Sharon Kleintjes

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 in South Africa: development process and content

INTRODUCTION Mental 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. METHODS Quantitative 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. RESULTS There 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. DISCUSSION The 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. CONCLUSION These 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.

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.

Meeting the Millennium Development Goals in Sub-Saharan Africa:What about mental health?

Mental health is a crucial public health and development issue in sub-Saharan Africa (SSA), a region where little progress has been made towards achieving the Millennium Development Goals (MDGs). In this paper we argue that not only will limited progress in achieving these targets have a significant impact on mental health, but it will be impossible to achieve some of these aspirations in the absence of addressing mental health concerns. We consider the strong relationship of mental health with dimensions of human development represented in the MDGs, including reducing poverty, achieving universal primary education, decreasing child mortality rates, improving maternal health, HIV, environmental factors and improving the lives of those living in informal settlements. With these links in mind, we examine the mental health context in SSA settings and provide some specific examples of best practice for addressing mental health and the MDGs. It is recommended that the role of mental health interventions in accelerating the realization of the MDGs is investigated; further efforts are dedicated to probing the impact of different development projects upon mental health outcomes, and that mental health is declared a global development priority for the remainder of the MDG period and beyond.

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.

South African mental health care service user views on priorities for supporting recovery: implications for policy and service development

Purpose: The paper documents the views of South African mental health care service users on policy directions and service developments that are required to support their recovery. Method: Semi-structured interviews were conducted with forty service users and service user advocates. A framework analysis approach was used to analyse the qualitative data. Results: Service user priorities included addressing stigma, discrimination and disempowerment, and the links between mental health and poverty. They suggested that these challenges be addressed through public awareness campaigns, legislative and policy reform for rights protection, development of a national lobby to advocate for changes, and user empowerment. Users suggested that empowerment can be facilitated through opportunities for improved social relatedness and equitable access to social and economic resources. Conclusions: This study suggests three strategies to bridge the gap between mental health care service users rights and needs on one hand, and unsupportive attitudes, policies and practices on the other. These are: giving priority to service user involvement in policy and service reform, creating empathic alliances to promote user priorities, and building enabling partnerships to effect these priorities. Implications for Rehabilitation People living with psychosocial difficulties have a right to involvement in policy and service development, and their involvement has value for their recovery. The range of priorities people living with psychosocial difficulties identify as policy and service priorities to support their recovery requires policy makers and practitioners to work within a development, not an illness-focused approach. Policy implementers and practitioners need support to transform their ideological and practice framework from that of expert to that of enabler of service user involvement in treatment decisions, and public policy research and service development.

Improving Addiction Care in South Africa: Development and Challenges to Implementing Training in Addictions Care at the University of Cape Town

South Africa has a high lifetime prevalence of substance use disorders, estimated at 13.3% of the general population. Despite this high prevalence, treatment rates remain relatively low compared to need. A key reason for low treatment rates is the lack of expertise among professionals for the detection and treatment of substance use disorders and the limited size of the addiction care workforce. Workforce development is thus essential for the implementation of a comprehensive strategy to reduce substance-related harm within South Africa. In response to this need, the University of Cape Town has introduced a Postgraduate Diploma in Addictions Care and a Master of Philosophy in Addictions Mental Health. These postgraduate courses have been designed to equip health and social welfare professionals with the necessary skills to provide evidence-based early intervention, treatment and aftercare services for children, adolescents, adults and families affected by substance use disorders. This paper provides an overview of both programmes and reflects on lessons learnt from the inaugural group of students enrolled for the Postgraduate Diploma in Addictions Care and from the cohort of professionals who completed the Master of Philosophy in Addictions Mental Health since its inception.

Rapid appraisal of substance abuse and HIV awareness messages in poster communication to disadvantaged youth in South Africa

In this study we explore the responses of youth from selected disadvantaged urban communities in Gauteng Province, South Africa, to a poster dealing with the topic of substance abuse and HIV/AIDS. The study involved focus group discussions with 73, 10-18 year old youth chosen by quota sampling from a high school, primary school, secure youth care centre and two homes of safety. The participants reported that although they understood that the poster targeted the subject of drug use and unsafe sex, this understanding derived from other sources of HIV information than the poster. They had difficulty understanding the intended messages of the poster as the chosen message comprised complicated words and was ambiguous (open to different interpretations). The participants indicated that they preferred direct messages that clearly identified unsafe behaviours and offered instructions on alternative, safe behaviours. Their interpretations of the visuals in the poster indicated difficulty in linking the visuals of the poster with its message, particularly in less literate participants. We recommend that messages be kept short and direct, use simple and unambiguous language, and that it includes a health-enabling component to promote safe behaviours amongst youth.