The mental health ‘treatment gap’ is at its widest in low-resource countries where the vast majority of its people have no access to mental health services and where developing effective models of primary mental health care that can expand from research pilot sites to large-scale population-based services is a major research and practice imperative.

The Mental Health in Zomba initiative builds upon an earlier pilot project to establish and sustain a district-wide scale-up of a village-based health workers’ mental health task-sharing intervention in Southern Malawi across a population of more than 600,000 people.

The article describes the development, implementation and structured evaluation of the impact of this task-sharing initiative.

Results from an examination of the care for 240 consecutive attendees show how the village-based workers recognised and responded to the needs of people experiencing both common and severe mental health problems and how they facilitated 850 mental health promotion events to more than 40,000 people within their communities.

A new and essential district-wide tier of mental health service was established at the crucial intersection between health centre and the community. Within the socio-cultural context of rural Malawi with its diverse explanatory models for psychological distress, the approach of the village-based health worker was found to be both credible and practical in meeting the needs of the population and therefore responding to both the ‘supply’ and ‘demand’ elements of the mental health treatment gap.