Down-referral of mental healthcare users (MHCUs) from specialised psychiatric hospitals to primary healthcare (PHC) facilities is a part of effective healthcare delivery. A functioning referral system allows for continuity of care across different tiers of health services and is central to achieving universal health coverage.^1,2 For referral systems to operate optimally, all levels of the healthcare delivery framework must function effectively. The World Health Organization (WHO) has long advocated for the integration of mental healthcare into primary care, a stance first articulated in its 1975 Expert Committee report on the Organising of Mental Health Care Services in Developing Countries.³ Subsequent WHO collaborative studies, including the Psychological Problems in General Health Care project, demonstrated that both common mental disorders, such as depression, anxiety and somatoform disorders and more serious psychological conditions, such as schizophrenia, bipolar disorder and severe forms of major depressive disorder associated with psychotic features can be effectively identified and managed within PHC settings across diverse cultural and resource contexts.^4,5 These findings highlighted that mental disorders, ranging from mild to severe forms associated with marked functional disability, frequently present in primary care and can be treated effectively when appropriate systems and training are in place. This evidence further reinforced global recommendations to integrate mental health into PHC as a means to improve accessibility, continuity and comprehensiveness of care.⁶

According to the Referral Policy for South African Health Services,¹ patients may be down-referred to their originating health establishment or another facility for further treatment after receiving necessary interventions at a higher level of care.¹ Despite evidence supporting the inclusion of mental healthcare in PHC, this goal remains largely unrealised in many countries.^7,8,9

Hattingh et al.¹⁰ highlighted the challenges faced by MHCUs during down-referral. Participants in that study expressed that the perceived disadvantages of referral to PHC centres often outweighed the perceived advantages. Common concerns included unavailability of medications, lack of specialised care, loss of established relationships with familiar healthcare providers, mistreatment by nursing staff at PHC facilities, longer waiting times and increased stigma.¹⁰ In contrast, Mukora et al.¹¹ identified several advantages to down-referral, including improved accessibility through proximity to clinics and reduced transport costs for patients. Participants in their study also noted that being treated at local clinics saved time, reduced the need to take leave from work and helped alleviate overcrowding at tertiary hospitals by allowing specialist services to focus on more acutely ill patients. Some even perceived down-referral as an altruistic act, enabling others with greater needs to access tertiary-level care. Other studies have similarly shown that down-referral can decrease waiting times, enhance continuity and retention in care and promote more efficient use of limited specialist resources, thereby reducing the overall cost burden on the health system.^6,11

Mental healthcare providers face numerous challenges when down-referring MHCUs. Many patients refuse down-referrals because of perceived fears,¹⁰ leaving tertiary-level providers overwhelmed with MHCUs who could be effectively treated at the primary level.^12,13 Although most patients were discharged to public PHC, a small number were down-referred to private facilities, but participants’ responses were related to the public sector PHC, and no participant mentioned down-referral to the private sector.

In South Africa, human resources limit the attainment of a well-functioning referral system. The limited availability of specialised mental health professionals hampers timely and comprehensive care. This scarcity highlights the need for increased investment and resources in mental healthcare to ensure access and optimal outcomes for down-referral systems.^{14,15,16,17,18,19,20}

Despite healthcare providers facilitating the down-referral of patients, little is known about their experiences and challenges.^13,16,21 Understanding their perspectives is essential for identifying factors influencing referral decisions and the impact of these decisions on treatment outcomes.

Madlala et al. explored the experiences of mental healthcare providers at a public hospital in KwaZulu-Natal and noted that a shortage of mental health professional nurses increased the pressure on already overburdened healthcare workers. Successful integration of mental health into PHC would require more PHC staff to alleviate this burden.¹² The WHO has also indicated that shortages of professional nurses have become a global phenomenon.^3,4,7,22,23

Exploring the experiences and opinions of mental health care providers may offer insights into the broader implications of down-referral on PHC systems. By examining their perspectives, we can better understand the support needed to ensure sustainable solutions for integrating mental health into PHC frameworks.

This study highlights the complexity of down-referral in mental healthcare within a resource-constrained context, such as South Africa. Similar findings have reported the importance of early preparation of MHCUs to facilitate successful down-referrals from tertiary to PHC services.^10,11,12 Structured discharge planning reduces readmission rates and improves long-term outcomes.^28,30,31,32 Accordingly, planning for down-referral should begin early during admission.

Early preparation for down-referral extends beyond clinical management to include psycho-education, family engagement and proactive communication.^33,34,35 Similarly, our participants stated that early planning helps manage patient and family expectations, enhances continuity of care and reduces the sense of abandonment often expressed by MHCUs during transitions.

Despite agreeing on its importance, early discharge planning seems to be inconsistently implemented at WKH. Participants emphasised the importance of initiating down-referral planning early in the admission process, rather than waiting until the outpatient stage. Delays in planning were believed to contribute to patient unpreparedness, resulting in resistance, confusion or emotional distress during discharge. Patients may misinterpret the lack of timely preparation as a form of abandonment or rejection. These observations support existing research underscoring the importance of early discharge planning and structured transitions in mental healthcare.^36,37 Without standardised processes, patients may disengage from follow-up care or develop mistrust in the system. Participants argued that discharge and down-referral should be a part of routine care, with consistent communication and family involvement. These practices align with the principles of coordinated care transitions, which prioritise predictability, continuity and preparation to reduce unnecessary reliance on tertiary services.^38,39

A major barrier to effective down-referral, according to participants, is the ongoing strain on PHC capacity. Overcrowded clinics, long waiting times and insufficient human resources, especially the lack of psychiatrically trained professionals, were identified as significant constraints. These conditions mirror national and global findings on the chronic under-resourcing of mental health services in low- and middle-income countries.^12,15,32 Staffing shortages lead to provider burnout, rushed consultations, incomplete assessments and a lack of continuity of care.⁴⁰ These factors collectively undermine MHCU’s and tertiary providers’ trust in PHC systems.

Participants highlighted gaps in the quality and completeness of referral documentation. They noted that referral letters frequently lacked essential clinical information, such as psychiatric history, treatment trials or early warning signs of relapse. These omissions were seen to compromise follow-up care and, in some cases, result in inappropriate medication substitutions or missed signs of deterioration. To address this, participants recommended improving referral documents and appointing specific coordinators at PHC facilities. Coordinators are professional nurses who are ideally placed to liaise directly with tertiary and primary care clinicians, ensure receipt of referrals and clarify care plans when necessary. They also ensure that state patients who are conditionally discharged follow up at their local clinics and adhere to the conditions of their discharge. Additionally, coordinators can assist in cases where certain state patients abscond.

In our study, participants noted that many patients were resistant to being down-referred. Participants described instances of patients refusing referral, exaggerating symptoms or threatening to discontinue medication in an effort to remain at, or return to, the tertiary facility. These behaviours may be driven by fear of perceived substandard care at the PHC level, past negative experiences or the comfort and familiarity associated with tertiary-level staff. Similar findings have been reported elsewhere, namely that MHCUs are often reluctant to transition to PHC because of perceived quality deficits and fear of relapse.^{10,29,41,42,43} This reflects a lack of trust in receiving facilities. Viewed through the lens of the Health Belief Model, such resistance occurs when perceived barriers outweigh perceived benefits.⁴⁴ Patient resistance will remain a major obstacle to effective down-referral unless trust is built by improving the system.⁴⁴

While less tangible, stigma emerged as a factor influencing patient behaviour. Participants observed that many MHCUs experience stigma from both PHC staff and community members, leading them to avoid follow-up care altogether. Stigma was primarily directed at MHCUs, with participants reporting that patients often felt unwelcome, misunderstood or even feared by PHC staff. In some cases, staff members were described as being afraid of psychiatric patients, particularly state patients, resulting in patients being reluctant to attend local clinics. Structural stigma refers to institutional practices, policies and norms that contribute to the marginalisation of vulnerable groups, including those with mental illness.^{10,11,22,29,45}

Participants emphasised the need for continuous psycho-education throughout the admission and follow-up process to ensure that patients are adequately informed about the purpose and benefits of down-referral, which in turn would reduce reluctance and reinforce acceptance by addressing underlying stigma. In this context, psycho-education can serve as a clinical tool and as a form of empowerment, helping patients to understand their condition, the rationale for down-referral and the resources available at the PHC level.^22,45

To address the various challenges, participants recommended strengthening PHC systems. These include increasing PHC staffing, rotating psychiatrically trained nurses and doctors to local clinics, improving medication supply and enhancing collaboration between tertiary and PHC providers via regular cluster meetings. These suggestions are in line with previous literature advocating for integrated mental healthcare models and greater community-based service provision.^12,22,43,46

Thus, the study’s findings highlight that strengthening PHC systems must occur alongside addressing the relational and procedural barriers embedded in the down-referral process. The grounded theory analysis positions ‘early planning and managing expectations’ as the central process through which providers attempt to overcome a broader ‘resistance block’ arising from interconnected factors such as PHC constraints, stigma, inadequate intersector communication and patient or MHCU attitudes. By conceptualising these dynamics together, the study highlights that successful down-referral depends not only on patient readiness but also on coordinated system-level planning and proactive communication across the continuum of care. Addressing the resistance block through structured early engagement and cross-sector collaboration can strengthen trust, reduce stigma and ultimately enhance the continuity and quality of community-based mental health services.

This study highlights structural and relational challenges in down-referral from tertiary to primary mental healthcare. Although essential for continuity and resource use, the process is weakened by poor planning, limited communication, stigma and under-resourced PHC services.Patients and families are often unprepared, partly because of the absence of standardised protocols. Consequently, improved discharge planning, stronger PHC capacity and better coordination are needed. Designating coordinators and fostering inter-facility collaboration may support smoother transitions. Future efforts should include MHCU and family perspectives to ensure responsive reforms in South Africa’s mental health system.