Summary of participant descriptive information.

South Africa’s public health care sector has changed dramatically, with a shift away from focusing curative health care primarily at tertiary health facilities towards the expansion of services into primary and secondary care health levels. This integration process has presented with a multitude of serious contextual and systematic difficulties. Limited studies have explored the integration of mental health services in poorer parts of the country where resources are scarce. We studied access to, and provision of mental health care in a predominantly rural area of the Eastern Cape to determine how primary and secondary care facilities that employ primarily generalist practitioners deal with psychiatrically ill patients and those facing life challenges with mental health implications. Data were collected through a descriptive data sheet and once-off semi-structured interviews. Narratives were imported into Atlas.ti 22 and analyzed through Thematic Analysis. Our results suggest that health care workers at primary and secondary health settings experience a high workload with diversity in patient population, and challenges at facility level, utilizing various means to deal with patients. Lastly, our participants suggested helpful strategies and proposed changes for more effective treatment. The integration of mental health services at primary health care and secondary hospital level introduces challenges to access and provision capacities. Despite facing intense challenges, at times our participants have found ways to adapt and work around the challenges. The decentralization and integration of mental health care into lower care sectors demonstrates a situation of great stress and, often, neglect. The mismatch between what is theoretically available and what is actually provided is worrying, and all mental health advocates and specialists should be engaged in advocacy about this. Ideologies of inclusion ring hollow when inclusion does not in fact occur.