Both countries engaged in activities associated with all four aspects of the framework which served to strengthen access to mental health services, albeit the focus of the integration process differed across the two country sites.
Sensitization efforts with district/sub-district management heightened awareness of the need to dedicate more specialist mental health resources to assist with the integration of mental health into primary healthcare in both country sites. However, it was only in South Africa that this awareness translated into an actual increase in dedicated resources within the study site. This was made possible by the deployment of existing psychiatric nurses within the system. As indicated in the introduction, South Africa is better resourced than Uganda and has a relatively higher number of psychiatric nurses available in the system (see Table 1), who could be deployed to mental healthcare duties. In contrast, in Uganda, increasing the number of mental health nurses in the study site during the life of the project was not possible as this entailed a lengthy process of needing to fund and source incumbents for these specialist posts.
The community collaborative multi-sectoral forums also proved useful in both country sites for mobilizing resources for mental health. In Uganda, resources were sourced from the agricultural sector to assist members of the self-help user-carer group to engage in sustainable livelihood agricultural activities. In South Africa, community participation emerged as a useful vehicle for accessing a community hall for the IPT depression groups. The lack of formal collaborative agreements and directives from sectors other than health, however, militated against any sustainable commitments from these sectors. This suggests the need for sector-wide approaches to the development of mental health services to be initiated at higher levels within government structures if they are to be implemented at district level.
With regard to task shifting, this was viewed positively in both country sites by district/sub-district management. In South Africa, shifting psychosocial care for people with CMDs to CHWs and CMHWs was also viewed positively by PHC staff and CHWs themselves. The supportive counselling and problem management training that general CHWs received reportedly strengthened their capacity to respond to psychosocial problems and related CMDs they encountered in their regular home visits. Further, having dedicated CMHWs provide a specific psychological treatment programme for women with depression was also viewed positively as it provided a referral pathway for people identified with depressive symptoms at both the community and facility levels of PHC. PHC nurses and general CHWs reported that they could not provide these specific treatment programmes themselves, feeling overburdened already with existing duties. This corroborates previous findings [4, 13]. They therefore welcomed the introduction of a referral pathway of care for these disorders. Given that CMHWs are equivalent to general CHWs in that they are community members with minimal training, they also require close supervision from mental health specialists, an essential component of the task shifting model . In the demonstration project, the mental health counsellor introduced into the PHC system provided this supervisory support. This task could, however, be undertaken by another mental health specialist within the system, such as a psychiatric nurse deployed to fulfil this supportive and supervisory role.
In Uganda, where the focus was on SMDs, the training reportedly improved identification and referral of these disorders. In the absence of sufficient psychotropic medication as well as healthcare personnel who have the authority to prescribe or confirm prescriptions, task shifting reportedly had a demoralizing effect on PHC staff. A bottleneck of users requiring services from limited mental health specialists was reported. Paradoxically, instead of task shifting alleviating this problem, it was exacerbated.
Based on the two different experiences in the South African and Ugandan sites, these findings collectively suggest that for task shifting to be successful in low resource settings, it needs to occur within a stepped care approach, with adequate infrastructure and a specialist referral and supervisory support structure. Task shifting is not a panacea for the paucity of mental health specialists nor psychotropic medication in LMICs. With respect to the former, a minimum number of specialist mental health personnel are still required to provide supervision and a referral service . Regarding the latter, an adequate supply of psychotropic medication at PHC level is an essential first step in the process of decentralization and re-integration of users with SMDs into society. Campaigns to raise the awareness of policy makers in LMICs and donor agencies of the need for a sufficient and constant supply of psychotropic medication need to be mounted. While this is best achieved by service users themselves, involvement of users with mental disorders in advocacy efforts is, however, difficult for a number of reasons , let alone in scarce resource settings where treatment options have been historically limited [27, 28]. Involvement of carers and service providers in these efforts as well, is thus important.
The findings of this study suggest that when some treatment is provided (medication for SMDs in Uganda, and psychological treatment for CMDs in South Africa), help seeking behaviour is strengthened, which results in a greater demand for services. In the absence of sufficient resources, this benefit needs, however, to be weighed against the demoralizing impact it can have on service providers and users alike, as was demonstrated in the Ugandan case study site.
The form of self-help groups developed in both country sites were contextually driven by country priorities. In the context of South Africa's AIDS pandemic and in the KwaZulu-Natal province specifically, where 38.7% of childbearing women are estimated to be HIV positive , it was not surprising that psychosocial support groups were formed, in the main, to assist HIV infected and affected women. A recent study suggests high levels of CMDs associated with HIV (47.3%) in South Africa . In Uganda, given the focus on developing services for people with SMDs, and within the context of an inconsistent supply of psychotropic medication, the initial focus of the self-help groups was on accessing medication.
Across both country sites, self-help groups generally incorporated some form of livelihood generating activities. This should assist to break the vicious cycle of poverty and mental ill health, now well established [31, 32], and promote social inclusion, which in turn can assist in reducing stigma and discrimination. In Uganda, medication played an important role in this process, with the findings suggesting that engagement in livelihood generating activities by people with SMDs was initially made possible through the stabilizing effect of psychotropic medication. In the context of findings from other African countries of the high financial burden of having family members with SMDs , the hope amongst carers of easing this burden through participation in the self-help group, was striking.