World Mental Health Day (WMHD) is celebrated annually on the 10th of October. This WMHD, the World Federation for Mental Health calls on countries to actualise accessible, quality mental healthcare for all. The theme for 2021 is ‘mental health in an unequal world’. For South Africa, the most unequal country in the world in 2019, this call is especially pertinent. In just 23 hours, the average CEO in our country earns what the average worker makes annually. The devastating social and economic impact of COVID-19 has amplified this chasm.
Concomitant to great disparities of economic resources is access to mental health care. Less than 1 in 10 people living with a mental health condition in our country receive the care they need. This access largely depends on if the person has medical aid and where they live (e.g. the province, rural or urban area). For example, in the Western Cape spending on mental health per uninsured person is R307.40 while in Mpumalanga it is R58.50 – that’s nearly a R250 variation.
It is evident that across our country, people have vastly different experiences in accessing care for their mental health conditions. A mental health care user in Limpopo shares: “I spend many hours in the waiting room before I get treatment.” This WMHD and beyond, South Africa must continue to grapple with how to ensure all people who require quality mental health care are able to do so. Indeed, reducing inequality means improving access to evidence-based, culturally appropriate mental health services and support.
Importantly, this message is not one of doom and gloom. It should be one of hope. We know that integrating mental health care into primary healthcare can reduce inequality. This is because it reduces indirect costs associated with accessing treatment and obtaining follow-up. For example, mental health care users and their caregivers do not need to spend excessive amounts on transportation to access their closest tertiary psychiatric hospital. Often, such facilities can be located 100kms+ away from where the person lives. Not only is the transportation costly, but people need to take time off work to access treatment. Integrating mental health care into primary healthcare can also improve the prevention and detection of mental health conditions. These can often remain undiagnosed if a person cannot afford specialist care. Early detection of mental health conditions (paired with suitable treatment) can ensure a person is able to maintain their job, income and ultimately avoid falling into the cycle of poverty.
Researchers have showed us that it is possible – and effective – to integrate mental health care into primary healthcare at a district level in our country. Economists have outlined sustainable financing options as to how we can achieve this. Policymakers have shown their commitment to creating legislature dedicated to enhancing population mental health. We must continue to build upon these excellent efforts and ensure that all relevant stakeholders work synergistically to reduce inequality by enhancing access to mental health care. This article reflects on areas in our policy, theoretical orientation, human and financial resources that we can focus on to make mental health services and support more accessible.
In the past twenty years, two landmark legislations have been developed to enhance mental health services in South Africa. The first being the Mental Health Care Act 17 of 2002, and the second, the National Mental Health Policy Framework and Strategic Action Plan 2013–2020 (MHPF).
While these legislations are vital to the efforts of mental health in the country, there were critical challenges in their implementation and the impact of the MHPF is rather unknown. This is largely because there was no concurrent budget dedicated to support the plan’s implementation or reporting requirements linked to the MHPF’s objectives.
More worryingly, the MHPF has now lapsed and there has been minimal talk from government about its renewal or what next steps may involve. We know that the National Department of Health has commissioned experts in the field of mental health to develop a mental health investment case that clearly demonstrates what packages of care are required at a community, primary and tertiary care level to make mental health care accessible in the country; how much this will cost; and who should be responsible for providing this care. We commend the National Department of Health for initiating this research and we urge that they earmark the requested budget prior to phasing in of the National Health Insurance. Rigorous accountability and monitoring systems must be implemented to ensure this budget will be spent as intended.
In addition to advocating for increased budgeting, accountability, and reporting mechanisms, we also need:
- More government departments (not just the Department of Health) to ring-fence a budget for mental health. For example, the Department of Human Settlements to provide capital investments in community-residential care infrastructure.
- More concrete mechanisms implemented at community level to ensure the inclusion of mental health care users in the design, execution, and monitoring of policy objectives.
- Guidance on how stigma should be addressed, specifically the implementation of evidence-based, anti-stigma programmes at a national and provincial level. These programmes must be culturally-relevant for the communities where they will be implemented.
Our mental health policies – and our constitution more broadly – underscore a human rights based approach to care. However, the success of a policy lies in its implementation. If the human rights of people living with mental health conditions are not recognised in the design and implementation of mental health services, our policies will fail.
Too often we hear stories from mental health care users and their caregivers about how healthcare providers’ attitudes proves a great barrier to accessing mental health care. This is often compounded when there are comorbid mental health conditions. For example, a mental health care worker in the Eastern Cape reflects: “The service for substance abuse is dismal. So people who are on drugs and things like that get dismissed. They go to the clinic and the clinic sister says, “No—sorry, your problem is drugs, we don’t treat drugs here.” Even if you might have schizophrenia, or depression””
On a national level, the gross violation of human rights was especially demonstrated by the Life Esidimeni tragedy in 2016, during which the Gauteng health department’s actions, through an ill-fated attempt at deinstitutionalisation, resulted in the deaths of more than 144 mental health care users, with many left unaccounted for. Currently – nearly 5 years after this event took place – a national inquiry is underway. Despite this severe time lapse, it is encouraging to see that we as a country will not forget the people who lost their lives in this atrocity. We have faith in our courts and our constitution for justice to be served and human rights for all to be observed.
Despite the presence of tragedy and continuing concerns about poor and inadequate services to mental health care users, there are glimmers of hope to be found. When community-based mental health care is done with passion and a true commitment to the person, there exists the possibility of making a positive impact on lives, even during challenging times such as the one we currently find ourselves in.
Loyd, a mental health care user receiving support from a community-based mental health NGO, shared the following with us during a recent campaign about the importance of elevating the voices of persons with mental illness: “My experience of lockdown was very scary. When the virus broke out, I didn’t know what this world was going to come to and I was scared for myself. At the time I was working at a grocery store and many of my colleagues were testing positive. I was very scared to pick up the virus. I received remote support from Mental Health Organisation B that motivated me and helped me cope with daily life in lockdown. It also helped me understand what it was I was dealing with during this pandemic and stay positive and calm during the process. I feel very supported by staff at Facility B which I belong to. I don’t have many friends so coming to the facility every day and doing activities as well as socialising with other members of the programme has been a big support for me”.
The preservation of mental health care users’ human rights and dignity should be the cornerstone of all mental health services. Therefore this WMHD we advocate for:
- All people, working within and outside of the health care sector, to reflect on their own biases in their approach to people living with mental health conditions. How could your beliefs and actions be more inclusive to all? How can you value the lives of people living with mental health conditions equally? What is stopping you from making reasonable accommodations for people living with mental health conditions? If you are an employer and need assistance in answering these questions, please feel free to reach out to SAFMH. We are here to assist you answer these questions.
- Criminal charges to be placed against those who orchestrated Life Esidimeni and made a mockery of human rights and our constitution.
- Government to work extensively to regain the publics’ trust in future deinstitutionalisation efforts and strengthen existing community-based mental health care. This involves financially investing in upskilling and resourcing existing community-based NGOs who provide mental health services in the community.
- Human rights educational programmes to be developed and rolled out nationally, for the benefit of staff and mental health care users.
It has become increasingly apparent that there is simply not enough specialised human resources for mental health care in the country. In 2019, only three of the nine provinces have child psychiatrists working in the public sector. Over a third of South African medical graduates leave to pursue careers in Higher Income Countries (WMHD Educational Material, 2021; pg. 72).
We have to get creative to be able to provide accessible mental health care and services. Through task-sharing – where non-specialist health workers (e.g. lay counsellors, peer mentors, community health workers) are trained to provide psychosocial interventions – mental health care can be more accessible.
There has been good evidence that task-sharing can work in South Africa to reduce the gap between those who need care, receive it. Importantly, mental health care users in our country find using non-specialist health workers to deliver mental health care to be acceptable, provided that specific conditions are met. These are (1) adequate training (including in stigma and harm-reduction, human-rights based approaches) for health workers involved in task-sharing; (2) ongoing structured supervision; and (3) functioning health care systems (e.g. better access to medication and clear referral pathways).
Community-based mental health NGOs play a vital role in bolstering the mental health treatment provided within the primary healthcare. In this setting, people with lived experience of mental health conditions receive holistic social and economic support through integrative community services. This ultimately links mental health care users’ abilities with opportunities for recovery and reintegration. After all, as the World Health Organisation highlights, mental health is not merely the absence of mental illness, but a state of wellbeing where a person actualises their potential, copes with the normal stresses of life, works productively, and enjoys being a member of their community.
In all provinces of our country, community-based mental health organisations already play a significant role in the expansion and delivery of mental health services. This is mainly through providing counselling, and mental health awareness and promotion. For example, despite the challenges created by COVID-19, Cape Mental Health provided mental health care in the form of facility, home, and face-to-face counselling as well as virtual interventions to retain contact, reduce isolation, and enhance mental wellness to over 6000 beneficiaries (WMHD Educational Material, 2021; pg. 26).
Importantly, neither government nor community-based organisations can provide quality, comprehensive mental health services as independent entities. This WMHD we emphasise that there must be a strong relationship between the two where, as equal partners, both sectors work together to reduce the inequities in our mental health care provision.
As emphasised throughout this article, there is greater need for improved strategic financial investment to increase access to mental health. So far we have discussed how, from a human-rights perspective, there is a need for more funds to be directed to mental health services to meet the mental health needs of the population. However, investing in mental health makes good economic sense too. In South Africa, the cost of not investing in mental health far outweighed that of when we do (WMHD Educational Material, 2021; pg. 69). In South Africa, lost workforce productivity due to poor mental health is costed at US$ 10.9 billion annually. This is 4% of the country’s gross domestic product (GDP). Comparatively, it would cost an annual average estimate of US$ 1.8 billion to scale-up mental health services in South Africa over fifteen years (WMHD Educational Material, 2021; pg. 69).
However, we don’t simply need more money for mental health care, we need commitment to investing it wisely. We know that to make mental health care more accessible in South Africa we must provide services, care, and support in community and primary healthcare settings. However, in 2016/2017, the total primary health care expenditure on mental health amounted to about 616 million rand, while community-based NGO services for mental health cost 250 million rand (based on the available data). Comparatively, the annual health system expenditure on inpatient care was equivalent to an estimated 1.5 billion rand – substantially more than the spend for community and primary healthcare combined.
Of course, tertiary facilities are a vital component of a strong mental health care system and require funding. However it is not feasible to expect for such settings to deliver the bulk of mental health services (including prevention and promotion) for our population. Community-based mental health NGOs contribute significantly to community-based mental health programmes. Their interventions are tailor-made to their local communities, increasing access to culturally-relevant mental health services (WMHD Educational Material, 2021; pg. 26).
Bharti Patel, Director of The South African Federation for Mental Health shares: “Politicians need to share their plans to improve mental health services as they address poverty. We want to see and hear from CEOs in the corporate space promoting the mental wellbeing of workers. We want to work alongside philanthropists and mental health care users to ensure mental health care is accessible in marginalised communities. This World Mental Health Day let us unite as human beings and commit to making mental health a reality for all.”
This WMHD we continue to be inspired by community-based mental health NGOs who work tirelessly to ensure mental health care users can access services and economic opportunities within their communities. We remain in awe of academics and people with lived experiences of mental health conditions who generate evidence regarding best-practices for mental health care in South Africa. We are hopeful that policymakers will amplify their support for mental health through strategic human and financial resource allocation. There has been much advancement made in the country when it comes to mental health care, this WMHD let’s continue striving for all to enjoy this progress.
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