Crick Lund

Public sector mental health systems in South Africa: inter-provincial comparisons and policy implications

BackgroundThere is growing recognition that mental health is an important public health issue in South Africa. Yet mental health services remain chronically under-resourced. The aim of this study was to document levels of current public sector mental health service provision in South Africa and compare services across provinces, in relation to current national policy and legislation.MethodsA survey was conducted of public sector mental health service resources and utilisation in South Africa during the 2005 calendar year, using the World Health Organization’s Assessment Instrument for Mental Health Systems (WHO-AIMS) Version 2.2.ResultsSouth African policy and legislation both advocate for community-based mental health service provision within a human rights framework. Structures are in place at national level and in all nine provinces to implement these provisions. However, there is wide variation between provinces in the level of mental health service resources and provision. Per 100,000 population, there are 2.8 beds (provincial range 0–7.0) in psychiatric inpatient units in general hospitals, 3.6 beds (0–6.4) in community residential facilities, 18 beds (7.1–39.1) in mental hospitals, and 3.5 beds (0–5.5) in forensic facilities. The total personnel working in mental health facilities are 11.95 per 100,000 population. Of these, 0.28 per 100,000 are psychiatrists, 0.45 other medical doctors (not specialised in psychiatry), 10.08 nurses, 0.32 psychologists, 0.40 social workers, 0.13 occupational therapists, and 0.28 other health or mental health workers.ConclusionsAlthough there have been important developments in South African mental health policy and legislation, there remains widespread inequality between provinces in the resources available for mental health care; a striking absence of reliable, routinely collected data that can be used to plan services and redress current inequalities; the continued dominance of mental hospitals as a mode of service provision; and evidence of substantial unmet need for mental health care. There is an urgent need to address weak policy implementation at provincial level in South Africa.

Mental Health Policy Development and Implementation in Four African Countries

The purpose of the research programme introduced in this article is to provide new knowledge regarding comprehensive multisectoral approaches to breaking the negative cycle of poverty and mental ill-health. The programme undertakes an analysis of existing mental health policies in four African countries (Ghana, South Africa, Uganda, Zambia), and will carry out and evaluate interventions to assist in the development and implementation of mental health policies in those countries, over a five-year period. The four countries in which the programme is being conducted represent a variety of scenarios in mental health policy development and implementation.

Stakeholder perceptions of mental health stigma and poverty in Uganda

BackgroundWorld wide, there is plentiful evidence regarding the role of stigma in mental illness, as well as the association between poverty and mental illness. The experiences of stigma catalyzed by poverty revolve around experiences of devaluation, exclusion, and disadvantage. Although the relationship between poverty, stigma and mental illness has been documented in high income countries, little has been written on this relationship in low and middle income countries.The paper describes the opinions of a range of mental health stakeholders regarding poverty, stigma, mental illness and their relationship in the Ugandan context, as part of a wider study, aimed at exploring policy interventions required to address the vicious cycle of mental ill-health and poverty.MethodsSemi-structured interviews and focus group discussions (FGDs) were conducted with purposefully selected mental health stakeholders from various sectors. The interviews and FGDs were audio-recorded, and transcriptions were coded on the basis of a pre-determined coding frame. Thematic analysis of the data was conducted using NVivo7, adopting a framework analysis approach.ResultsMost participants identified a reciprocal relationship between poverty and mental illness. The stigma attached to mental illness was perceived as a common phenomenon, mostly associated with local belief systems regarding the causes of mental illness. Stigma associated with both poverty and mental illness serves to reinforce the vicious cycle of poverty and mental ill-health. Most participants emphasized a relationship between poverty and internalized stigma among people with mental illness in Uganda.ConclusionAccording to a range of mental health stakeholders in Uganda, there is a strong interrelationship between poverty, stigma and mental illness. These findings re-affirm the need to recognize material resources as a central element in the fight against stigma of mental illness, and the importance of stigma reduction programmes in protecting the mentally ill from social isolation, particularly in conditions of poverty.

Mental health policy process: a comparative study of Ghana, South Africa, Uganda and Zambia.

BackgroundMental illnesses are increasingly recognised as a leading cause of disability worldwide, yet many countries lack a mental health policy or have an outdated, inappropriate policy. This paper explores the development of appropriate mental health policies and their effective implementation. It reports comparative findings on the processes for developing and implementing mental health policies in Ghana, South Africa, Uganda and Zambia as part of the Mental Health and Poverty Project.MethodsThe study countries and respondents were purposively selected to represent different levels of mental health policy and system development to allow comparative analysis of the factors underlying the different forms of mental health policy development and implementation. Data were collected using semi-structured interviews and document analysis. Data analysis was guided by conceptual framework that was developed for this purpose. A framework approach to analysis was used, incorporating themes that emerged from the data and from the conceptual framework.ResultsMental health policies in Ghana, South Africa, Uganda and Zambia are weak, in draft form or non-existent. Mental health remained low on the policy agenda due to stigma and a lack of information, as well as low prioritisation by donors, low political priority and grassroots demand. Progress with mental health policy development varied and respondents noted a lack of consultation and insufficient evidence to inform policy development. Furthermore, policies were poorly implemented, due to factors including insufficient dissemination and operationalisation of policies and a lack of resources.ConclusionsMental health policy processes in all four countries were inadequate, leading to either weak or non-existent policies, with an impact on mental health services. Recommendations are provided to strengthen mental health policy processes in these and other African countries.

Mental health policy in South Africa: development process and content

INTRODUCTIONnMental health is increasingly acknowledged as a crucial public health issue in South Africa (SA). However, it is not given the priority it deserves on policy agendas in this and many other low- and middle-income countries. The aim of this analysis is to describe the content of mental health policy and the process of its development in SA.nnnMETHODSnQuantitative data regarding SAs mental health system were gathered using the World Health Organization (WHO) Assessment Instrument for Mental Health Systems. The WHO Checklist for Mental Health Policy and Plans was completed for SAs 1997 mental health policy guidelines. Semi-structured interviews provided understanding of processes, underlying issues and interactions between key stakeholders in mental health policy development.nnnRESULTSnThere is uncertainty at provincial level regarding whether the 1997 policy guidelines should be considered national policy. At national level the guidelines are not recognized as policy, and a new policy is currently being developed. Although the guidelines were developed through wide consultation and had approval through national policy development processes, difficulties were encountered with dissemination and implementation at provincial level. The principles of these policy guidelines conform to international recommendations for mental health care and services but lack clear objectives.nnnDISCUSSIONnThe process of mental health policy implementation has been hindered by the low priority given to mental health, varying levels of seniority of provincial mental health coordinators, limited staff for policy and planning, varying technical capacity at provincial and national levels, and reluctance by some provincial authorities to accept responsibility for driving implementation.nnnCONCLUSIONnThese findings highlight the importance of national leadership in the development of new mental health policy, communication between national and provincial levels, the need for provincial structures to take responsibility for implementation, and capacity building to enable policy makers and planners to develop, monitor and implement policy.

Increasing the priority of mental health in Africa: findings from qualitative research in Ghana, South Africa, Uganda and Zambia

Despite the high prevalence of mental illness, mental health remains a low priority in Africa. There has been no investigation of the views of stakeholders in Africa on why this is and what can be done. This paper reports a comparison of the views of stakeholders in Ghana, South Africa, Uganda and Zambia, focusing on the priority given to mental health by the government at the national and regional/province levels. We conducted semi-structured interviews with key stakeholders and used a two-stage approach to analysis: firstly framework analysis in each study country, followed by comparative analysis of the country data. Mental health was largely considered a low priority at national and regional/provincial levels in all four countries. We identified nine factors affecting the priority of mental health, which were grouped into three categories: legitimacy of the problem, feasibility of response and support for response. Respondents put forward a range of experiences and suggestions for increasing the priority given to mental health. We conclude with broad suggestions to raise the priority of mental health. These suggestions are particularly relevant as mental health increases in priority on the international agenda, in order to inform advocacy for increased priority for mental health in Africa.

Mental health care user participation in mental health policy development and implementation in South Africa

This paper describes current support for mental health care user participation in policy development and implementation in South Africa and suggests strategies for improving participation. The World Health Organization (WHO) Mental Health Policy Checklist and WHO Mental Health Legislation Checklist were completed. Between August 2006 and August 2009 96 semi-structured interviews with national, regional and district stakeholders were conducted. Most respondents felt that inclusion of user perspectives in policy processes would improve policy development. In practice, mental health care user consultation in policy development and implementation has been limited during the 16 years of democracy in South Africa. Strategies to create a supportive environment for user participation include social action directed at reducing stigma, advocating for acceptance of users’ rights to participate in decision making, crafting a supportive regulatory framework to promote participation, and equipping providers and policy makers to support inclusion. User capacity for participation could be strengthened through early and effective access to treatment and support, development of a national user lobby, skills training and practical exposure to the policy and service development environment.

'Mental health is everybody's business': Roles for an intersectoral approach in South Africa

Intersectoral action is increasingly recognized as necessary to address the social determinants of mental health. This study aims to assess South Africas progress in intersectoral collaboration for mental health, and provide recommendations for intersectoral collaboration, to generate lessons for other low- and middle-income countries. We conducted a survey of the existing mental health system in South Africa using the World Health Organization Assessment Instrument for Mental Health Systems. We also conducted 96 semi-structured interviews and 12 focus group discussions with a range of stakeholders at national, provincial and district level. Data were analysed thematically to understand the roles and responsibilities of different sectors in realizing the right to mental health. A range of key sectors were identified as having roles in mental health promotion, illness prevention and service delivery. In discussing South Africas progress, respondents gave several suggestions about how to formulate an intersectoral response in this context, including increasing high level political commitment, and using leadership from the health sector. We outline roles and responsibilities for various sectors and lessons that can be learnt from this context. These include the importance of developing programmes alongside legislation, employing targeted awareness-raising to engage sectors, and developing a structured approach to intersectoral action.

Mental Health Services in South Africa: Taking stock

There is new policy commitment to mental health in South Africa, demonstrated in the national mental health summit of April 2012. This provides an opportunity to take stock of our mental health services. At primary care level key challenges include- training and supervision of staff in the detection and management of common mental disorders, and the development of community-based psychosocial rehabilitation programmes for people with severe mental illness (in collaboration with existing non-governmental organizations). At secondary level, resources need to be invested in 72-hour observation facilities at designated district and regional hospitals, in keeping with the Mental Health Care Act. At tertiary level, greater continuity of care with primary and secondary levels is required to prevent revolving door patterns of care. There are major challenges and also opportunities related to the high level of comorbidity between mental illness and a range of other public health priorities, notably HIV/AIDS, cardiovascular disease and diabetes. The agenda for mental health services research needs to shift to a focus on evaluating interventions. With current policy commitment, the time to act and invest in evidence-based mental health services is now.

Barriers to the participation of people with psychosocial disability in mental health policy development in South Africa: a qualitative study of perspectives of policy makers, professionals, religious leaders and academics

BackgroundThis paper outlines stakeholder views on environmental barriers that prevent people who live with psychosocial disability from participating in mental health policy development in South Africa.MethodFifty-six semi-structured interviews with national, provincial and local South African mental health stakeholders were conducted between August 2006 and August 2009. Respondents included public sector policy makers, professional regulatory council representatives, and representatives from non-profit organisations (NPOs), disabled people’s organisations (DPOs), mental health interest groups, religious organisations, professional associations, universities and research institutions.ResultsRespondents identified three main environmental barriers to participation in policy development: (a) stigmatization and low priority of mental health, (b) poverty, and (c) ineffective recovery and community supports.ConclusionA number of attitudes, practices and structures undermine the equal participation of South Africans with psychosocial disability in society. A human rights paradigm and multi-system approach is required to enable full social engagement by people with psychosocial disability, including their involvement in policy development.