Life Esidimeni shone a spotlight on the mental healthcare system in South Africa, but what is the way forward?
What is set to change? How will this change be brought about?
All of these questions give rise to a need to explore the system as it currently stands and to question not only the circumstances surrounding Life Esidimeni, but also other areas of the system that appear to be crumbling.
The following will serve to illustrate some of the blockages with which mental healthcare users are faced.
On March 19 2018, the families of the victims of the Life Esidimeni tragedy each accepted an amount of R1.2 million compensation from the state.
This was hailed as a watershed moment and the arbitration leading up to this point was deemed a success.
While officials involved in the series of tragic events were questioned and asked for explanations, to this day it remains to be seen who will truly be held accountable and how this will come about.
It is also still unclear what exactly the reasons behind the termination of the Life Esidimeni contract were, as evidence given during the arbitration hearings indicated that cost cutting and savings had possibly not been the main drivers behind the process after all.
Subsequent to this, the government published policy guidelines for the licensing of residential and/or daycare facilities for persons with mental illness and/or severe or profound intellectual disabilities.
These guidelines set out requirements for an non-governmental organisation to obtain a licence to operate a facility caring for people with psychosocial disabilities and people with severe or profound intellectual disabilities.
Stringent in nature, they seek to ensure that all facilities are licensed according to a set of strict criteria.
The difficulty with these guidelines is that they are so stringent that virtually no community-based organisation will ever be able to comply with them.
The guidelines are thus another bottleneck, in and of themselves, containing no capacitation plan and no accompanying document setting out how they are going to be implemented.
A further difficulty that has arisen from the Life Esidimeni tragedy is that there has been a loss of trust in non-governmental organisations on the part of both the government as well as the general public.
Non-governmental organisations as a whole are painted with the same brush as those organisations at which the Life Esidimeni victims died, and this is having the effect that they are struggling to obtain subsidies and funding.
This poses an immense challenge because, at present, non-governmental organisations are the only option for community-based care and community-based care is the only answer to propositions of deinstitutionalisation, as outlined in the South African Mental Health Policy Framework and Strategic Action Plan 2013-2020.
While the community-based model is sound and steeped in evidence-based research, poor understanding has led to ultimately catastrophic outcomes.
This has the effect that people believe the system cannot work.
A likely effect of this is that, once again, those with, inter alia, psychosocial disabilities will go back to being warehoused in hospitals that are either state hospitals or private hospitals the state contracts to care for patients, when these people could, given the availability of the necessary community-based resources, function well outside of them and have the opportunity to be integrated into and live as part of the community.
There is thus the concern that a state-heavy model of rehabilitation could bring about certain challenges such as the provision of treatment inappropriate to the needs of mental healthcare users, needless expenditure of resources and restrictions imposed upon them that violate their fundamental rights.
The Life Esidimeni Tragedy came across to many as a revelation – never before had the mental healthcare system been under so much scrutiny.
It seemed that before the tragedy, nobody had ever thought about the lot of persons with mental illness. Since Life Esidimeni, other areas of the system have also come under analysis.
Of late, it has been revealed that, in fact, the problem lies not only in “deinstitutionalisation gone wrong” but in the heart of the institutions themselves.
Shocking details have come to light, for instance, in the Eastern Cape, wherein atrocities in several hospitals have reportedly been found to have taken place.
With a damning report from the South African Society of Psychiatrists surrounding poor hospital records having been kept, deaths not having been properly reported, inappropriate use of below-par seclusion rooms and general poor standard of patient care, Tower Hospital has been identified as a facility in crisis.
In the psychiatric unit at Cecilia Makiwane Hospital, staff and patients are reportedly put at risk every day due to staff shortages.
A former mental healthcare user is reportedly seeking compensation from the hospital in the courts after having been assaulted by a patient at the facility.
An assault charge has also been in the news for having been brought against Fort England Hospital itself, as a response to abuses by nursing and security staff.
Deteriorating conditions and faltering management make it likely that this practice will continue if not increase in prevalence.
In Gauteng, there have been a spate of reported deaths among mental healthcare users in hospitals, the most recent of these having taken place at Thelle Mogoerane Hospital in Vosloorus where a patient fell to his death after breaking through burglar bars.
In brief, the situation has not changed, the treatment of people with psychosocial disabilities continues to have deleterious effects on their well-being and very little is being done to ensure they are adequately cared for.
Mental healthcare users so-situated continue to suffer with no tangible solution in sight.
The government’s attempts to regulate residential care and daycare facilities represent a concerning level of ignorance as to what will benefit mental disabilities and with psychosocial disabilities, and the emergence of other horrifying acts against these individuals in other parts of the country give credence to the notion that it is not only the mental healthcare users in Gauteng that were, and are, being failed on all fronts by duty bearers.
Much must be done – and fast – to save lives.
» Nicole Breen is project leader for information and awareness at the South African Federation for Mental Health