Given the limited data on the views of service providers at grassroots level in the Western Cape about CAMHSS, this study sought the perspectives of a range of frontline service providers across all levels of care and across all health districts in the province. We conducted face-to-face semi-structured individual interviews and focus group discussions and asked clinical staff about their experiences on CAMHSS, and their recommendations for future strategies that might strengthen CAMHSS. The themes that emerged not only highlighted challenges with both hardware and software elements of the health systems for child and adolescent mental health, but also pointed to a number of potential solutions to strengthen CAMHS in the province.
In terms of hardware elements, participants expressed challenges with the lack and inequitable distribution of CAMH resources, heavy workload and the lack of financing. These challenges highlight the lack of structure and coordination, and of governance and leadership in CAMHS, thereby suggesting that services are currently unresponsive to the needs of children and adolescents with mental health problems, and unresponsive to the requirements of service providers at grassroots level. A particular point was made about the lack of child and adolescent mental health services at secondary care (level 2), where primary care staff perceived there to be nothing in between them and specialist CAMH (level 3/tertiary services), and which they found difficult to access.
The software-related challenges identified included a lack of intersectoral collaboration, inadequate training on CAMHS, lack of support for staff, lack of acknowledgement of staff initiatives, negative attitudes of some staff towards the mental health of children and adolescents, and comments on external contributing factors such as stigma, socio-economic challenges and substance use in local communities. These issues suggest gaps in relationships between the provincial leadership, managers, planners and policymakers on the one hand, and service providers at grassroots level on the other. It was clear from the qualitative data that this perceived disconnect had a negative impact on the morale of service providers, risking the quality of service provision for users.
We also observed interactions between hardware and software elements, and how they impact on each other. For instance, service providers expressed feeling demoralised and inadequate in rendering effective services because of the structural challenges and lack of good leadership and governance in CAMHS. If these challenges are left unresolved, they will continue to threaten job satisfaction and sustainability for service providers . The capacity for CAMHS may be further reduced if and when service providers become intolerant of continuing to work under unfavourable conditions and leave the service.
We were, however, encouraged by the recommendations made by the participants to strengthen CAMHS. With the exception of hardware recommendations to increase staffing and develop dedicated CAMHS at secondary care level, all other recommendations appeared to be software elements that could be implemented almost immediately. The example of one facility where staff introduced innovations to provide a responsive service despite their hardware challenges, exemplified the importance of software elements in service strengthening, i.e. leadership, positive attitudes, acknowledgement and recognition of staff initiative. Chunharas and Davies  pointed out that good leadership at different levels can strengthen a health system. This requires having a vision, setting priorities and mobilising stakeholders and resources to achieve the goals. However, without support from the leadership, staff morale can be impacted negatively, and grassroots innovations can fail, instead of being celebrated and rolled out to other settings. Our findings therefore identified a strong message about the potential to use the local expertise and innovation of mental healthcare staff (often mental health nurses) at grassroots level to strengthen CAMHSS.
The recommendations call for a review of the current structure and service delivery model for CAMHSS. The ideal structure for CAMHSS as recommended by service providers should ensure: 1) proper coordination of the services at top provincial level, within the DoH and with other departments, and down to the primary care level, 2) adequate capacity for CAMH across all levels, 3) collaboration between senior and grassroots level stakeholders, and 4) reasonable and relevant performance requirements for service providers. They also recommended provision of good leadership and governance at provincial level.
Many of the themes identified in this study were very similar to those identified in the situational analysis . The findings of these three investigations validates and reinforces the significance of the challenges for child and adolescent mental health services in the Western Cape. Our findings also concur with broader South African and international literature. For instance, a qualitative study that explored multistakeholders’ perceptions of CAMHSS in another South African province (KwaZulu-Natal) found that there was a shortage of CAMH resources (human and infrastructure) resulting in service providers being overwhelmed with their workload, inadequate CAMH training for non-specialists, lack of a coordinated system of CAMH, and stigmatisation of mental illness in children and adolescents . In an international systematic review that explored primary care practitioners’ perceptions of the barriers to the effective management of CAMH problems, the authors found lack of staff training, lack of prioritisation of mental health problems, lack of resources, and family issues as key barriers . Our findings are therefore likely not only to be applicable in the Western Cape and in South Africa, but also in other settings, particularly in LMIC.
Limitations of the Study
We acknowledge a number of potential limitations of the findings in this study. First, data were collected in 2017 and therefore there may have been some hardware or software changes in CAMHS after the study. However, as practitioners within the system under investigation we have not observed any significant changes that would invalidate the observations made here. Our findings are also the most comprehensive exploration of service provider perspectives in the province to date. Second, given the qualitative nature of the work, we acknowledge the possibility that we may have missed important themes in this study. However, to mitigate against that, data analysis was performed by two independent raters (one of whom had never worked in the CAMH system) to ensure robustness. Third, participants did not include all professional groups (e.g. occupational therapists, speech and language therapists or psychologists) or adequate rural representation. We acknowledge that the full range of allied health professionals are crucial to comprehensive CAMHS and that additional themes may have emerged through their participation. Similarly, rural CAMHS requires much further exploration. It would therefore be important to include these groups in future studies. Finally, the voices of children and families were not included. However, given the importance of their voices, we have opted to perform a separate investigation dedicated to the perspectives of families and CAMH service users.
Relevance Of Findings To Other Low And Middle-income-countries
Our findings also concur with broader South African and international literature [18, 19]. Our findings are therefore likely not only to be applicable in the Western Cape and in South Africa, but also in other settings, particularly in LMIC.