At the coalface of collaborative mental health care: A qualitative study of governance and power in district‐level service provision in South Africa

Abstract

Globally, there is an urgency to address fragmented mental health systems, especially in low-to-middle income countries. State and non-state mental health service collaboration is a central strategy to strengthen care. The study was undertaken to analyse the power in governance processes of public mental health service provision. Semi-structured interviews were conducted with state and non-state actors in mental health care in a South African district. Transcriptions were thematically analysed using the Framework for Assessing Power in Collaborative Processes. Findings suggested that collaborative processes were significantly state-owned, in terms of funding models, administrative and legislative jurisdiction, and state hierarchical referral structure. No formal agreements were in place, elevating the importance of key network actors to bring less-endowed NGOs into the service network. Fragmentation between the Departments of Health and Social Development was telling in district forums. Resistance to power structures unfolded, some participants sidestepping traditional hierarchies to leverage funding and support. The paper highlights the complexities and different facets of power in integrated mental health care in a South African district, adding to growing literature on the social mechanisms that influence collaboration.

Health System Governance for the Integration of Mental Health Services into Primary Health Care in the Sub-Saharan Africa and South Asia Region: A Systematic Review

“… 29 In this regard, the principles of good governance most referred to are the following 9 principles introduced by the United Nations Development Program (UNDP): accountability, strategic vision, rule of law, transparency, participation, effectiveness and efficiency, responsiveness, consensus orientation, and equity. 7 , 42 …”

“… 35 , 39 More specifically, Nepal had an absence of leadership at the Ministry of Health level, whereas Ethiopia and South Africa included strong mental health leadership at the highest level, with weaker leadership at the lower levels of their respective health systems. 34 , 41 , 42 In addition, there were unhealthy conflicts between the central and provincial leadership, which was attributed to their political struggle for power. For instance, the leadership at the central level failed to provide sufficient direction for successful governance.…”

“… 35 Other studies stated the need for appropriate cross-subsidization and private-public partnerships in order to deliver mental health services, upgrade health facilities and optimize the limited resources in the public sector. 37 , 42 …”

“…37 The studies also included countries in different income groups and used various frameworks to assess the governance of each country. However, the most commonly used frameworks were those by Siddiqi et al 38 and Mikkelsen-Lopez et al 39 Furthermore, the findings on Abdulmalik et al, 12 Hanlon et al, 34 Marais and Petersen, 35 Petersen et al, 40 Upadhaya et al, 41 Janse van Rensburg et al, 42 van Ginneken et al, 43 Mugisha et al 46 Minor Moderate confidence Some concerns about the fit between the data from 3 primary studies that mention priority given by government for mental health integration and the review finding.…”

“…Abdulmalik et al, 12 Hanlon et al, 34 Marais and Petersen, 35 Petersen et al, 40 Upadhaya et al, 41 Janse van Rensburg et al, 42 van Ginneken et al, 43 Mugisha et al 46 Minor methodological limitations. Abdulmalik et al, 12 Hanlon et al, 34 Marais and Petersen, 35 Petersen et al, 40 Upadhaya et al, 41 Janse van Rensburg et al, 42 van Ginneken et al, 43 Mugisha et al 46 Minor methodological limitations.…”