Fiscal realities and future directions: insights and innovations from South Africa’s Mental Health Investment Case

Aim Mental health is increasingly recognised as a key component of national development and health equity, yet investment remains insufficient. This paper presents the South African Mental Health Investment Case, which aims to inform policy and financing decisions, particularly within the National Health Insurance framework, by estimating the costs, implementation requirements, and potential returns of scaling-up mental health services. Method The Mental Health Investment Case was developed in two phases. Phase 1 involved a national costing analysis to estimate current spending and identify inefficiencies and gaps. Phase 2 employed a structured Delphi process and stakeholder consultations to prioritise a package of clinical and programmatic interventions, which were then costed using a bottom-up modelling approach. Projected returns on investment were calculated based on productivity gains and avoided illness and mortality. Results Modelling indicates that scaling up cost-effective interventions, particularly for common mental disorders, can significantly increase coverage, yield high returns, and reduce treatment costs over time. Stakeholders highlighted implementation barriers, including fragmented governance, lack of dedicated financing, and weak intersectoral collaboration. Recommendations include dedicated provincial mental health directorates, formalised multi-sectoral co-ordination platforms, strengthened monitoring and evaluation systems, and a phased implementation plan aligned with fiscal realities. Conclusion The Mental Health Investment Case provides an evidence-informed roadmap for strengthening mental health systems in South Africa. It expands the investment case by incorporating efficiency, equity and rights-based arguments. The findings support the development of tailored implementation guidelines, prioritised benefit entitlements under NHI, and dedicated budgeting mechanisms such as conditional grants. Sustained advocacy, inter-departmental collaboration, and robust data systems will be essential to ensure delivery of equitable and effective mental health care.