Understanding the local context for the application of global mental
health: a rural South African experience
Stine Hellum Braathena,b,*, Richard Vergunsta, Gubela Mjic, Hasheem Mannandand Leslie Swartza
aStellenbosch University, Department of Psychology, Private Bag X1, Matieland 7602, South Africa;bSINTEF Technology and Society,
Department of Health, PB 124 Blindern, 0314 Oslo, Norway;cStellenbosch University, Centre for Rehabilitation Studies, PO Box 19063,
Tygerberg 7505, South Africa;dTrinity College Dublin, Centre for Global Health, School of Psychology, Phoenix House, South Leinster
Street, Dublin, Ireland
*Corresponding author: Present address: SINTEF Technology and Society, Department of Health, PB 124 Blindern, 0314 Oslo, Norway.
Tel: +4798230472; Fax: +4722067909; E-mail: email@example.com
Received 16 August 2012; revised 23 November 2012; accepted 10 December 2012
Background: The global mental health movement has supplied ample evidence of treatment gaps for mental
health care in low and middle-income countries. It is also clear that substantial progress has been made in
developing an evidence base for innovative treatments which have been shown to work. It is only through
rich and detailed understandings of local contexts and individual experiences that the challenges global
mental health faces can be fully appreciated.
Methods: In this article, we use a single, qualitative case study from one context and of one family affected by
mental disorder. This is to elucidate core issues which we regard as key to further developments in the global
mental health agenda.
Results: Core issues are poor mental health literacy, transport and lack of outreach, limitations of formal health
care, challenges at the interface with indigenous health care and lack of follow-up and rehabilitation.
Conclusion: We propose shifting the focus of mental health care from cure to promotion and prevention, using
an interdisciplinary team of lay and trained health workers from the professional, folk and popular sectors. The
challenges are complex, as this small study shows, but it is only by looking closely at local conditions that it is
possible to develop interventions which are contextually appropriate and make optimal use of local resources.
Keywords: Mental disorder, Mental health service, Rural, Poverty, South Africa, Community mental health
of treatment gaps for mental health care in low and
middle-income countries (LMICs).1–7It is also clear that substan-
novative treatments which have been shown to work in
low-income contexts.8,9Despite these improvements, and while
there is now good evidence of cost-effective mental health inter-
ventions, there is as yet little evidence of how to implement
these in real-life settings beyond those already identified in in-
novative recent studies.8,9The questions at stake are far broader
than simply those of scale-up of transportable technologies:
and interfaces between seemingly incompatible sets of demands
and needs. There is good evidence for the importance of addres-
disease care and treatment.10,11In overburdened health care
settings far removed from centres where there is a critical mass
of expertise around mental health, however, mental health
issues may continue to be seen as ephemeral and unimportant.
Africa has the greatest disease burden of any continent but
has the poorest health services.12Despite the relative wealth
of South Africa, compared to other countries in the region, uni-
versal and equitable access to health care is yet to be attained,13
and the country is still grossly underserved in terms of mental
health services compared to wealthier countries.5–7Poverty is
still rampant for a large majority of the South African population,
and rural areas in South Africa, in particular areas in the Eastern
Cape Province, remains the poorest, most underserved and his-
torically neglected.6,13Xhosa-speaking people comprise the ma-
jority of the population of the Eastern Cape. The Xhosa people are
a group of clans within the Nguni, Bantu-speaking people in
southern Africa. The culture is patrilineal, with a strong hierarch-
ical system of kin networks and chiefdoms. Ancestors play an im-
portant role in guiding traditions and cultural practices.14Mental
# Royal Society of Tropical Medicine and Hygiene 2013. All rights reserved. For Permissions, please email: firstname.lastname@example.org
Int Health 2013; 5: 38–42
at NTNU University library on February 26, 2013
disorders are bound up in complex belief systems, with culture
bound syndromes and culture specific events closely linked to
the understanding and treatment of mental disorders. There is
widespread use of traditional healers in the management of
mental disorders among Xhosa-speaking people.15,16
Influenced by Kleinman17we conceptualise patients and
healers as key components of systems of health and illness.
Kleinman describes the health care system as composed of
three overlapping sectors: the popular, professional and folk
sectors. The popular sector refers to the individual, family,
social networks, community beliefs and activities. The profes-
sional sector is usually synonymous with modern scientific medi-
cine (biomedicine). Lastly, the folk sector, referred to as
non-professional and non-specialist, consists of healers and indi-
genous practices of various kinds.
It is only through rich and detailed understandings of local
contexts and individual experiences that the challenges global
mental health faces in making its best possible contribution
can be fully appreciated. In this article, we use a single case
study to elucidate core issues which, from our experience in
rural mental health care in South Africa, we regard as key to
further developments in the global mental health agenda. The
data we present form part of a larger, multi-national research
project studying access to health services for vulnerable popula-
tions. (For more information see www.equitableproject.org.)
We utilised a qualitative, grounded theory approach, as it is best
suited to explore cultural contexts and phenomena from the per-
spectives of the members of the cultural groups explored, and to
build theory from data.18Data were collected from various
sources that shed light on the questions under study,18such
as people with mental disorders, their family members,
members of the community, health workers from the profession-
al and folk sectors, traditional leaders, management at hospital
and clinics, relevant literature, policy documents, strategies and
plans at international, national, provincial and local levels. Data
collection techniques utilised in the project of which this case
study is a part are observation, in-depth interviews (individual
and group), informal conversations and desk study. In this
article we focus on the case of a woman with mental disorder
and her family; we add other contextual data from various
health sectors and health users as required.
In grounded theory research, data collection and data ana-
lysis are concurrent processes, allowing for continuous altera-
tions and additions to the data collection and analysis based
on the research findings.18–20Grounded theory analysis has
been used, generating categories and creating hypotheses
from the data. The data were labelled through open coding,
using conceptual categories to develop the codes.20The codes
were derived from the literature, and from the actual data.19
In the results section the data are presented in a purely descrip-
tive manner, to best capture the complexities of the context and
the experience of the patient and her family, in line with the
Madwaleni – the study setting
Madwaleni District Hospital catchment area is located in the
Amathole District, in the Eastern Cape Province of South Africa.
The Madwaleni area is characterized by rugged hills, deep
valleys, rivers, forests, unpaved gravel roads, free running
animals and round grass-thatched mud-huts. The settlement is
spread out, placed on top of hills, with most people owning big
pieces of land, where they grow vegetables and keep livestock.
There is a scarcity of sewerage systems, running water and elec-
tricity to the general Madwaleni community.
Madwaleni health system – professional sector
Madwaleni Hospital, established in the mid 1950s, serves a popu-
lation of about 120 000 in a 35 km radius. After the advent of
democracy in 1994, eight clinics were built around Madwaleni
Hospital as a result of the implementation of primary health
care (PHC) policies. The clinics are nurse-driven, staffed primarily
by nurses and community health workers (lay health workers).
Most of the health providers are from the area, and are
Xhosa-speaking. There is a severe shortage of health care provi-
ders both at the hospital and the clinics, and those who are there
are extremely overworked, and work under difficult working con-
ditions with shortage of equipment and medication, long
working-hours, seeing many patients per day and hence have
very little time with each patient. At the time of the data collec-
tion there were no social workers, no psychologist, no psychiatrist
and no psychiatric nurses in the area. The health services have
had short-term visits by psychologists in the past, but these
usually do not stay long, and have very little sustainable
impact. There are no dedicated professionals at the clinic or
the hospital to diagnose mental disorders. The professional
nurses and doctors have some basic mental health training,
but none of them have practised it much, if at all. There is a re-
habilitation department at the hospital, with physiotherapists
and occupational therapists, but these are not involved in the
acute care of people with mental disorders. The health providers
explained that the most commonly seen mental disorder at the
hospital and at the clinics is acute psychosis, often in young men,
usually linked to alcohol and drug use. When asked about disor-
ders such as depression, bipolar disorder and schizophrenia, they
said that they rarely diagnose or treat people with these disor-
ders. Those patients that are admitted to, or treated at the hos-
pital, invariably are there because of violent or aggressive
behaviour, and because they are viewed as a potential danger
to themselves or to others. These patients will be referred from
the clinic, which is the primary health care unit, to the Madwaleni
hospital. At the hospital they will most likely be treated with
sedatives or anti-psychotic medication. If they are not behaviour-
ally more settled within 72 hours, they will be referred to the psy-
chiatric wing at Mthatha General Hospital, which is a two hour
Madwaleni health system – folk sector
There are a number of traditional/faith/spiritual healers working
in Madwaleni. Most of the health service users we spoke to
were currently using or had at some point made use of these ser-
vices, either instead of or in concurrence with professional health
at NTNU University library on February 26, 2013
care. While there are several traditional healers in the area that
provide treatment for mental disorders, in this article we will
draw upon information gained through one interview with a spir-
itual healer. He reported that he treats severe cases of mental
disorder. This treatment is in the form of special water which
has been prayed over. He says that he heals more people than
does the hospital. His patients drink the water, they bathe in
the water, are sprayed with the water or they vomit the water.
He explained that the people he treats have been exposed to
witchcraft, and the water washes the witchcraft away or
empties the body of it. He says that prayer is a key element in
eradicating witchcraft, and that a lot, but not all disorders are
caused by witchcraft.
The case of a Madwaleni health care user – popular
The case is a Xhosa-speaking woman of approximately 65 years.
Pumla (pseudonym) is the oldest in her household of seven
people, and the mother or grandmother of most of them. The
household survives on three social grants. They have no livestock,
but they have a garden where they grow vegetables for con-
members of her family. Her oldest son answered most of the
questions, but she, herself, answered when spoken to directly.
The son told us that:
She was ’sick of the brain’ about ten years ago, and she has
never gotten well again. She went ’crazy’; shivering heavily,
bleeding from the nose and mouth, running around aimlessly,
running away, being violent and not knowing what she was
doing. She was a danger to herself and others. At night she
thought that she was being attacked by her small grandchild
and by men in the community who were trying to kill her, but
this was not real. The bleeding stopped after one day, but the
rest of the symptoms lasted for about six months, on an
everyday basis, before we the family took her to the hospital
The hospital is about 20 minutes by car from the house of the
family, and several hours walk on narrow paths, up and down
steep hills, across a river and on roads that flood during the
rainy season. There is scarce public transport in the area, un-
affordable to many, and unreliable at the best of times. Pumla
and her family used public transport to get to the hospital. Of
their experiences seeking health care her son told us:
At the hospital a nurse looked at my mother’s head, and said
that she did not know what was wrong with her, but she gave
her some medicine. We were not told what it was, or what it
was for, just how many and at what time to take the tablets.
They also gave her painkillers for a bad headache she had,
and told her to go to a traditional healer for help and medi-
cine, and to combine these treatments. So we sought help
from a spiritual healer just a few minutes’ walk from our
house. The healer gave my mother a bottle of something to
drink. After this she got a bit better; she stopped hallucinat-
ing, and she shivered less. She took the treatment for six
months, during which time she had to go to the hospital
once a month for follow-up and medication. After six
months a nurse told her to stop taking the treatment from
the hospital. She has not been on any treatment since
then, and she has not had hallucinations or been running
around or away since then. After her illness, my mother has
become very sad, she has lost her physical power, she can
communicate, but she rarely does, she suffers from head-
aches, and she has stopped socializing. As a result, I have
decided that she might as well do nothing. She now sits in
the same spot every day, sleeping or just sitting there, she
does not contribute to household chores, but she dresses
and washes herself.
The family says that no one ever told them what was wrong with
Pumla or what had happened to make her ill. The health provi-
ders just asked the family to explain to them what had hap-
pened. Pumla herself says she does not know what happened
to her. She says she now has pain in her head, and that before
the disorder she was fine. The son says that she is now mostly
a burden to the family. He wishes some doctor could help her
get well, or that the family could get some help with the house-
hold chores that she used to do before she became ill.
We shall use the case study to elucidate key challenges for
mental health care in this context as they emerged throughout
the data collection and data analysis process. We will then
explore the implications of these for global mental health.
Mental health literacy
Care for physical or mental disorders most often start at popular
sector level, where some basic health care can be carried out, or
decisions about further health care steps are made.17When
Pumla became ill, neither she, her family nor the community
around her recognized that she was suffering from a mental dis-
order, and that there was health care available to help her. Due
to the limited knowledge of the family and the community
around her, help for her was sought only when she was present-
ing with behaviour that was potentially dangerous to herself and
to others, and this was six months after she presented with the
first symptoms of mental disorder. To this day the family have no
idea what happened to her, and they struggle to talk about what
kind of help they would want for her, mainly because they do not
know what kind of help could exist. Mental health literacy—or
the lack of it—is a clear challenge in the Madwaleni context.
Transport and lack of outreach
The next challenge for the family was getting to the hospital,
which is where they decided to seek treatment. They decided
to use public transport, which is expensive for them and even
more so because someone had to accompany her to the hos-
pital. Transport is a big problem for most people in the Madwa-
leni community, and while the health services do offer some
outreach programmes and home based care, these are limited,
and there is nothing for people with mental disorder.
S. H. Braathen et al.
at NTNU University library on February 26, 2013
Limitations of professional health care
Arriving at the hospital they saw a nurse, and were given pills for
Pumla to take. The most effective mental health interventions
require access to proper diagnosis, medication and skilled
health workers such as psychologists, psychiatrists, mental
health nurses or social workers,8,9none of which is available in
Madwaleni. As a result it is the general nurses and sometimes
doctors who are left with the responsibility of diagnosing and
caring for patients with mental disorders. Not only are these
health professionals already overworked, they also only have
very basic knowledge of diagnosis and treatment of mental dis-
order. The result can been seen in our case, where the family feel
that they received very little information about what had hap-
pened to her, what medication she was given, and why. Further-
more, treatment of mental disorders is a problem in Madwaleni.
Common mental disorders are rarely diagnosed and treated in
the professional health sector, and it is likely that this is due to
a lack of diagnostic capacity for these disorders, and not that
they are less common in this particular community. The only
treatment available is drugs, and even these are limited at
both the hospital and the clinics. The family was advised by a
professional health care provider to seek help also from a trad-
itional healer, the rationale for which they do not know. This
may be linked to the health worker’s lack of skill, confidence
and capacity to manage mental disorder. Or it may be
because of the health worker’s holistic attitude towards collab-
orative practice between the two sectors.
Challenges at the interface with the folk sector
As advised by a health worker at the hospital, Pumla also sought
treatment from a traditional healer. The spiritual healer is only a
short walk from her house, and he gave hera different treatment.
Though there was referral from the professional sector, there was
no mechanism to bridge the different health care contexts for
Pumla and her family, and no follow-up. It appears that this is
not a collaboration as such between the sectors, but the sending
of a patient to traditional healing at least partly because of the
health system challenges within the formal health sector.
Lack of follow-up and rehabilitation
While Pumla, at the time of the interview, had recovered from
the most immediate and acute mental disorder, the aftermath
of her mental disorder was still very much a defining factor in
her life. Despite this, she has not received any form of mental
health care in the past decade. The follow-up from both the pro-
fessional and folk sectors ended when her acute symptoms were
gone, and the family, part of the popular sector,17were left with
the care responsibilities for a woman they describe as ‘being able
to do nothing’. While the family see that she has never gotten
back to her ’normal self’, they do not know of any other places
to seek help for her.
The experiences of this family are embedded in a complex web of
different sectors of healing, together with practical challenges,
including those of terrain, poverty and lack of resources. Issues
of belief and paradigm are key: even professional health provi-
ders in Madwaleni, trained and working within the paradigm of
biomedicine, are socially linked to and live within a more holistic
health approach. An example of this is the health provider at
Madwaleni hospital who told the family that they should seek
help from a traditional healer alongside the treatment they
received from the hospital. Regardless of the rationale for this
advice, the challenges at the interplay between the two health
sectors remain real. In contexts like Madwaleni, there are
many challenges for cross-referral across health systems. From
a professional mental health perspective, there is clearly a
need for greater mental health literacy, for both community
members and for professional and other health personnel. But
it is also crucial, if limited resources are to be used optimally,
that outcome evaluations of treatments within and across the
full range of health care sectors are conducted.
It is unlikely that there will be an abundance of mental health
specialists in Madwaleni or similar contexts any time in the near
future. So while this may still, for many, be the ideal treatment
option, this is not a likely solution to the problem in Madwaleni
at this point. Within the global health and mental health litera-
ture, there is currently a great emphasis on what has been
termed ‘task-shifting’, which is the deployment of lower-level
health providers or lay health workers to provide basic prevention
and treatment services, supervised by more skilled health
workers at secondary or tertiary level.3,4This may well be an
option in contexts like Madwaleni, however, in task-shifting one
must be mindful of the already challenging conditions health
workers work under. Given the strong link between physical
and mental health conditions,10,11an interdisciplinary approach
should be employed. For instance, there is already a rehabilita-
tion team in Madwaleni, but these are currently not involved in
the treatment or prevention of mental disorder. A more difficult
question, but one that needs to be addressed, is how to integrate
different forms of healing (including indigenous or spiritual
healers) in evaluated innovations in task-shifting.
The global mental health literature emphasises shifting the
focus of mental health care from cure to promotion and preven-
tion. It also stresses the value of using an interdisciplinary team
of lay and trained health workers from the professional, folk and
popular sectors. This strategy needs to be complemented by
other strategies, for example, integrating mental health into
other projects focussing on sustainable livelihoods and develop-
ment of infrastructure. The challenges are complex, as this small
study shows, but it is only by looking closely at local conditions
that it is possible to develop interventions which are contextually
appropriate and make optimal use of local resources.
Authors’ contributions: All authors participated in designing the protocol
for the study. SHB, RV and GM contributed to the collection of the data.
SHB, RV, GM and LS contributed to the analysis and interpretation of
the data. All authors have contributed to the drafting of the article and
approval of the final manuscript. SHB and LS are guarantors of the paper.
Acknowledgements: We would like to thank the following for their
assistance: our brilliant interpreters for their assistance in interpretation
both of the language and the Xhosa culture; traditional authorities in the
area for allowing and assisting us in getting access to the field; and the
at NTNU University library on February 26, 2013
staffatMadwalenihospitalandthesatelliteclinicsfortheirparticipationas Download full-text
informants and helping us identify relevant informants outside the clinics.
A special thank you to the Community Health Workers!
Funding: This research was funded by the European Commission
Framework Programme 7; Project Title: Enabling Universal and Equitable
Access to Healthcare for Vulnerable People in Resource Poor Settings in
Africa; Grant Agreement No. 223501 and through the Department of
Science and Technology, South Africa. The opinions expressed in this
article are those of the authors alone.
Competing interests: None declared
Ethical approval: This project is part of a larger research project, which
obtained ethical clearance from the Health Research Ethics Committee
at Stellenbosch University. Furthermore, approval has been obtained
from the Eastern Cape Department of Health to conduct research at
the health facilities in the relevant study area
1 Raviola G, Becker AE, Farmer P. A global scope for global health—
including mental health. Lancet. 2011;378:1613–5.
2 WHO. Mental Health Atlas 2011. Geneva: World Health Organization;
3 Thornicroft G. Most people with mental illness are not treated. Lancet.
4 Saraceno B, van Ommeren M, Batniji R et al. Barriers to improvement
of mental health services in low–income and middle–income
countries. Lancet. 2007;370:1164–74.
5 Swartz L. Culture and mental health in South Africa and neighbouring
countries In: Bhui K, Bhugra D, editors. Culture and Mental Health: A
Comprehensive Textbook. London: Hodder Arnold; 2007.
6 Pillay AL, Lockhat MR. Developing community mental health services
for children in South Africa. Soc Sci Med 1997;45:1493–501.
7 Burns JK. The mental health gap in South Africa – A human rights
issue. Equal Rights Rev 2011;6:99–113.
8 Patel V, Boyce N, Collins PYet al. A renewed agenda for global mental
health. Lancet. 2011;378:1441–2.
9 Patel V, Araya R, Chatterjee S et al. Treatment and prevention of
mental disorders in low–income and middle–income countries.
10 Leucht S, Burkard T, Henderson JH et al. Physical Illness and
Schizophrenia – A Review of the Evidence. Cambridge: Cambridge
University Press; 2007.
11 Prince M, Patel V, Saxena S et al. No health without mental health.
12 WHO. World Health Report: Working Together for Health. Geneva:
World Health Organization;2006.
13 Barron P, Roma–Readon J, editors. South African Health Review 2008.
Durban: Health Systems Trust; 2008.
14 Duncan M. Human Occupation in the Context of Chronic Poverty and
Psychiatric Disability. Stellenbosch: Stellenbosch University; 2009.
differentiated by a family history of schizophrenia and other
psychiatric disorders. Psychopathology 2004;37:59–63.
16 Mzimkulu KG,SimbayibLC.Perspectivesand practices ofXhosaspeaking
African traditional healers when managing psychosis. Int J Disability,
Develop Educ 2006;53:417–31.
17 Kleinman A. Patients and Healers in the Context of Culture: an
Exploration of the Borderland Between Anthropology, Medicine, and
Psychiatry. Berkeley: University of California Press; 1980.
18 Corbin J, Straus A. Basics of Qualitative Research: Techniques and
Procedures for Developing Grounded Theory (3e) Los Angeles: SAGE
19 Corbin J, Strauss A. Grounded theory research: procedures, canons
and evaluative criteria. Qual Sociol 1990;13:3–21.
20 Silverman D. Doing Qualitative Research (3rd ed.). London: Sage;
S. H. Braathen et al.
at NTNU University library on February 26, 2013