are correctly guided or managed. In NGOs we don't have people with the correct skills to manage and look after those patients."
According to Goliath it's not only what NGOs can do, but it's a whole government approach. "What can other government departments and sectors do? Education, social development, etc. It's not only DoH and the NPOs, it's a wider responsibility. We usually struggle with those inter-sectoral activities and action plans."
The new National Mental Health Policy Framework and Strategic Plan 2023 – 2030 was unveiled at the recent SA Mental Health Conference held in Johannesburg. Concerns are not about the policy itself but rather about the implementation of the policy, as well as resources. Chambers told Spotlight that these are the same concerns that professionals in the field had over the previous policy. "It is because the document was good, the policy was good. However, how it was implemented was not happening," she said.
Professor Crick Lund, Co-Director, of the Centre for Global Mental Health at King's College London, told Spotlight that in order for the new policy framework to work better than the previous one "we need to get all the sectors involved working together – the Department of Health, Education, Social Development, the criminal justice system, and also the NGO sector."
What healthcare practitioners are in short supply?
"It's across the board" says Photo. "We could do with more but are experiencing budget limitations. Especially mental healthcare nurses are in short supply. We are lagging behind and I don't see us turning a corner very soon. The recruitment and selection processes are not attracting people with the type of skills that we need. There is a shortage of specialists out there in the primary healthcare setting. Once we discharge people they need continuation of care and we don't have those social workers, professional therapists, psychologists and psychiatrists out there in the community readily available."
Goliath adds: "We are lacking advocate rehabilitation staff because you can, from a medical perspective, be stabilised, but then you actually require rehabilitation and further input to continue your care so that you can continue back into your living home environment. That is a resource lacking further out in the community to support those kinds of services. And general social work services."
Cossie explains that Valkenberg is an adult hospital, for people over the age of 18 and under the age of 60. "Youth and adolescents and the geriatric population are groups that are at a particular disadvantage. We don't have enough services and resources to focus on those two groups as much as we would like to."
In an interview with Spotlight, Minister of Health Dr Joe Phaala also states that "gaps in the country's mental health services are not because of a lack of policy and plans but due to implementation issues and sometimes the shortage of resources and psychiatrists".
Where to from here?
"Yes there are challenges but the service still continues and we still try to deliver the best within our capabilities to serve the needs of the patient," says Goliath. "We need to be able to start shifting our focus to prevention and strengthen rehabilitation services rather than just acute therapeutic inputs."
South Africa has taken a number of steps to strengthen mental health care over the last 20 years, including reforming the Mental Health Care Act and developing the new National Mental Health Policy Framework and Strategic Plan 2023–2030. However, there are still many gaps that are limiting the country's sustainable response to mental health care. Despite many challenges, the professionals working in public mental healthcare services are dedicated individuals who do the best they can with what they have.
Helplines
- Government Mental Health Helpline - 0800 12 13 14
- Suicide Helpline - 0800 567 567
- 24 hour Cipla Mental Health Helpline - 0800 456 789
- 24 hour Substance Abuse Helpline - 0800 12 13 14 SMS 31393
- Website www.sadag.org
Other helplines:
- Dr Reddy's Help Helpline - 0800 21 22 23
- Pharmadynamics Police &Trauma Helpline - 0800 20 50 26
- Adcock Ingram Depression and Anxiety Helpline - 0800 70 80 90
- Destiny Helpline for Youth & Students - 0800 41 42 43
- ADHD Helpline - 0800 55 44 33
- 24hr Department of Social Development Substance Abuse helpline - 0800 12 13 14 SMS 32312
- 24hr Suicide Crisis Helpline - 0800 567 567
- 24hr Cipla Mental Health Helpline - 0800 456 789
- 24hr University of Cape Town Student Helpline 0800 24 25 26
- 24hr University of Pretoria Student Careline - 0800 747 747
- University of the Western Cape after hours Student Helpline - 0800 222 333
- 24hr Discovery Medical Student Helpline - 0800 323 323
- Tshwane University of Technology after hours Student Helpline - 0800 687 888
You can also contact:
- Youthline for counselling services and youth mentoring programmes: Free call 0800 376 633
- Contact the Childline services and speak to counsellors: +27 (0) 31 201 2059
- SA Federation For Mental Health: +27 (0) 11 781 1852; +27 (0) 86 558 6909

Charlyn Goliath is the CEO of Valkenberg Hospital. She has a wide range of experience in health system and service research as well as service design, planning, implementation support and monitoring.

Mapitsi Photo is the Deputy Manager of Nursing at Valkenberg Hospital. He has worked in the public health service for over 30 years, with 15 years in the mental health space.
Dr Qhama Zamani Cossie is jointly appointed in the Department of Health, Western Cape and University of Cape Town, as well as the Clinical Head of Acute Services at Valkenberg Hospital.