Strengthening mental health care in Southern Malawi: contested meanings and the search for culturally embedded approaches

Mental health problems represent a significant burden of disability worldwide and there is mounting attention on how best to develop health care responses that are acceptable, effective and deliverable to scale. Alongside resource constraints, concerns have been expressed about the extent to which Western biomedical models of healthcare are transferable to other cultural settings, especially in the Global South. This integrative chapter introduces a body of published work describing a task-shifting initiative in Malawi to test the feasibility and acceptability of health surveillance assistants (HSAs) delivering culturally appropriate mental health interventions across one district. With the overall aim of strengthening HSAs’ care responses, the four papers describe structured evaluations of the pilot and scaled-up interventions, a qualitative study of stakeholder perspectives and experiences and a further historical and socio-cultural analysis of the key findings. The bespoke mental health training initiative, delivered to scale, led HSAs to offer assessment, advice, counselling, practical support and signposting for people in distress and their families. The initiative also demonstrated a vast reach within communities. However, pluralistic and negotiated beliefs concerning mental health and illness, and its place within the sociocultural space and community mores, were evident and revealed the rich indigenous cultural philosophy of umunthu underpinning HSAs’ work. Navigating between biomedical understandings of mental illness and traditional African understandings, the HSAs fashioned supportive interventions attuned to cultural norms under both the gaze and guise of biomedicine. While HSAs responded therapeutically and strengthened support for people in distress, their efforts to do so typify wider tensions over the dominance of particular knowledge systems, such as biomedicine. These findings add to evidence signalling the importance that mental health care initiatives are co-created with respect for communities’ historical and contemporary sociocultural contexts through establishing collaborative partnerships respectful of social justice and culturally negotiated meaning.