Here's why mental health care in SA is still in shambles


With all the promises and good intentions expressed at the Life Esidimeni hearings, the SA Federation for Mental Health (SAFMH) hopes that mental health care will become a priority; that funding and resources will be made available; and that policies which have been passed will be implemented.

The Mental Health Care Act 17 of 2002 was passed into legislation more than a decade ago. It was created to repeal outdated laws, and to take care of and protect SA citizens who need mental health care.

Not long after, the National Mental Health Policy Framework and Strategic Plan was established. One of the main objectives of this policy is to recognise that "... health is a state of physical, mental and social well-being and that mental health services should be provided as part of primary, secondary and tertiary health services" - this is documented in the policy.

Another main objective is to recognise that "... there is a need to promote the provision of mental health care services in a manner which promotes the maximum mental well-being of users of mental health care services and communities in which they reside".

Money still the issue

As so often, money appears to be at the root of the problem – the lack of funding for mental health continues to cause a major problem throughout South Africa.

Marthé Kotze, Programme Manager for Information and Awareness at the SAFMH, said: "SA has the policies and legal framework to improve mental health care, but our biggest problem now is the fact that they are not being implemented. 

"Mental health care needs to become a priority, in terms of funding and resource allocation. Until this happens, there will never be adequate mental health services to meet the needs of SA mental health care users."

More financial hardship

Recently the Alan J Flisher Centre for Public Mental Health (CPMH) hosted a debate where several industry professionals presented information and findings from research they conducted. They also detailed their experiences working in communities and witnessing the numerous challenges people are facing on a daily basis.

Sumaiyah Docrat is a Health Economist and Doctrate candidate at the University of Cape Town's Department of Psychiatry and Mental Health. She has done extensive research on a project called Emerald – Emerging Mental Health Systems in Low- and Middle-Income Countries.

The Emerald Project is funded by the European Union and has conducted surveys in South Africa, Ethiopia, India, Uganda, Nepal and Nigeria.

"As part of this work, we wanted to understand whether households affected by mental disorders – alcohol use disorders, depression, epilepsy and psychosis – are economically worse off when compared to households affected by physical health problems," said Docrat.

Across the six countries over 4 000 households were surveyed. Docrat said that about half of the households were affected by one of these mental disorders, and the other half affected by a physical health condition.

"We consistently found that households affected by mental disorder were more likely to report lower levels of wealth which resulted in withdrawing their children from school, reducing the frequency of their meals and restricting their use of health care – due to financial hardship, when compared with households affected by physical health conditions.

"This is extremely worrying, particularly when you see that the ways these households are responding to financial difficulty are likely to have long-term intergenerational impacts – entrenching themselves in a vicious cycle of poverty," said Docrat.

Ridicule associated with mental health

For years and even to this day, a dark cloud hangs over mental health. In the past, people who needed mental health care needed "special" care and were separate from those "normal" people. There was no integration, even though most people would be able to live normal lives with the aid of good mental health care.

Docrat said that the government has committed itself to transforming mental health services and ensuring the "quality mental health services are accessible, equitable, comprehensive and are integrated at all levels of the health system".

"While the policy and strategic plan is consistent with the ongoing efforts to re-engineer the primary health care system and implement National Health Insurance, the objectives of this policy and plan have been notably absent from national health reform and transformation in SA.

"At provincial level, no resources or budgets have been allocated to support the achievement of the goals and commitments outlined in the policy and strategic plan. This clearly indicated that the provincial departments of health do not regard mental health as a priority. The implementation thus far has been largely determined by each province's priorities, with limited financial incentives to improve efficiency of resource allocation for mental health services," added Docrat.

Deinstitutionalisation and Life Esidimeni

A few changes proposed in the act and the policy and strategic plan speaks to deinstitutionalisation, integrating mental health care with primary health care and making it more accessible.

The only thing is, when we think deinstitutionalisation these days, we think about the lives lost in the Life Esidimeni tragedy.

Ingrid Daniels, director for Cape Mental Health, said that this tragedy could have been avoided, had deinstitutionalisation been carried out properly. Kotze and the SAFMH echoed Daniels' sentiment when she told Health24 that we should be moving away from the model of institutionalised care to a model that allows mental health care users to receive treatment within their communities.

Kotze said: "We should focus on the upscaling and development of community-based mental health services. International studies have shown that mental health care users benefit if there are mental health services based within their community, which they can easily access and receive support from."

Integrating mental health care into primary health care services may increase awareness and lessen the stigma and discrimination associated with mental health, something which is still an issue in society today, especially in certain cultures where people are still told "get their act together" and "stop looking for attention".

Kotze added: "Adequate community based services lead to lower relapse rates. We need deinstitutionalisation, but it needs to be done in right way to avoid more tragedies like Life Esidimeni."

Crick Lund, director for the Alan J Flisher CPMH and UCT Psychiatry and mental health professor, told Health24: "The critical point about deinstitutionalisation is that the money must follow the patient into the community. Where deinstitutionalisation has failed, as in the case of Life Esidimeni, there was inadequate budget allocated to mental health care facilities in the community.

"Where it has succeeded in countries, like Italy, the closure of psychiatric institutions was accompanied by major new investments in community-based care. It is absolutely imperative that those with severe and chronic mental health needs are able to access the support they need, whether for housing, rehabilitation and/or treatment within their communities in a humane and safe way."

Skilled, well-compensated workers needed

Stellenbosch University professor and CPMH Co-Director, Ashraf Kagee, added that more posts are needed in public hospitals and that mental health workers, including counsellors and community care workers need to be paid properly and given due respect for the important work they do.

"There has to be a lot more oversight and monitoring of mental health service provision. This, of course, requires resources from government, who at present moment lack the political will, but this may also be a symptom of broader government inefficiency," said Kagee.

Health24 approached the National Department of Health for comment, but due to the Life Esidimeni hearings being sub-judice, they declined to comment on any of the issues raised.

Image credit: iStock

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