Mental health in rural SA needs a dedicated strategy to ensure communities are not left behind
As a country South Africa has strong mental health policies on paper. But these are not being implemented equitably. Rural areas are especially disadvantaged, with shortages of trained mental health professionals, limited support to integrate mental health into primary care, and almost no specialised services for children and adolescents.
RHAP spoke to Dr Bianca Moffett from the SA Medical Research Council’s research unit Agincourt about the urgent and often overlooked mental health challenges in rural South Africa.
RHAP: How would you describe the mental health burden in South Africa’s rural communities? Which illnesses are most common?
BM: The mental health burden in South Africa’s rural communities is deeply under-recognised. Rural populations face a complex mix of risk factors, including poverty, unemployment, high rates of chronic diseases, exposure to violence and gender-based violence, and poor service delivery within education and healthcare systems, all of which contribute to poor mental health outcomes. Access to appropriate care remains extremely limited, and stigma and low awareness prevent people from seeking help.
Population-based surveys indicate that mental health conditions such as depression, anxiety, and substance use disorders are common in rural areas, as in other parts of South Africa. Severe mental illnesses (psychotic disorders), dementia, cognitive impairment, and childhood developmental disorders also contribute substantially to disability and caregiver burden. Among individuals with mental health conditions, there is high comorbidity of other mental and physical health conditions. However, for most individuals, mental distress goes undiagnosed and untreated, often presenting in the form of somatic symptoms or being attributed to social or spiritual causes.
A recent study found that only 5% of South Africa’s health budget is allocated to mental health and the vast majority of this is spent on tertiary psychiatric services in urban environments. This creates a cycle in which suffering is invisible, and support is out of reach in rural areas.
RHAP: How does this differ from South Africa’s urban settings?
BM: While mental health challenges are present across all communities in South Africa, rural areas face a unique and compounded disadvantage. Urban settings tend to have better access to mental health infrastructure, including psychologists, psychiatrists, social workers, and NGO-run services, even if these resources are still overstretched. In contrast, rural areas often rely on a small number of generalist primary healthcare doctors, nurses and community health workers, many of whom have limited mental health training and are working in chronically inefficient and under-resourced facilities, and facing a complex burden of disease.
Stigma also tends to be more pronounced in rural communities, where mental illness may be poorly understood or attributed to spiritual or moral causes. This can lead to delays in seeking care, reliance on traditional healers as a first point of contact, and shame or isolation for affected individuals and families.
In urban areas, there tends to be greater awareness of mental health issues, particularly among youth and a growing number of initiatives targeting school-based mental health, workplace wellbeing, and digital mental health support. But rural communities often miss out due to infrastructure, connectivity, and language barriers.
RHAP: Based on your research, what trends have emerged in rural mental health in the last two years, either positive shifts or growing concerns?
BM: Over the past decade, we’ve seen growing awareness of mental health needs in rural South Africa, among healthcare workers, policymakers and the general public, particularly youth and adolescents. In a series of interviews with primary healthcare providers in rural Mpumalanga they reported an intergenerational shift in mental health awareness, due in part to increased access to information through mobile phones and the internet.
Growing awareness has unfortunately not been coupled with substantial increased investment in services. Promising opportunities include integrating mental health into primary care and expanding task-sharing with trained non-specialist providers like nurses and community health workers.
With growing access to mobile phones and the internet, many young people turn to digital solutions, however very few mental health apps have been specifically developed for or rigorously evaluated in rural African contexts. The DoBAt Study in rural Mpumalanga was one of the first randomised controlled trials of digital intervention to address depression among adolescents in Africa. We achieved unusually high uptake (more than 80% of adolescents completed at least 4 out of 6 of the prescribed sessions) – indicating a strong appetite for treatment – however further work is required to strengthen the effectiveness of the treatment.
Overcoming service gaps is one part of the solution, however important social determinants affect mental health. In rural South Africa, high exposure to adversities early in life, including threats (violence, GBC) and deprivations (poverty, food insecurity, parental loss/ absence) provide a common explanatory pathway for the development of many mental health conditions. Work done by Agincourt-affiliated researcher Molly Rosenberg has shown that cash transfers can be protective of mental health conditions including depression and cognitive decline.
RHAP: What are some of the biggest barriers rural communities face in accessing mental health care. How have these changed or persisted in recent years?
BM: There are several barriers.
- Severe shortages of trained mental health professionals: Rural areas often have no resident psychologists or psychiatrists, and primary care providers may not feel confident in managing mental health issues. While task-sharing models are expanding, coverage remains patchy and underfunded.
- Stigma and lack of mental health literacy: In many rural communities, mental illness is still heavily stigmatised or misunderstood, with distress often framed in spiritual, moral, or physical terms. This prevents people from seeking help and contributes to isolation.
- Distance, transport, and costs: Accessing care often requires long, costly travel to health facilities. For people experiencing depression, anxiety, or trauma, especially those who are unemployed or caring for others, this is a major deterrent.
- Fragmented services and lack of integration: Mental health is not consistently integrated into primary care in rural areas. Where services exist, they are often disconnected from other parts of the health system, including HIV and chronic disease care, maternal health, or youth services.
- Language and cultural disconnects: Many existing mental health tools and services are not available in local languages or don’t align with the cultural context, making them less acceptable or effective.
While mental health is now on the policy agenda, and there’s growing recognition of its importance in rural areas, without a dedicated rural mental health strategy, implementation remains uneven. This means rural communities are at risk of being left behind.
Bianca Moffett (MBChB, MSc) is a clinician and early-career researcher with over 10-years’ experience in rural primary healthcare and public mental health. Her research addresses 3 key areas: 1) adolescent mental health 2) implementation of mental health and psychosocial support in low-resource contexts, and 3) social determinants of mental health. Since 2020, Bianca has worked at the SAMRC/ Wits Rural Public Health and Health Transitions Research Unit (Agincourt) in Mpumalanga, South Africa, where she co-leads the Mental and Neurological Health and Wellbeing Thematic Area, and is working to build capacity for mental health research, policy and practice in rural and under-served communities.