Mental health support must start where people are

When we talk about mental health in Uganda, we often begin with the health system. We talk about the shortage of mental health professionals, the need for more services, the pressure on facilities and the importance of increasing funding. All of these things matter. But there is another question we need to ask: where do people actually experience their mental health, and where are they most likely to seek help when something is wrong?

For most people, the answer is not a psychiatric hospital. It is home. It is school. It is a health centre. It is a workplace. It is a church or mosque. It is among friends, family and neighbours. It is in the community. For a young person, it may be a classroom, a teacher, a parent, a friend or another adult they trust. If this is where people live their lives and experience distress, then this is also where part of our mental health response needs to exist.

This may sound obvious, but much of the way mental health systems are organised still assumes that the person with a mental health problem will eventually find their way to a specialist service. That assumption does not work well in a country where access to mental health care remains limited. The State of Uganda Population Report 2025 estimates that fewer than one in ten people who need mental health care receive appropriate support. At the same time, Uganda is experiencing a rapidly growing burden of mental health conditions, with reported cases increasing by more than 71% between 2021 and 2024.

We therefore need to think beyond the question of how many mental health professionals Uganda has. That question matters, but it is only part of the problem. We also need to ask what happens before someone reaches a specialist, who notices when something is changing, who provides the first response, where someone can seek help without fear or stigma, and how that person is connected to more specialised care when it is needed. These are questions about the system around mental health, not simply the number of professionals within it.

Think about a young person who starts struggling at school. Perhaps they have become withdrawn, stopped participating in class, started missing school or are no longer performing as they used to. Perhaps there is something happening at home. Perhaps they are being bullied. Perhaps they are dealing with grief, anxiety, depression or pressure about their future. The young person may never describe what is happening as a “mental health problem.” They may simply say that they are tired, that they do not want to go to school, that they cannot concentrate or that they do not feel like talking.

Someone usually notices before the health system does. It might be a teacher. It might be a friend. It might be a parent. It might be a sibling. It might be a community health worker. The question is whether that person knows what to do next. This is why mental health support cannot begin and end with specialist services. We need specialist professionals, but we also need people and institutions around them that can recognise concerns earlier, respond appropriately and connect people to care. Without those connections, the specialist part of the system will continue to receive people late, often when problems have become more severe and more difficult to address.

Uganda's own policy direction has recognised this for some time. The Ministry of Health's Child and Adolescent Mental Health Policy Guidelines were developed to promote mental health and prevent mental, neurological and substance-use disorders among children and adolescents, with the aim of making services accessible to children and young people across Uganda. The guidelines also recognise that responding to child and adolescent mental health requires collaboration across government, communities, schools, families and other stakeholders.

The challenge, therefore, is not that Uganda has never recognised the need for a broader response. The challenge is how we turn that recognition into systems that work in everyday life.

This is particularly important for schools. Uganda has an enormous opportunity to strengthen mental health support through the education system because schools already bring millions of young people together every day. A school does not need to become a mental health clinic to play an important role. It needs to be a place where mental health is understood, where teachers and other staff know how to recognise concerns, where students can safely ask for help, where safeguarding is taken seriously and where there are clear pathways to appropriate support.

Teachers are often in a unique position because they see young people regularly. They may notice changes that others do not. But noticing is not enough. A teacher who recognises that a student is struggling needs to know how to respond without causing harm, when to involve a parent or another responsible adult, when a concern requires urgent action and where the student can be referred for further support. Without this wider system, training a teacher can easily become another isolated activity rather than part of a functioning response.

The same principle applies to primary healthcare. A person should not have to travel to a specialist facility simply to have their mental health concern recognised for the first time. Primary healthcare workers are often the first point of contact with the health system, and strengthening their ability to identify and respond to common mental health needs can bring support closer to people. But integration also needs functioning referral pathways and specialist services behind it. Integration should not mean asking primary healthcare workers to carry responsibilities without the training, supervision, medicines, referral options and specialist support they need.

This is an important distinction. Bringing mental health closer to people does not mean replacing specialist care. It means connecting different levels of care so that people receive the right support at the right time. A community health worker should not be expected to manage a severe mental health condition. A teacher should not be expected to provide therapy. A parent should not be expected to navigate the health system alone. Each has a role, but those roles need to connect.

The Ministry of Health is now explicitly talking about moving mental health services into primary healthcare and community-based systems, expanding the mental health workforce and increasing funding. The National Planning Authority has also called for a shift from a specialist, facility-centred model toward a more integrated, community-based and system-wide approach.

That is the direction Uganda needs. But moving services closer to people requires more than changing where a service is delivered. It requires us to think about the entire journey a person takes when they need support. Who notices? Who listens? Who responds? Who assesses risk? Who provides basic support? Who refers? Who receives the referral? Who follows up? And who takes responsibility for making sure the person does not disappear between one part of the system and another?

Too often, we treat referral as the end of our responsibility.

We tell someone where to go and assume the problem has been transferred to someone else. But a referral is only useful if the person can reach the service, the service is available, the person is accepted and appropriate care is provided. For young people, there may be additional barriers involving parents, transport, cost, stigma, consent, confidentiality and simply not knowing what to expect. A functioning mental health system therefore needs more than referral directories. It needs relationships and mechanisms that allow people to move through the system.

This is why I believe Uganda needs to move from thinking about mental health programmes to thinking about mental health systems.

• A programme can train teachers for three days. A system ensures that those teachers know what to do afterwards.

• A programme can hold a mental health awareness event. A system ensures that the young person who asks for help afterwards knows where to go.

• A programme can create a referral form. A system makes sure that the referral leads somewhere.

• A programme can establish a counselling service. A system connects that service to schools, families, communities and professional care.

The difference may sound small, but it is fundamental. We have to stop measuring success only by whether an activity happened and start asking whether the system around the person actually worked.

There is also a human reason for bringing mental health support closer to people. Seeking help is difficult enough without making people travel through unfamiliar systems, explain their situation repeatedly or fear being judged at every step. For a young person who is already struggling, the distance between “I am not okay” and “I know where I can get help” can be enormous. The closer we can make that journey, the greater the chance that someone will seek support before a crisis develops.

This is where schools, communities and primary healthcare can play an important role. They are not alternatives to specialist mental health services. They are bridges to them.

At Twogere, this is the thinking behind our focus on school-based mental health systems. We believe schools can be an important part of the wider support environment around young people, particularly when teachers are equipped with practical skills, students have meaningful ways to seek support and schools have functioning referral pathways. But the school cannot operate alone. It needs connections to families, communities and health services. The goal is not to create another isolated school programme. The goal is to strengthen the system around the young person.

This also means that we need to stop designing mental health interventions as though every community has the same needs and the same resources. Uganda is diverse, and the barriers facing a student in an urban school may be very different from those facing a young person in a rural community. Some areas may have access to health professionals but weak referral systems. Others may have community structures that are strong but limited access to specialist care. A good system has to understand these realities and build on what already exists rather than importing a model that assumes the same solution will work everywhere.

We also need to recognise the role of families. Families are often the first place where distress becomes visible, but they may also be the place where stigma and misunderstanding make it harder for a young person to seek help. Parents and caregivers need practical information about mental health, how to respond when a young person is struggling and where to seek appropriate support. This is not about turning parents into mental health professionals. It is about ensuring that the people closest to young people are not left without guidance when something goes wrong.

And then there are young people themselves. A system designed around young people cannot be designed without them. Young people know what it feels like to seek help, what makes a teacher approachable, what makes a referral frightening, where stigma shows up and what kinds of support feel useful. Their experiences should inform how these systems are designed and improved. We cannot build support that is technically available but practically difficult for young people to use.

The shift we need is therefore bigger than moving mental health services from one building to another. It is about changing our understanding of where mental health care and support belong. They belong in the health system, but they also belong in schools, communities, families and workplaces. They belong in prevention as well as treatment, in early identification as well as crisis response, and in everyday systems as well as specialist services.

Uganda does not necessarily need to build an entirely new system from scratch. We already have schools. We already have primary health facilities. We already have community structures. We already have health workers, teachers, families, young people and specialist services. What we need is to strengthen these parts, define their roles clearly and connect them so that a person does not fall through the gaps between them.

That is the opportunity in front of us.

The State of Uganda Population Report 2025 has made the scale of the mental health challenge harder to ignore. It has also created an important policy moment. Government is now calling for greater investment, stronger community-based approaches and integration of mental health into primary healthcare. The next question is whether we can translate that direction into systems that people can actually experience in their everyday lives.

For us at Twogere, that means starting with a simple principle: mental health support should be available where people already are, not only where the specialist happens to be. For a young person, that may mean starting at school. For another person, it may mean a primary health centre or community service. For someone else, it may mean a family member who knows how to respond and where to seek help. And when someone needs specialist care, the system should make that next step possible.

The goal is not to make every place a mental health clinic.

The goal is to make every part of the system better at supporting people.

If we can do that, mental health stops being something people encounter only when they reach crisis point and becomes part of how Uganda supports people to live, learn, work and thrive. Mental health must start where people are. And in Uganda, that means building the support around people, not waiting for people to find the system.