One way of addressing resource issues in the South African public health system has been through the introduction of the compulsory community service (CS) programme for doctors.¹ The programme aims to ensure improved healthcare for all South Africans. It also aims to provide young doctors with an opportunity to develop their skills, facilitate professional development, and prepare them for their future careers. The majority of CS doctors between 2000 and 2014 reported having an overall positive experience during their placements. They experienced making a difference by aiding service delivery, and reported having developed professionally.^1,2

Schierenbeck et al.³ highlighted that healthcare workers perceived barriers to access to mental healthcare for service users in the Eastern Cape province, and these problems appear to have persisted.⁴ However, there is a gap in literature that highlights CS doctors’ experiences of providing mental healthcare at district hospital level in South Africa. An investigation into CS doctors’ experiences in this part of the country is needed.

The Eastern Cape is one of the poorest provinces in South Africa with a high mental health service user load and limited mental health resources.⁵ We know that healthcare workers find it difficult to provide adequate care in overstretched healthcare systems.⁶ Given the aforementioned circumstances and challenges existent in the Eastern Cape, these issues may come into sharper focus in this province.

This study forms part of a broader study on mental healthcare provision in the Eastern Cape. We explored the experiences of a range of service providers (e.g., nurses, social workers, doctors, and facility managers) and of patients regarding access to and provision of public mental healthcare services at primary and secondary healthcare level.⁷ During our investigation, we became aware of the particular challenges faced by a CS doctor in this context that we wish to highlight and report on. This case study focusses on the experiences of this CS doctor, who chose the pseudonym Cottonwool.

Cottonwool described that they are overwhelmed with work responsibilities at facilities that are not fully equipped with, for example separate wards or enough specialised nursing staff for appropriate mental healthcare provision. Facilities such as this district hospital in the DBNLM area do not have adequate infrastructure to house acute mentally ill patients. This places a significant strain on the facility and its healthcare workers. In line with the literature on the CS placement year,¹ Cottonwool’s account describes how doctors are committed to making a difference for their patients. However, they are challenged by the reported hurdles in the public health sector when trying to fulfil that commitment. The challenges are so extensive that basic service delivery to patients is obstructed. The combination of high work volume and lack of resources results in the reality that service users are not receiving appropriate mental healthcare.

Cottonwool’s narrative suggests that the current state of public healthcare in this region of the country not only burdens our young doctors, but also diminishes civilians’ right to adequate mental healthcare. It leads to a scenario where doctors like Cottonwool struggle physically and mentally to meet the demands of their work. At the same time, the treatment gaps can contribute to diminished recovery and therefore returning service users, which perpetuates the burden on public healthcare facilities.

Healthcare facilities in this part of the Eastern Cape are in need of assistance. Many patients need specialised mental health assessment, treatment and management – expertise that clinicians like psychiatrists and psychologists receive many years of training for. Assistance from other professionals like occupational therapists and social workers may offer relief and has been suggested by others¹⁰ as key service providers at this level of care. But they also have a wide range of competing demands. Doctors cannot manage the overflow of mental health patients together with the physically ill who need their attention.

South Africa has among the most progressive legislation in the world in the form of the Mental Health Care Act, 2002 (MHCA),¹¹ and there are numerous important interventions in terms of strengthening mental health systems in the country. The MHCA, for example, instructs that MHCUs are entitled to appropriate care and rehabilitation by adequately trained clinicians or suited facilities. What Cottonwool’s heartfelt account demonstrates, however, is the gap that is experienced at a personal level between principles and policies on the one hand, and practice on the other. It makes sense logistically to give CS doctors the responsibility to provide mental healthcare as it forms part of facilitating a person’s holistic general health and well-being, but we can see from Cottonwool’s experiences that this may have unintended consequences. Their experiences suggest that they desperately want to help patients, but do not have access to resources to facilitate adequate mental healthcare. Patients with complex, acute, and serious mental illness may overwhelm young generalists like Cottonwool who have limited training of the nuances in psychiatric management and care. Cottonwool’s experiences of MHCUs are focussed on behavioural disturbance and serious mental disorders in a context of severely limited discussion of the crucial role of support and interventions for people with common mental disorders, which form a substantial part of the burden of mental disorders in health services globally. There are also possible knock-on effects to what seems from Cottonwool’s experiences, that is, a ‘sink or swim’ approach, where inexperienced medical personnel take on the responsibilities Cottonwool speaks of. Their experiences would be unlikely to encourage them to consider a future career in healthcare and mental healthcare provision in this same context. If Cottonwool’s experiences are similar to those of others, this has implications for the growing and maturing of a workforce well equipped to implement evidence-based mental health interventions at scale to our country.

Our focus on one doctor’s experience in this study is a limitation, which means that we cannot know how generalisable Cottonwool’s experiences are. Our aim with the presented work was not to produce generalisable data, but rather to explore and report on the issues and concerns that young non-specialist doctors, like Cottonwool, may experience in providing mental health treatment at general healthcare level. However, we are able to say from the data from our larger project that the observations are in keeping with experiences of other healthcare personnel (e.g. social workers, and nurses), facility managers and patients, data which we will formally report on elsewhere. Cottonwool’s experiences are also similar to those reported by other clinicians that provide mental healthcare in a range of South African settings.^12,13

It is difficult to change health systems, an issue that is well documented,^14,15,16,17 and we do not pretend to have the answer to the issues raised by Cottonwool. We believe, however, that a close-up account like this one is important, as it highlights the personal consequences for individuals of being placed on the front line of a challenged and under-resourced system, and underscores the fact that investments in health service skills and continuity of service are essential if provision is to match the high ideals of policy.