Mental health is recognised as a human right both in South Africa and internationally. The right to access mental health care is a human right guaranteed to “everyone” in terms of section 27 of our Constitution. Section 28 provides a more direct right for children — thereby signalling the need to prioritise children and adolescents in protecting children’s right to mental health care, and the need to consider specific measures in this context.

Internationally, mental health is also recognised as a fundamental human right. For instance, both the United Nations Convention on the Rights of the Child and the African Charter on the Rights and Welfare of the Child recognise states’ obligation to provide the highest attainable standard of physical and mental health by enabling access to resources to meet children and adolescents’ physical, psychological and social needs.

Where a child is under the care of a parent or caregiver, the primary responsibility to provide for the child’s mental health lies with the parents. However, where the parent cannot afford appropriate services or is otherwise absent or unable, as is the case with many South Africans, then children and adolescents in these circumstances have a direct entitlement to receive mental health care services from the state. However, despite this legal protection, the reality is that only a small number have access to quality mental health care in South Africa.

Many of us understand mental health as the subjective experience of well-being, contentment and happiness — where one feels safe in the world, is in optimal and meaningful relationships and can self-regulate and cope with everyday stress and life obstacles. However, this view of mental health is incomplete: mental health, like other human experiences, exists on a spectrum.

On the one end of the spectrum, a child, like all persons, can have a thriving experience of mental health where they‘re happy, cared for and experience well-being in an enabling, nurturing and supportive environment. Towards the middle of the spectrum, a child may suffer anxiety and stress in some areas of their lives while remaining functional.

On the extreme opposite end of the spectrum, children and adolescents can struggle with mental health to varying intensity, including struggling with everyday stressors, events and activities. Here a child may develop subclinical indicators for mental distress, including self-soothing behaviours such as alcohol or drug use. Where this remains unattended, it may develop into a mental condition, which in turn can lead to psychological disability.

Therefore, all of us exist on this spectrum, and each of us moves across the spectrum depending on life’s challenges and experiences as well as the extent to which our immediate and external environments support our full potential and realisation. 

At the moment, there is no up-to-date data on the state of mental health in South Africa. Further, children and adolescents are often overlooked in studies on the state of mental health in the country. For instance, children were excluded from the 2009 South African Stress and Health study.

The available data indicates that children and adolescents do not realise the right to access mental health care services. A recent study looking at the Western Cape reveals that less than 10% of children and adolescents who need mental health support, diagnosis and treatment will actually receive any. This is a breathtaking 90% treatment gap. Our experience and monitoring tell us the picture looks even worse in rural areas, which generally continue to be especially marginalised in terms of social services.

Several factors contribute to this treatment gap, including poor mental health literacy and lack of information; stigma and discrimination; lack of human resources and budget allocation; unavailability of child and adolescent services at the already insufficient and inadequate facilities providing mental health services; inconsistent availability of medication; and limited mental health service availability in the criminal justice and correctional system.

Most of the children and adolescents in South Africa reside in townships, informal settlements, rural and peri-urban areas — at the height of unemployment, poverty, and food insecurity. This is often compounded by overpopulation, gender-based violence, substance abuse, inadequate infrastructure and inequitable access to social services.

In addition, of course, these conditions result from broader societal and structural challenges, including coloniality and legacies of apartheid and the appalling corruption and mismanagement of the government post-1994.

These conditions of poverty and marginalisation increase the risk for poor mental health through marginalisation and exclusion, high levels of stress hormones in the body, poor parenting, family disintegration, diminished access to social protections, malnutrition, violence and trauma.

In some parts of South Africa, these circumstances can further make adolescents vulnerable to gangs, substance abuse, criminal activity and other maladaptive behaviours.

The Covid-19 pandemic exacerbated the matter by significantly reducing household income and exposing children to poor mental health drivers such as poor nutrition, dropping out of school, drug and substance abuse and domestic violence. This ultimately leads to a decreased capacity for families to care for children and adolescents’ mental health and other basic needs.

This leads to a social drift with worse educational outcomes, unemployment and poverty. In poverty, their experience is likely characterised by economic deprivation, debt, unemployment, a lack of basic amenities, inadequate housing and overcrowding.

Today South Africa is still the most unequal nation in the world. As such, the poorest of children suffer the highest risk of mental, emotional and behavioural health challenges. Unfortunately, it is also the poorest of children who will fall through the cracks.

In conclusion, an intersectional approach is critical here to allow us to appreciate the different ways in which social characteristics such as class, gender, race and ability give rise to intersecting patterns of exclusion and marginalisation, which in turn shape children’s and adolescents’ mental health.

Bongani Majola

Advocate Bongani Majola is the chairperson of the South African Human Rights Commission and is responsible for its healthcare focus area.

The views expressed are those of the author and do not reflect the official policy or position of the Mail & Guardian.