Community Mental Health Service Closure of Physical Clinics and Digital-Only Access: Quasi-Experimental Effects on Severe Mental Illness Engagement in South African Townships

The closure of physical community mental health clinics in South African townships and their replacement with digital-only access has been justified as a cost-effective response to resource constraints, yet the consequences for engagement among people with severe mental illness remain poorly understood. The framework specifies engagement as a function of access modality, illness severity, and the interaction between them, and it identifies the conditions under which digital-only access is expected to widen rather than narrow engagement gaps. To anchor the framework in observable parameters, the paper reports a secondary analysis of the DHS Program indicator 'Discontinuation due to access/availability' across 28 African countries and 74 country-survey observations from 1992 to 2025. The mean value of the indicator was 1.712 (SD = 1.37), with country-level values ranging from 0.25 in Morocco to 4.90 in Lesotho. These descriptive parameters establish the scale of access-related discontinuation in comparable settings and inform the power calculations that any evaluation of clinic closure would require. Digital-only access is not a neutral substitution for physical clinics but a modality shift that redistributes engagement costs onto the most severely ill, and it proposes a set of falsifiable propositions and a research design capable of testing them. The contribution is a specification of the mechanisms through which access modality affects engagement, together with the empirical parameters needed to evaluate closure policies in township contexts.