Mental and addictive disorders affect a substantial proportion of the world’s population and are major contributors to the global burden of disease . It was estimated that a total of 162.5 million disability adjusted life years (DALYs) were due to mental and addictive disorders which is 6.8% of the total DALYs in 2016 . In sub-Saharan Africa there was a 113.9% increase in total DALYs lost between 1990 and 2017 due to mental disorders . Psychiatric epidemiological data for South Africa (SA) is limited, but the available data suggests that mental illness is a significant problem. The most recent nationally representative mental health data comes from the National Income Dynamics Study (NIDS) which only screens for depression . In the fourth wave of the NIDS (2014–2015), 26% of adult participants were found to have significant depressive symptoms . Suicide data provides an indication of mental illness burden [4, 5] and SA’s crude suicide mortality rate in 2016 was 11.6 per 100 000 population - higher than the global average of 10.6 per 100 000 population . COVID-19 is likely to result in a rise in mental illness in SA as the pandemic and social distancing measures have resulted in stress, loneliness, and a reduction in social interactions which are known to increase the risk of mental illness .
There is a worldwide shortage of the human resources needed to deliver essential mental health interventions , and this shortage is a critical barrier preventing low- and middle- income countries improving their mental health services [9, 10]. According to the World Health Organization , SA had 1.52 psychiatrists per 100 000 population in 2017. While this is above the global median, it falls short of the South African Society of Psychiatrists recommended target of 3.0 per 100 000 population . It was reported that in 2019, 70% of psychiatrists in SA were servicing the small private sector . As with the health workforce in general in SA, there is an urban-rural maldistribution of mental health human resources [13, 14].
Task shifting and task sharing approaches have been implemented in many countries in order to address mental health workforce shortages. More efficient use can be made of the health workforce by moving appropriate tasks to health workers who have fewer qualifications and have undergone shorter training . The types of non-specialist health workers who deliver mental health services elsewhere include medical officers, nurses, and lay health workers [8, 16]. These workers have contributed to mental health services in various settings including clinics, community outreach services and halfway homes [8, 16]. The mental health tasks performed by these non-specialist health workers differ and depend on their level of training [8, 16]. These tasks include prevention, detection, and treatment of mental disorders [8, 16]. In a Cochrane systematic review assessing non-specialist health worker interventions in mental health, the authors found that there may be potential benefit to the use of non-specialist health workers in general and in perinatal depression, dementia, alcohol-use disorders and post-traumatic stress disorder .
The available evidence suggests that SA has a high prevalence of mental disorders and these are a significant contributor to the disease burden and the COVID-19 pandemic is likely to exacerbate this. South Africa has a shortage of specialist mental health professionals with public-private sector and urban-rural maldistribution. Task sharing approaches are critical to ensure mental health service provision in underserved areas. South Africa trains mid-level health workers in the non-physician clinician category through a three-year Bachelor of Medicine in Clinical Practice (BMCP) degree at Walter Sisulu University and the Bachelor of Clinical Medical Practice (BCMP) degree at the University of Pretoria and University of Witwatersrand . Named clinical associates, the first cohort entered the SA health system in 2011 . The role of clinical associates in mental health service provision is currently ill defined and they are possibly an under-utilised resource in mental health task sharing approaches. While mental health does form part of their scope of practice , the extent or utility of the training is not clear. This study explored the mental health curriculum content of the undergraduate clinical associate training programmes in SA.