SA’s healthcare system treats schizophrenia as a crisis, not a recovery journey

When a patient is diagnosed with a lifelong physical illness like diabetes or a visual impairment, the South African healthcare system triggers a formulaic network of care, and society generally responds with sympathy.

A schizophrenia diagnosis forces patients and their families on a radically different path. For most South Africans living with the condition, state intervention is restricted to the acute ward. Once the hospital doors close, the institutional safety net vanishes.

The World Health Organization characterises schizophrenia as a condition that causes psychosis and carries a profound burden of disability. Though less prevalent than other mental health conditions, it affects roughly 24 million people worldwide. Local data remains severely limited, but a benchmark 2006 study estimated that 1% of the South African population is affected.

In the face of this, a staggering 86% of SA’s public mental health expenditure is swallowed by in-patient care, with nearly half of that concentrated in specialised psychiatric hospitals. Yet, despite this significant investment, nearly one in four mental health patients is readmitted within a mere three months of discharge.

Professor Laila Asmal, a psychiatrist and researcher at Stellenbosch University, maintains that this “revolving door” rate is not a clinical mystery; it is a structural failure.

“We are funding a model of crisis containment, not recovery. When hospital doors shut behind a discharged patient, that patient steps into a resource vacuum, and in that large systemic gap South African families are thrust into the role of primary care­givers…”

These families continue to carry a profound clinical and emotional burden on their own, with no immediate lifelines from our healthcare system.

The weight of the unspoken

To understand why being a caregiver by default can be devastatingly isolating, it is important to recognise the silence that precedes it. In the resource vacuum left by the state, South African organisations like Family Support for Schizophrenia (FSS) witness this isolation first-hand.

Professor Maureen Robinson, chairperson of FSS, explains that the painful truth often emerges in support meetings.

“The general stigma clouding mental illness forces families into hiding long before they reach a doctor’s office. Unlike physical conditions that elicit sympathy, schizophrenia is treated like a social penalty. It is still widely viewed as something families are conditioned to feel profound shame about.”

Paralysed by stigma, a family’s withdrawal actively prevents them from seeking timely medical advice and early psychiatric intervention. Robinson notes that early intervention leads to significantly better long-term outcomes.

By forcing families into the shadows, societal stigma delays treatment, worsening the clinical prognosis before a doctor is even consulted. The FSS helps to dismantle this barrier by connecting families to a community that understands their reality and sharing stories of individuals who are leading stable, fulfilling lives.

Yet, the mountain remains steep. Even when a family breaks through the barriers of stigma to seek help, their victory is short lived. The state’s clinical intervention remains brief and confined, and the system eventually hands the patient back to the household, leaving families to navigate the realities of recovery without the structural tools, funding or training required to cope.

Our system treats schizophrenia as a medical crisis to be contained within hospital walls, but Asmal argues that true recovery requires a different paradigm.

“Recovery from schizophrenia is as much a social process as it is a medical one, which involves rebuilding a sense of self and finding a meaningful place in community life again.”

The state’s current response is minimal: a monthly medication appointment, a disability grant and a psychiatric bed only when the situation is dire. To break this mode of “crisis containment”, Asmal advocates a “hybrid” care model that stops imposing ­rigid, Western frameworks and instead starts from the lived realities of South African communities by treating families as genuine partners.

Crucially, this model acknowledges the central role of traditional and spiritual healers.

“In SA, most individuals ­living with schizophrenia may consult a ­traditional or spiritual healer, typically before approaching psychiatric services, and frequently continuing alongside them,” Asmal says.

She says an integrated model would make this dual navigation visible and safe. Research in Africa shows that patients comfortably hold multiple explanatory frameworks – biological, social and spiritual – without contradiction. The goal is to build formal pathways of communication between psychiatric services and traditional practitioners.

This communal approach is already proven locally. The Prize study – a randomised controlled trial with isiXhosa-speaking participants in Nelson Mandela Bay – tested peer-led recovery groups run in local venues, where caregivers and patients participated alongside co-facilitators with relevant experience. The clinical results showed that the relapse rate plummeted to just 2%, compared with 17% in the control group.

By creating an inclusive space that dismantled stigma, the trial provided what patients need to heal: dignity, respect and mutual support. The evidence is clear, but as Asmal points out, these models do not exist at scale: “Until government investment aligns with this data, the heavy burden of this structural gap will continue to fall squarely on unsupported families.”

A call for action

World Schizophrenia Awareness Day, which is held on 24 May, cannot just be about passive awareness. It must be a policy lever to demand structural change.

Robinson maintains that true social integration requires funding hospital day programmes, building safe housing and opening doors to supported employment.

“These steps provide the structure, purpose and economic dignity that is foundational to recovery.”

Implementing these steps requires shifting resources away from the focus on institutional containment and towards expanding community-based infrastructure.

A hybrid care model builds an integrated care framework that formally collaborates with the resources communities use – including peer-led networks and traditional or spiritual healers. Only by acknowledging these parallel systems can we create a care landscape that is both clinically safe and culturally responsive.

Until funding expands to include community care, SA remains haunted by the warning of the Life Esidimeni tragedy, which showed the catastrophic consequences of deinstitutionalising patients without a community-based safety net to catch them.

It is time for the state to step into the resource vacuum and stop asking families to carry a clinical and societal burden that should never have been theirs alone. DM

Dr Florence de Vries is a board member of the Ithemba Foundation, a non-profit organisation that focuses on mental health awareness.

This story first appeared in our weekly DM168 newspaper, available countrywide for R35.