Policy, power, stigma and silence: Exploring the complexities of a primary mental health care model in a rural South African setting

Abstract

AcknowledgementsThe author would like to thank the Professor Susan Rifkin for her invaluable comments on drafts of this work. AbstractThe movement for global mental health's (MGMH) efforts to scale up the availability of mental health services have been moderately successful. Investigations from resource poor countries like South Africa have pointed towards the value of an integrated primary mental health care model and multidisciplinary collaborations to support mental health needs in underserved and under-resourced communities. However, there remains a need to explore how these policies play out within the daily realities of communities marked by varied environmental and relational complexities. Arguably, the lived realities of mental health policy and service delivery processes are best viewed through ethnographic approaches, which remain underutilised in the field of global mental health. This paper reports on findings from a case study of mental health services for HIV-affected women in a rural South African setting, which employed a motivated ethnography in order to explore the lived realities of primary mental health care model and related policies in South Africa. Findings highlighted the influence of three key symbolic (intangible) factors that impact on the efficacy of the primary mental health care model: power dynamics -which shaped relationships within multi-disciplinary teams, stigma -which limited the efficacy of task-shifting strategies, and a silencing of women's narratives of distress within services. The resultant gap between policy ideals and the reality of practice is discussed. The paper concludes with recommendations for building on existing successes in the delivery of primary mental health care in South Africa.

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