Scaling up an integrated primary mental health screening programme in South Africa through co-development and continuous quality improvement.

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Learn more: PMC Disclaimer | PMC Copyright Notice BMC Prim Care . 2026 Mar 5;27:131. doi: 10.1186/s12875-026-03223-7 Search in PMC Search in PubMed View in NLM Catalog Add to search Scaling up an integrated primary mental health screening programme in South Africa through co-development and continuous quality improvement André J van Rensburg André J van Rensburg 1 Centre for Research in Health systems, School of Medicine, University of KwaZulu-Natal Howard Campus, Berea, Durban, South Africa Find articles by André J van Rensburg 1, ✉ , Zamasomi Luvuno Zamasomi Luvuno 1 Centre for Research in Health systems, School of Medicine, University of KwaZulu-Natal Howard Campus, Berea, Durban, South Africa Find articles by Zamasomi Luvuno 1 , Tasneem Kathree Tasneem Kathree 1 Centre for Research in Health systems, School of Medicine, University of KwaZulu-Natal Howard Campus, Berea, Durban, South Africa Find articles by Tasneem Kathree 1 , Nikiwe Hongo Nikiwe Hongo 2 Directorate for Mental Health and Substance Abuse, KwaZulu-Natal Department of Health, Town Hill Hospital, Pietermaritzburg, South Africa Find articles by Nikiwe Hongo 2 , Londiwe Mthethwa Londiwe Mthethwa 1 Centre for Research in Health systems, School of Medicine, University of KwaZulu-Natal Howard Campus, Berea, Durban, South Africa Find articles by Londiwe Mthethwa 1 , Merridy Grant Merridy Grant 1 Centre for Research in Health systems, School of Medicine, University of KwaZulu-Natal Howard Campus, Berea, Durban, South Africa 3 Curtin enAble Institute, Curtin University, Kent Street, Bentley, Australia Find articles by Merridy Grant 1, 3 , Arvin Bhana Arvin Bhana 1 Centre for Research in Health systems, School of Medicine, University of KwaZulu-Natal Howard Campus, Berea, Durban, South Africa 4 Health Systems Research Unit, South African Medical Research Council, Durban, South Africa Find articles by Arvin Bhana 1, 4 , Deepa Rao Deepa Rao 5 Department of Global Health, Hans Rosling Center, University of Washington, Global Health, Seattle, USA Find articles by Deepa Rao 5 , Inge Petersen Inge Petersen 1 Centre for Research in Health systems, School of Medicine, University of KwaZulu-Natal Howard Campus, Berea, Durban, South Africa Find articles by Inge Petersen 1 Author information Article notes Copyright and License information 1 Centre for Research in Health systems, School of Medicine, University of KwaZulu-Natal Howard Campus, Berea, Durban, South Africa 2 Directorate for Mental Health and Substance Abuse, KwaZulu-Natal Department of Health, Town Hill Hospital, Pietermaritzburg, South Africa 3 Curtin enAble Institute, Curtin University, Kent Street, Bentley, Australia 4 Health Systems Research Unit, South African Medical Research Council, Durban, South Africa 5 Department of Global Health, Hans Rosling Center, University of Washington, Global Health, Seattle, USA ✉ Corresponding author. Received 2025 Jul 21; Accepted 2026 Feb 11; Collection date 2026. © The Author(s) 2026 Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/ . PMC Copyright notice PMCID: PMC13069758  PMID: 41781879 Abstract Background Despite global progress in developing integrated mental healthcare on primary healthcare level, particularly in low-and-middle income countries, descriptions of scaling-up efforts remain scarce. The aim of this study was two-fold. First, to describe a collaborative approach to embed a common mental health conditions screening tool and process within district primary health care systems in KwaZulu-Natal, South Africa. Second, to explore perceptions of participating frontline workers and policy makers of the barriers and facilitators to embedding the tool using this collaborative approach as part of a scale-up process. Methods Following a participatory action research approach, a learning collaborative was established that involved (1) mental health service coordinators from each district of the province of KwaZulu-Natal ( n = 11), (2) provincial managers and policymakers ( n = 4), and (3) members of the local research team. The capacity building programme was co-developed during a series of participatory workshops, and the common mental health conditions screening tool and associated processes were implemented and workshopped iteratively. The development and implementation of this programme as part of scaling up the screening intervention was assessed drawing from workshop proceedings, individual interviews with district coordinators ( n = 11), and a focus group discussion ( n = 8). Data were transcribed verbatim and thematically analysed guided by the Consolidated Framework for advancing Implementation Research. Results The participatory development and implementation process resulted in consensus building, curriculum development, situational analyses, training, and continuous quality improvement. The collaborative and co-development approach to the capacity building curriculum was broadly favoured. Outer Settings emerged in terms of a lack of formal guidance documents for district mental health services, limited intersectoral collaboration, and limited community mental health literacy. In terms of Inner Settings, mental health continued to be under-prioritised in district services, with a lack of ring-fenced funding and data monitoring systems. Regarding Individuals, PHC staff were less well-trained and did not always want to engage in mental healthcare, with limited opportunity for capacity development. In terms of Implementation Processes, the flexibility of programme was particularly well illustrated during the disruptions of COVID-19, and adaptations were added to the programme to help address mental health and containing leadership among primary healthcare workers. While this period resulted in virtual workshops, face-to-face meetings were favoured. Conclusions The scaling-up of an integrated primary mental health screening innovation requires capacity building among mid-level management, and a co-developed, collaborative programme built on continuous quality improvement provides promise in providing flexibility and communal problem-solving for more sustained implementation. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-026-03223-7. Keywords: Capacity-building, Continuous quality improvement, Primary mental healthcare, Mental health screening, Integrated care, Scale-up Background The integration of mental health into primary healthcare (PHC) has been a continuing priority in global health as a strategy to increase access to mental health services, particularly in low- and middle-income countries (LMICs). There has been admirable progress at an advocacy and policy level through the Movement for Global Mental Health [ 1 ] and the World Health Organization’s (WHO) Comprehensive Mental Health Action Plan 2013–2030 [ 2 ]; as well as in global mental health research through the generation of the evidence base of interventions and models that enable integration using task sharing and collaborative care models [ 3 – 7 ]. However, in practice, integrated primary mental healthcare remains limited in most countries. It is estimated that only 25% of all WHO Member State countries have achieved functional integration of mental health into PHC, which translates to less than one-third of 2030 global target of 80% [ 8 ]. To hasten the achievement of this 2030 global target, global mental health needs to move beyond innovations in service reform and mere policy adoption towards work to embed innovations within the system at scale. This is important, given challenges that may hinder implementing innovations at scale post-adoption, leading to partial diffusion, abandonment or tokenist implementation [ 9 ]. Further, the scaling of healthcare interventions from research products to embedded practice has been a persistent challenge in health systems globally [ 10 – 13 ]. Similarly, in Global Mental Health, effectively taking interventions to scale has dogged ideals for systemic reform [ 14 – 17 ]. Common barriers to effective scale-up of mental health into primary health systems include programmes having a limited evidence base, being overly complex, or being costly to implement [ 14 ]. The lack of continuous support, mentorship and oversight in implementation processes; lack of clear goals; lack of policy support, a lack of consensus in how to scale programmes; and a lack of government and policy-maker involvement further constrain scale-up efforts [ 17 ]. On the other hand, it has been suggested that scale-up can be facilitated by the flexibility of programmes; the degree to which programmes can be adapted to local needs and resources; the degree to which programmes are in line with policies and guidelines; the perceived advantages of programmes over alternatives among implementers; and policy-makers motivated by the aims of scaling up integrated mental healthcare [ 14 , 17 ]. Key features of successfully and sustainably scaling up mental health care programmes – specifically in LMIC contexts – include the need to invest in strengthening local governance with technical skills and support; the inclusion of mental health indicators in health information systems; and the enabling of collaborative and community- oriented PHC-service delivery platforms through continuous quality improvement (CQI) [ 16 , 18 ]. Implementation science and participatory approaches have been particularly useful in better guiding scale-up efforts [ 14 , 16 , 17 ]. The sustainable embedding of innovations requires efforts to better understand processes of change in healthcare [ 19 ], and how these processes can be leveraged in pursuit of integration of mental health into PHC. Recent conceptualization of these processes suggests the need for a shift from top-down policy making processes towards collaborative forms of management, that incorporates the evidence and experience of frontline adopters in how best to embed innovations in systems of care through a collaborative process of learning, adapting and institutionalizing [ 9 ]. Learning occurs through accumulating the experience of implementation of the innovation across contexts. Adaptation of the embedding mechanism follows to customise its implementation to the local context. This is followed by institutionalising the mechanisms, with such processes important for providing legitimacy and incentives to encourage adoption and implementation by frontline health care workers [ 20 ]. The Southern African Consortium for Mental Health Integration (S-MhINT), together with the KwaZulu-Natal Department of Health (DoH) in South Africa, adopted this approach in our efforts to embed a collaborative Mental health INTegration (MhINT) care package [ 21 , 22 ] for common mental health conditions (including depressive symptoms, anxiety, and substance abuse) within PHC clinics within the province of KwaZulu-Natal [ 20 , 23 , 24 ]. This package initially comprised strengthened supplementary training of professional nurses within PHC clinics to assess, identify and initiate a cascade of care for common mental health conditions for further intervention at either local or higher levels of care. Care for common mental health conditions on PHC level had been largely limited to referral for initiation of anti-depressant medication by PHC doctors visiting the facilities on a sessional basis, and referral to the district hospital where a limited number of psychologists were located. These referral pathways were strengthened to include referral to a clinic-based HIV counsellor who were designated and trained in a manualised counselling intervention using evidence-based problem solving, health thinking and behavioural activation techniques. Following iterative implementation research, the MhINT package was strengthened to integrate, inter alia , the Brief Mental Health (BMH) screening tool (a locally validated instrument used by PHC nurses to detect symptoms of depression, anxiety and substance abuse) and its associated training and support package into PHC clinics [ 22 , 24 ]. The aim of this study was two-fold : First, to describe our process of scaling-up screening for common mental health conditions – specifically the integration of the BMH screening package within the PHC system in KwaZulu-Natal – through a participatory process of district-level capacity building; Second, to explore perceptions of district mental health coordinators and policy makers of the barriers and facilitators to embedding the BMH screening approach in their respective districts. Methods Site where the BMH tool has been embedded in the system The province of KwaZulu-Natal on the eastern seaboard of South Africa was the scale-up site. It is home to approximately 11 million people who are predominantly isiZulu speaking. The province is divided into 11 health districts which provide PHC through a network of PHC clinics supported by community health centres and district hospitals. The Amajuba district was one of these 11 districts where the initial evidence-based integrated care package was iteratively evaluated and refined for real-world implementation [ 7 ]. Approach Our approach reported here is rooted in participatory action research (PAR), a methodological approach that foregrounds experiential knowledge, with authentic participation of and leadership from stakeholders. Key elements of PAR include the building of relationships; the establishing of working practices; the establishing of a common understanding of the issue at hand; observing, gathering and generating insights and materials; collaborative analysis; and collaborative planning and action [ 25 ]. Importantly, PAR requires researchers to work closely with the community involved in the research process, calling for strong collaboration and involvement throughout the research cycle [ 26 ]. The S-MhINT research consortium identified the capacitating and supporting of key actors in the health system, including policymakers and implementers, as a key supporting mechanism for the scale-up of the BMH screening process in KwaZulu-Natal [ 27 – 31 ]. In following a PAR approach, we launched a capacity building quality improvement programme within a learning collaborative [ 19 ]. The learning collaborative comprised the research team from the University of KwaZulu-Natal, policy makers from the Mental Health Directorate of the KwaZulu-Natal DoH and district mental health programme coordinators from the 11 districts in the province of KwaZulu-Natal. The learning collaborative co-developed a capacity-building programme, which was undertaken in iterative cycles of exploring, learning and action. District coordinators were empowered with tools to assist them with implementation of the BMH screening process in PHC clinics, followed by routine participatory workshops where co-learning and improvement occurred, as well as adaptations to the BMH screening process. Data collection Data related to describing the capacity building programme as a scale-up mechanism for the BMH screening process was generated through outputs from participatory workshops. These engagements included four workshops aimed at co-developing the programme, two workshops aimed to empower participants with CQI tools, four workshops aimed at iterative learning and improvement, and one workshop for co-interpretation of findings. In terms of exploring participants’ views on barriers and facilitators to the capacity-building programme and its implementation as part of a scale-up initiative for the BMH screening process, interviews and a focus group discussion was undertaken. Semi-structured interviews were conducted with participating district health coordinators ( n = 11) followed by a focus group discussion ( n = 8). Two interviews were undertaken telephonically (due to the large distance between the districts), while the rest of data collection occurred face-to-face. Three district coordinators were unable to participate in the focus group discussion due to pressing work commitments emerging shortly before the day of the session, though these participants did contribute in the research findings workshop. The interviews and focus group discussion focused on reflections of the participants on the process of co-development, the structure, content and delivery of the programme, main challenges and assets, and recommendations for current and future capacity building activities (see Supplementary File 1). Data were audio recorded and transcribed verbatim. Data analysis Data were combined and analysed thematically, guided by the Consolidated Framework for advancing Implementation Research (CFIR) [ 32 ]. Data transcripts were imported into NVivo (version 13) [ 33 ], where a prepopulated template for CFIR allowed two researchers to independently undertake thematic analysis based on CFIR domains and constructs [ 32 ]. Collated findings were workshopped with the learning collaborative, and recommendations were generated collaboratively. Findings are presented in two sections: First, the co-development and implementation of the capacity building programme is described, and second, perceived barriers and facilitators related to the programme is presented in step with CFIR constructs, with illustrative quotations from data transcripts. Trustworthiness of the data was enhanced in several ways: Data was triangulated between sources (workshop proceedings, interviews, focus group discussion), and triangulated between two researchers analysing independently and comparing findings with the larger learning collaborative. Member checking occurred throughout, as the PAR design allowed for iterative sharing of findings on a routine basis, while an additional findings workshop added to the shaping of more mature findings. Results Scale-up capacity building intervention The programme was co-developed and ran from 2018 to 2022 (see Fig. 1 ). We started with the implementation of the screening component of the MhINT intervention package at the PHC clinics following collaborative agreement on the strategic direction and content of the programme. Fig. 1. Open in a new tab S-MhINT capacity building quality improvement programme A co-developmental approach was adopted starting with the first component of the MhINT intervention at the PHC facility level and included the following phases: i) Consensus Building During this phase, engagement between the research team and the KZN DoH Directorate for Mental Health and Substance Abuse resulted in agreement on the capacity building approach. This was to deviate from the normal approach of offering a structured implementation science course to participants; and that instead, we would include programme implementers, namely the mental health coordinators from the 11 districts in KwaZulu-Natal in a quality improvement collaborative to capacitate them to scale-up the MhINT evidence-based package in line with the KZN DoH strategic objective of integrated mental health care within PHC. The mental health coordinators’ home language was isiZulu, nine were women and two were men, with ages ranging between 37 and 63. The co-generated vision (“To generate capacity in developing responsive, people-centred district mental health systems, through blended learning, collaboration and support”), key outcomes and outputs in the short, medium and long term of the initiative is depicted in Figure 2 . ii) Curriculum development A participatory process of curriculum development was undertaken. To this end, a three-day workshop was held with all KwaZulu-Natal district mental health coordinators and the provincial mental health directorate participants, guided by principles from Continuous Quality Improvement (CQI)[ 21 ]. Participants were split into groups and paired with members of the research team to undertake process mapping exercises of the mental health service cascade. Process maps to explore system bottlenecks were produced focusing on 1) mental health screening and case identification and 2) case referral and treatment in the service cascade, for the following mental health clusters: severe mental health conditions, common and mild mental health conditions, substance use, and child and adolescent mental health. Based on the bottlenecks identified in the process maps, different bottlenecks for inclusion into a programme were brainstormed and ranked for importance. This informed the mutually agreed upon curriculum content and structure for addressing the bottlenecks identified, and included the following: a) Co-development of a situational analysis toolkit that would provide a data-driven foundation required for CQI; b) Training in MhINT tools to be cascaded to the PHC service providers in the district; c) Capacity building in CQI including process mapping, problem identification (fishbone method, a root-cause analysis), generating potential solutions, and iteratively testing these (plan-do-study-act cycle). iii) Situational analysis A district situational analysis toolkit was co-developed, paired with technical support, with participants to undertake a situational analysis of mental health screening in PHC settings in their districts, focusing on where and which personnel were best placed at facilities to conduct the screening. A spreadsheet-based situational analysis tool was developed based on the Consolidated Framework for advancing Implementation Research [ 34 ]. Following repeated input from the quality improvement collaborative participants, the tool as well as an accompanying data dictionary for included data elements were finalised. The tool allowed for the comprehensive recording of data from the 2019-2020 and 2020-2021 financial years, that included the following: Routine health data, Socio-demographic and economic data Priority mental health indicators Mental health programme staffing according to levels of care Data reporting structures Existing district mental health plan information and Non-government resources such as private, for-profit facilities and organisations. iv) Training Mental health coordinators were trained as trainers during three face-to-face and two virtual workshops, to cascade the training of the MhINT interventions to PHC clinic service providers. v) Continuous Quality Improvement (CQI) Mental health coordinators were capacitated in CQI methodologies to use the mental health indicators to identify bottlenecks hindering implementation in the clinics and to iteratively and collectively identify and implement solutions. Fig. 2. Open in a new tab Co-developed vision and goals It was agreed to start with the screening component of the cascade at a PHC clinic level, so as to capacitate district mental health coordinators to cascade the use of the BMH in the PHC clinics. This would set a blueprint for future uptake of indicators for the rest of the care cascade, i.e. referral, treatment, and mental health outcomes (Table 1 ) (Fig. 3 ). Table 1. Application of the curriculum to the implementation and scaling up of the BMH screening in the province Application of the curriculum to the implementation of the embedding and scaling up of the BMH screening tool in the province Situational Analysis: Mental health coordinators collected PHC data on mental health screening as routine data as well as identify providers within PHC facilities who could implement the screening Training: Mental health coordinators were trained through an online training programme (during COVID 19) in the use of the BMH and how to cascade this training down. (We may want more detail here) as well as links to this online training Application of CQI to implementation of the BMH tool in district PHC clinics: A workshop was held to identify and generate solutions to bottle-necks in implementation of the BMH. Using situational analysis data, mental health coordinators identified inconsistencies between high treatment numbers and low numbers screened across facilities in their districts. Participants were divided into four groups and were guided to develop fishbone diagrammes, which were then consolidated (Figure 3). Accordingly, several issues with the screening process were identified, including issues related to the use of the tool; the available staff and training required to administer the tool; the physical and organisational environment within which screening was administered; issues related to data capture and health information systems; client-related challenges such as stigma; and screening procedural challenges. Further discussions led to the generation of key priority areas to be addressed: issues related to the BMH Tool, especially the training needed to administer it as intended; a lack of consensus on where mental health screening should be done in the physical lay-out of PHC clinic buildings; and lack of clarity on definitions of mental health indicators (Supp 1) Open in a new tab Fig. 3. Open in a new tab Mental health screening fishbone (consolidated from all districts) Following the consolidation of causal factors and prioritisation in the screening process, groups were guided to generate potential ideas that could be used to address the factors raised, following the same thematic clusters. Accordingly, several strategies were suggested that could be launched to improve the priority areas highlighted before. These included suggestions such as integrating the BMH tool into existing documents, continuous training and supervision, health education, staff training on mental health indicators and verification, and better routine recording of mental health referrals and medication (Fig. 4 ). Fig. 4. Open in a new tab Group change ideas Towards the end of the CQI orientation process, participants were asked to return to their districts and, using the tools that have been workshopped, generate improvements in mental health screening in their districts. They were asked to form a small task team that includes people from PHC services as well as from monitoring and evaluation programmes, with whom the CQI process could be driven. The inclusion of partners from key areas both meant to elevate the quality and robustness of improvement processes, as well as to ensure minimal bureaucratic barriers when instituting change. This was necessary in large part due to the reporting structure of the DoH, whereby district managers in the Mental Health and Substance Abuse Directorate do not have authority over services (they have been designated a purely technical support function), and therefore an authority over PHC service changes becomes quite essential to any improvement undertaking. Ultimately, the Mental Health Directorate engaged in a process of adopting the validated MhINT BMH [ 35 ] into policy, and refining the Standard Operating Procedure for it use based on learning generated from the aforementioned CQI process (Fig. 1 ). Post-funding continuation During this try-out stage, the S-MhINT project funding cycle ended, meaning that further collaboration within the quality improvement collaborative had to continue without dedicated funding. Feedback sessions were held on virtual platforms, and when participants came together for quarterly departmental meetings, time was scheduled to engage with district improvement processes. This ultimately led to formal changes to the provincial standard operating procedure for PHC mental health screening, and as well changes to mental health indicators in the provincial District Health Information System dataset, both changes formally adopted by the KwaZulu-Natal DoH in 2023. An important final decision in the S-MhINT capacity building programme was that the quality improvement collaborative would be continued beyond the funding period, to become a permanent partnership of mutual learning and support. Presently, the same structure is being used to inform the development of a community-based psychosocial support system for people living with severe mental illness, again funded by the National Institute for Mental Health. In this way, the quality improvement collaborative is used as a rapid implementation and scale-up vehicle, while promoting continuity and strategic cohesion across districts. A current goal is to use various lessons learnt in strengthening mental healthcare in KwaZulu-Natal to develop provincial policy guidelines, which would allow for districts to lobby for the inclusion in district policy and budgets. Perceived barriers and facilitators of the capacity building programme for scale-up Themes were organised according to CFIR constructs, which is summarised in Table 2 , and discussed below with supporting quotations and examples from the data. Table 2. Themes and subthemes guided by CFIR [ 32 ] Themes and subthemes Definition Innovation The programme being implemented, in this case the co-developed capacity-building programme. Outer settings The settings outside of the immediate settings where the programme is being implemented, for instance districts, communities, local health systems. Policies and Laws Government legislation, policy guidelines and regulations that influence implementation and/or delivery of the innovation. Partnerships & Connections Referral networks, academic affiliations, collaboration and professional organisation networks. Local Attitudes and Conditions Sociocultural values (e.g., shared responsibility in helping recipients) and beliefs (e.g., convictions about the worthiness of recipients), as well as economic, environmental, political, and/or technological conditions that influence implementation. Inner settings The setting in which the innovation is implemented. Relative Priority, Incentive Systems, and Information Technology Infrastructure Perceptions that implementing and delivering the innovation is important compared to other initiatives; Tangible and/or intangible incentives and rewards and/or disincentives that support implementation; Technological systems for tele-communication, electronic documentation, and data storage, management, reporting, and analysis that support implementation. Cultural aspects of mental health engagement Shared values, beliefs, and norms, including about the inherent equal worth and value of all human beings; caring, supporting, and addressing the needs and welfare of recipients and deliverers; and the psychological safety, continual improvement, and using data to inform practice. Work Infrastructure The organisation of tasks and responsibilities within and between individuals and teams, as well as staffing levels. Physical infrastructure The layout and configuration of space and other tangible material features. Individuals The roles and characteristics of relevant individuals involved. Innovation deliverers Individuals who are directly or indirectly delivering the innovation. Mid-level Leaders Individuals with a moderate level of authority, including leaders supervised by a high-level leader and who supervise others. Implementation process Activities and strategies used to implement the innovation. Open in a new tab Innovation Participants reflected on the capacity building process in terms of its approach and content, and were particularly positive about the iterative cycles of learning and practical implementation. The concepts of CQI were conceptually challenging to some (e.g. “ Because it was very difficult to grasp , when you are doing it. There are still some concepts that I still do not understand ” FGDP2). The disruption of COVID meant that not much practical implementation could occur due to re-directed priorities, and the lack of application was felt: “ And then there was this huge gap where we went through a lot of steps but without practical using. Yeah. Now I got lost. ” (FGDP1). Some elements of the programme were favoured, especially problem identification tools such as fishbone diagramming. The situational analysis was seemingly quite helpful, as it helped identify critical gaps in the screening sequence in PHC clinics: “… it also taught us to identify all relevant stakeholders. Because we realized that screening was not only done at one area. There were other potential people who needed to do screening , like , your HIV counsellors. Because they were also providing some adherence counselling to clients , which I felt not what they needed to be undertaking on. Because how can you provide counselling for someone that you don’t know? ” (FGDP2). Finally, the potential of scaling up the programme to other contexts, particularly other provinces in South Africa, was explored and there was a general consensus that the flexibility of the approach would be able to effectively address changing health system dynamics and complexities involved in integrating mental health into a PHC space. Outer settings Policies and laws A key challenge that emerged during interviews was the lack of formal policies to help guide the changes that are being undertaken, as well as to provide strategic clarity. Specifically, a lack of operational guidance in implementing screening for symptoms of mental health conditions on PHC level was telling. This was exemplified by the following quotation: “ Currently we’re trying to implement all these changes without guidelines. It’s very difficult .” (IP1). Partnerships and connections Collaboration with other sectors is limited. Although there are many overlaps between the work of the DoH and the Department of Social Development, the collaborative work only covers issues related to substance abuse. Further, there seemed to be a lack of clarity in reporting lines within disciplines, underlining disciplinary fracturing: “ We don’t know who the social workers report to even as province cause they’re not nurses , they’re social workers. But there’s no one that is employed as a senior social worker to supervise or to oversee the functioning of these alliance services. Which becomes a challenge. Cause as a coordinator we expected to know exactly what is happening with these other allied services. They support the component of mental health but it becomes a challenge in terms of the expertise which you , we are not an expecting that field. ” (IP5). Collaborative relationships with other sectors were in place to form a local drug action committee, to help combat substance abuse. In another example, relationships with people working in the Department of Social Development and the Department of Home Affairs were leveraged to assist a client who lost his identification document and required fingerprints, after not being successful in following the normal bureaucratic routes. Some districts have active NGOs that help alleviate the pressure on PHC and hospital services, and coordinators often play a brokerage role in facilitating access to services for those who need it. The coordinators were often left to solve problems through relationships with senior clinicians in the province, and one participant reported that collaboration in a key requirement for this work: “ It’s just that sometimes if you are trying it on your own , it’s really a bit tricky. So , you just needed someone that you can try call to assist when you get stuck ” (IP1). Local attitudes and conditions Many participants provided indications that mental health has not been integrated into the PHC ward-based outreach services system, where a crucial disparity in health literacy exists among communities. The lack of mental health literacy was seen to delay help-seeking behaviour, due to cultural practices and beliefs taking precedence whenever mental health symptoms emerge. Pre-COVID mental health education was not perceived to be adequate, though an unintended consequence of COVID-19 was a rise in community awareness of mental health: “ And with the education we went , it wasn’t enough. It wasn’t enough for community dialogues , it wasn’t enough because we were fighting against mental illness and cultural beliefs , those things that they were saying because it’s deep , deep , deep rural. But with Covid , Covid it helped for other people to recognise there’s this thing called mental illness. ” (IP6). KwaZulu-Natal is a large province, with a wide geographical spectrum. Participants working in more rural areas mentioned difficulties reaching these spaces, in terms of traveling distances as well as mobile phone coverage, rendering communication challenging. The burden of mental health conditions in the province was perceived to be large. Without the availability of prevalence data, these views were largely based on experience, and treatment fatigue among people with HIV and other chronic illnesses were perceived to contribute to a growing burden of depressive symptoms. Similarly, substance abuse (including alcohol, methamphetamine, and cannabis) was seen as a key driver of mental illness in the province. Mental health stigma also continues to be problematic, in part due to the misconceptions around mental illness, and an erroneous focus on more extreme variants such as psychosis: “ Once you are mentally ill , the only thing that they think of , we are going , we we’re aggressive , we’re going to assault somebody. So even in the community stigma still when it comes to mental health , even the names that are used for people that are mentally ill , you won’t get a diabetic patient being called diabetic. But for us , a patient that is having schizophrenia , they’re not called with , they’re having schizophrenia. They’ll say this is a schizophrenia. Now that your diagnosis become so now the stigma manager is a big issue in terms of mental health. ” (IP6). Given the centrality of cultural beliefs and practices, participants were keen to integrate services with traditional health practitioners, and also reported that these practitioners are willing to integrate with mental health services on the PHC level. While political will was often seen as lacking, participants did reflect on the change that can occur with the right leadership, and referred to a stronger emphasis on mental health being driven by a mayor from one of the districts. Inner settings Relative priority, incentive systems, and information technology infrastructure A theme that emerged strongly during analysis was the perceived lack of priority and accountability for mental health on senior district management level. This was illustrated by a lack of funding as well as by a lack of monitoring in health information systems. However, the lack of priority was not only emergent at the higher organisational levels, but also in meetings. For instance, it was noted that mental health is typically the last agenda item and given a comparatively brief discussion time. This lack of prioritisation was also illustrated in recording mental health data on routine data registers for all conditions, with little space provided on the last page. Further, poor monitoring of the few mental health service indicators within PHC facilities is fostered by a lack of accountability at facility, district and provincial levels, unlike “priority” programmes such as HIV, tuberculosis and antenatal care – with little attention to performance on the indicators. The low priority afforded to mental health is reflected in the lack of financial investment in mental health services and mental health literacy campaigns. Central to these perceptions were the lack of political will, and mental health only receiving lip service from upper levels of management: “ Everyone is singing mental health is important and we need to do something about mental health. But actually , there’s nothing being done ” (IP1). “ No buy-in from influential people. You know , with HIV , even the municipality , even the mayor , everyone. So , if something goes wrong , or if there’s a complaint from the community , even they may complain , everyone but mental health don’t have buy-in from influential people. We know how it works in South Africa , we need influential people to be on board for service to improve. ” (FGDP2). Competing priorities were also highlighted between tools and approaches promoted by national government, versus provincial instruments. Cultural aspects of mental health engagement Apart from lack of training or interest in providing mental health services, some staff also actively resist getting involved in mental healthcare, presumably due to fear (arising out of stigma and misunderstanding) and a lack of knowledge: “ And there is so much resistance… Everyone’s running away from anything that touches or talks about mental health. ” (FGDP1). “ They say…just saying …those people , they’re scared of them. And they don’t have enough knowledge and they’re not confident to work with them. ” (FGDP5). Work infrastructure Several mentions were made of the lack of programme integration. Not only were participants pressed to continually lobby for the inclusion of mental health into programmes such as HIV, but some also perceived a disjuncture in the understanding of integration between frontline and upper management levels, the latter not fully comprehending the complexity of the approach. A lack of clarity also emerged in terms of changes in mental health indicators without registers that support these changes, causing discrepancies in terms of tools administered and data being collected. In response, a provincial data element was introduced as a positive status indicator (presumptive mental health condition) in the absence of a mental health positive indicator in PHC registers. Finally, the burden on health professionals was highlighted, and staff were perceived to be overburdened by a range of complex health needs and the sheer numbers of people that flow through a PHC clinic per day. The emotional toll of working under such conditions were illustrated by the following quotation: “ They’re overwhelmed with work. They said you have to fill your cup up before you can fix somebody’s cup. So , I think that is where the problem starts with. If I’m overwhelmed with the emotions and I have not dealt with my emotions , how am I going to deal with somebody’s emotions? ” (FGDP2). Physical infrastructure “… most of the time we talk integration at the lower level and it doesn’t translate to upper level. ” (IP2). In terms of physical resource constraints, a lack of dedicated funding resulted in limited printing and distribution capabilities, while the physical infrastructure of many PHC clinics did not allow for privacy when administering mental health screening. Individuals Innovation deliverers An almost unanimous view was that much of PHC staff have not been trained in mental health, nor show much interest in providing mental health services. “Generalist” nurses were mentioned to not have received enough basic training in mental health, which makes integration difficult. The capacity of PHC staff to deliver mental health services was also perceived to be curtailed by a lack of opportunity for further training: “ There is no development for the staff…because they cannot further their studies. Either some of them are just ENAs [enrolled nursing assistants], and then they are not going to be professional nurses , because they are not given a chance for some time. And those who are already there , as professional nurses , they cannot advance because there is no chance for them to get the specialty. ” (FGDP1). Mid-level leaders An important function of mental health coordinators is lobbying, and finding ways to drive mental health onto official agendas, and its inclusion in other programmes: “… you have to participate in other programmes also so that you ensure your programme is also implemented in other streams. ” (IP3). Implementation process A useful dimension to the programme in terms of COVID-19 was its flexibility. Once a quality improvement collaborative was established, working could continue in some way or the other, and the platform was used to develop and implement self-help and containing leadership videos to support the mental health of HCWs. The set of videos was an unintended consequence of the programme, but was perceived by participants to be useful amidst crisis conditions. A common theme that emerged related to COVID-19 disruptions, in that face-to-face workshop and learning sessions had to be changed to online platforms. This was challenging in many ways, including limited computer literacy, a lack of access to computers and data, electricity outages, and, most importantly, unstable digital connectivity across a large province that is mostly rural. Some of these challenges are illustrated in the quotations below: “ For me , visual is a problem because of the network. I know you haven’t been to [location] district office. If you can see where we are , we are underground. So , whenever there is load shedding , we have to walk out of the building. So , there’s no network. Even that terminal… I was trying to connect…I couldn’t. I had to go out and stand. When you’re outside , there’s cars moving around. So , it becomes a fruitless expenditure. So , face to face is much better than the video. ” (FGDP6). “ I feel sitting around the table helps because I feel that that’s where everyone is more likely to open up as compared to virtual. Because virtual one we have a network issue. So , others do get cut out. Either they just sitting there hoping that this meeting will end soon. But then when it’s a table method , you can ask one by one what is your problem? Where you work , what is your problem , where you are , and how do we work around it? ” (IP2). In terms of recommendations, it was felt that mentorship was lacking during the application of the CQI tools, as well as post-project, in general. Importantly, mentorship was requested both for the participants themselves, and for PHC clinics in driving mental health screening in step with the training. “ Yes. It’s just that sometimes if you are trying it on your own , it’s really a bit tricky. So , you just needed someone that you can try call to assist when you get stuck. Now when I got stuck then I had a problem. ” (IP1). “ Mentoring as I’m saying , it has to be done by a person that is within the facility. If we can have champions though , it’s not easy because all these programmes have champions , so people are pulled in many directions. So , if you can have champions solely for mental health , who is going to take the hands. ” (IP4). The latter quotation above further speaks to an on-going tension between championing mental health and integrating it within a general package of PHC services. In terms of the packaging of the programme, some recommended that it could have been implemented in a more inclusive fashion and include district coordinators from other programmes as well towards creating a more coherent and sustained understanding of quality improvement. It was also suggested that the learning curve was steep within the time period of the programme, and that basics in research and implementation science, in short course format, would have better prepared participants: “ I felt it was going to be better if we started by a short course. On implementing science. We understand it first. Even introduction to implementation science that maybe could have run for maybe , six weeks? We write a short test. Then , we then do it practically .” (FGDP2). Discussion The improvement of detection rates for common mental health conditions is a complex task, with mixed results in African settings [ 36 – 39 ]. The complexity of integrating screening processes on PHC level underlines the importance of continuous engagement and mentorship in tandem with the introduction of an evidence-based intervention. This paper reports on the approach, content and implementation of the S-MhINT capacity building programme in its South African site. Our experience illustrates a pragmatic, action-driven approach to capacity building, as a solely theoretical programme focusing on the enhancement of individual capabilities without real-world application is very often not sufficient [ 40 ]. Further, programme co-design is an essential element in health system reform, particularly in the context of learning health systems [ 19 , 41 , 42 ]. In this vein, we established a quality improvement collaborative towards setting in place structures for district-level continuous learning and improvement in the integration of care for common mental disorders in PHC in uMgungundlovu, KwaZulu-Natal, South Africa. The co-designed curriculum, which entailed the undertaking of a situational analysis, followed by problem identification and continuous quality improvement using iterative group-based solution testing and learning, took a similar shape to human-centred design [ 43 ]. This approach allowed for cyclical processes where the “ what” (integrate mental health into PHC) was expanded to “ how” (how can integration goals be sustainably achieved with minimal resources), by supporting participants in identifying key system bottlenecks and workshop and test potential solutions, before being formalised in policy. The pressing need for contextual solutions to health system challenges, especially the understanding of communities and interventions [ 44 ], remains a critical piece of scaling-up methodology. A systematic review suggested that programmes designed for the improvement of screening for common mental health conditions have been noted to be more effective and long-lasting when training engagements are more participatory and active. The review also highlighted that screening effectiveness can be enhanced through local adaptation of collaborative care packages, supported by quality improvement processes [ 45 ]. Our experience supports the application of these lessons as part of a capacity programme supporting the scale-up of the BMH screening tool and processes in KwaZulu-Natal. As reflected in participants’ views in terms of the Innovation theme, the iterative cycles of learning and practical implementation was particularly well received. This kind of dynamic co-learning within a collaborative has– despite its paucity in capacity building programmes among district managers in sub-Sahara Africa [ 46 ] – been noted to generate new insights and practices in health systems [ 47 ]. Further, the application of CQI as a central capacity-building focus has shown great potential in African settings, particularly in the area of HIV programmatic research and taking interventions to scale [ 48 – 50 ]. We believe that our approach of sustained participation and continuous learning and improvement in supporting the scaling of an evidence-based screening process for common mental health conditions is novel. Key lessons from the Ethiopian experience in scaling up services for common mental health conditions in PHC settings underscore the importance of persistently and consistently nurturing relationships with government healthcare leadership (as opposed to more limited and once-off buy-in efforts) [ 51 ]. Our co-development experience in S-MhINT provides guidance for future scale-up efforts of mental health innovations in LMICs, and particularly highlights the importance of strong and sustained partnership between research and implementation spheres [ 52 ]. Ultimately, co-production is “best seen as generative processes that are less about delivering predictable impacts and outputs and more about developing new communities, interactions, practices, and different modes of knowledge and value production” [ 47 ]. Our experience in scaling-up screening for common mental health conditions in PHC settings builds on a very limited base of evidence from LMICs. The Friendship Bench initiative, a task-sharing mental health intervention that draws from problem-solving therapy to address common mental health conditions, provides limited comparability. From its inception in 2006, the programme has been scaled to more than 100 urban settings in Zimbabwe [ 53 – 55 ]. Similar to our experience, research from the Friendship Bench stressed the necessity for coordinated efforts among health authorities and communities to establish referral systems and capacity. As noted in our findings, the use of process mapping was instrumental in collectively analysing service user pathways within the screening intervention, and aiding in amending who should be empowered to apply the screening (enrolled nurses). In addition, researchers highlighted the importance of policy stakeholder buy-in as an important element in scale-up feasibility [ 53 ]. Our approach was guided by the South African health system structure, where the vast majority of healthcare is provided in government facilities, within a hierarchy of district health services. Our PAR approach and intentional inclusion of policymakers on provincial and district levels allowed for local ownership and programmatic flexibility throughout the scale-up process. The focus on district coordination capacity building further helped to develop government-led mental health prioritisation, an important element in achieving impactful and sustained integrated mental healthcare [ 16 , 56 ]. It foregrounds co-producing processes in quality improvement to ensures relevance, acceptance and sustainability, but also requires peer support and strong leadership [ 57 ]. Systems change through such processes is further dependent on external support, alignment with and embeddedness in existing systems, and, crucially, capacity for quality improvement [ 19 ]. The feedback described under the Inner Settings theme noted the lack of incentives and priorities for mental health persisting in PHC settings, underlying the importance of capacitating district coordinators to promote integrated mental health as a programme. Importantly, the common denominator for all co-production processes lies in the quality of relationships, and shared values and policy agendas [ 47 , 58 ]. This approach was particularly helpful in responding to two challenges reported in the Friendship Bench scale-up process, namely (1) difficulties in integrating research programme data within routine health data systems, and (2) enabling the integration of mental health into PHC systems in a way that is resilient to resource constraints and priority changes [ 59 ]. As reported under the Work Infrastructure sub-theme, the collaborative learning process aided in the introduction of a provincial data element as a positive status indicator (presumptive mental health condition) in PHC clinic registers. This speaks to an increasing need for co-produced, bottom-up policy, embedded in a governance perspective that emphasises implementation networks [ 60 ] which, in turn, also allows for the necessary flexibility to appropriately respond to external shocks such as COVID-19, as described in the Implementation theme. Regarding the content and implementation strategy of the capacity building programme, there was a strong sense that face-to-face workshopping was superior in acceptability over virtual platforms. While the latter is more convenient and cost-effective, especially in large geographies, the communication dynamics of problem-solving workshops might be better suited for face-to-face meetings [ 61 ]. The co-production of the programme content fills a particular gap in capacity building initiatives, namely the lack of programmatic content that collectively emerge in co-productive spaces (as opposed to the much more widely used prescribed content delivered in group settings) [ 46 ]. As described under the Implementation Process theme, while participants were satisfied in general with the co-produced content, there were suggestions that such a programme should include an introduction to basic research and implementation science in order to place the skills-building into a broader context. This, however, is significantly dependent on longer timeframes, something that a grant-funded research projects usually do not allow for. Short-term funding cycles simply do not allow for deep engagement and sustainable implementation [ 28 ]. It also affected the possibility of post-funding mentoring, an element crucial in capacity-building efforts [ 46 ]. As mentioned in the Innovation theme, some participants found aspects of the CQI toolkit challenging, and requested additional, on-going mentorship and support. This kind of support is a crucial consideration in the success of CQI implementation in health service management [ 62 , 63 ], and should ideally be embedded in the structures of the DoH in order to be responsive and sustainable. Some key limitations should be noted. The large geography of KwaZulu-Natal, along with busy schedules of mental health coordinators, resulted in difficulties in setting up face-to-face meetings for individual semi-structured interviews. Subsequently, a mix of face-to-face and telephonic interview methods were employed. The same factors made it challenging to set up a centralised meeting where all coordinators could be present for a focus group discussion, meaning that three coordinators did not participate. In terms of funding, as mentioned, the capacity-building dimension of S-MhINT was linked to a scale-up research programme, with a fixed funding time period. This meant that the intensity of mentorship and support was curtailed post-funding – on-going support was highlighted by many participants as a need. COVID-19 necessitated a move to a virtual workshop platform, which was not an ideal change given the difficulties it presented in terms of communication, despite effort to ease the impact of the transition through an allocation of laptop computers and data modems. Finally, a key learning was that successful integration requires the need for broader inclusion, a strategic involvement of people and structures in the DoH who have influence over parts of the district health system beyond technical programming. Conclusions Our experiences in supporting the scaling of an evidence-based screening tool and process for common mental health conditions through a participatory process of district-level capacity building adds valuable insights to global efforts to strengthen mental health in PHC. A co-production approach can help navigate common pitfalls in capacitating district health managers in sub-Sahara African contexts. The importance of sustainability beyond funding horizons renders integration into existing organisational processes all the more important, and the approach that we have described in this paper is firmly grounded in using minimal resources and working as far as possible within the scope of existing roles and responsibilities. Ultimately, a key strength in our experience was a meaningful relationship between university and government partners, established over several years of collaborative work This allowed a degree of flexibility and mutual trust, which in turn facilitated a more rapid response and adaptation to emerging system pressures and shocks. The CQI process embedded in the capacity building programme allowed for bottom-up strategic guidance, leading to important adaptations to the screening process. These lessons affirm the centrality of co-production and full participation throughout efforts to scale evidence-based interventions, particularly in low-resource contexts. Supplementary Information Supplementary Material 1. (15.5KB, docx) Acknowledgements Ther authors would like to thank the 11 district mental health coordinators for their participation and support throughout the S-MhINT initiative. We would also like to extend our gratitude towards the KwaZulu-Natal DoH for supporting these efforts. Abbreviations BMH Brief Mental Health screening tool CFIR Consolidated Framework for advancing Implementation Research CQI Continuous Quality Improvement DoH Department of Health LMICs Low- and middle-income countries MhINT Mental health INTegration PHC Primary Health Care S-MhINT The Southern African Consortium for Mental Health Integration WHO World Health Organization Authors’ contributions AvR conceptualised and wrote the first drafts of the paper. All authors contributed to the study design, data analysis, interpretation of findings, and approved the final manuscript. Funding This research was supported by the National Institute of Mental Health (NIMH) (U19MH113191-01) which funds the Southern African Mental Health Integration (S-MhINT) U19 hub. Data availability The datasets used and analysed during the current study are available from the corresponding author on reasonable request. Declarations Ethics approval and consent to participate This study involves human participants and was approved by the Biomedical Research Ethics Committee at the University of KwaZulu-Natal (BF190/17) and the Directorate of Health Research and Knowledge Management in KwaZulu-Natal (HRKM253/17 KZ_2017RP15_388) in the KwaZulu-Natal DoH. Participants gave informed consent to participate in the study before taking part. All research involving human data was carried out in compliance with the Declaration of Helsinki. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Footnotes Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. References 1. Moitra M, Owens S, Hailemariam M, Wilson KS, Mensa-Kwao A, Gonese G, Kamamia CK, White B, Young DM, Collins PY. Global mental health: where we are and where we are going. Curr Psychiatry Rep. 2023;25(7):301–11. 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(15.5KB, docx) Data Availability Statement The datasets used and analysed during the current study are available from the corresponding author on reasonable request. 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