Right of reply: Strengthening public mental health services in South Africa
By Yogan Pillay, Department of Health
The Business Day article on 11 October titled ‘SA spends too little on mental health – study’ by Tamar Kahn and the Spotlight article by Alicestine October of October 15th bears response. The former to note the Department’s involvement in the study and the latter because of unforeseen circumstances the response by the National Department was not provided to Spotlight.
The study which was released by the University of Cape Town on World Mental Health Day was requested by the National Department of Health. As the authors acknowledge in the report dated September 2019: “This research endeavour was a joint effort of the National Department of Health (NDOH), the Provincial Departments of Health, the South Africa Medical Research Council and the Alan J Flisher Centre for Public Mental Health, University of Cape Town, South Africa”. This is an important point to make – which was omitted from Kahn’s article as it reflected the Department’s intentions to strengthen financing for mental health services. Secondly the article mentions that work is underway to “develop a business case to put to the Treasury” – again, this decision was one taken by the National Department who also solicited funding from donors to fund UCT and the SAMRC to do this work for us. Again, this reflects the Department’s intention to strengthen both resources and services for public mental health care.
As noted above, it is a pity that the Department’s input to the Spotlight article was not provided to the author – to illustrate our commitment to strengthen mental health services.
Let us first briefly contextualise the provision of mental health services globally. According to a global review published in the Lancet (Vigo et al, 2019) the global average percentage of mental health expenditure as a total of all health expenditure is 2.4% and the percentage of mental health expenditure spent on psychiatric hospitals is 80%. In addition, the World Health Organization (WHO) suggests that the global average expenditure on mental health in 2011 was just $3 per person per year. Against the global average expenditure South Africa spends 5% of total public health expenditure on mental health, although there are large inter-provincial differences. Similarly, in 2016/17 per capita expenditure uninsured person was R180 (around $12).
Compared to the public sector the private sector expenditure (covering 20% of the population) is much higher – with more mental health professionals servicing this sector. According to the Council for Medical Schemes in 2018, the private sector spent R3.9 billion on mental health services funded by the Schemes, 2.3% of total health expenditure and a per capita expenditure of R444 per beneficiary. This level of inequity cannot be sustained and will be addressed through the National Health Insurance (NHI) system.
As reported in the Lancet Commission on Global Mental Health published in 2018, mental health services are underdeveloped and under-invested globally. The Commission noted that globally: “The quality of mental health services is routinely worse than the quality of those for physical health. Government investment and development assistance for mental health remain pitifully small. Collective failure to respond to this global health crisis results in monumental loss of human capabilities and avoidable suffering”. However, the Commission also acknowledged that with the Sustainable Development Goals a “historic opportunity exists to reframe the global mental health agenda in the context of the broad conceptualisation of mental health and disorder…”.
However, these data cannot be used to justify any neglect of services for people with mental illness. The Department of Health is committed to strengthening mental health services in line with our progressive Mental Health Care Act and our Mental Health Policy Framework and Strategic Plan.
Here is an update of the Department’s activities to strengthen mental health services.
- Establishment of Mental Health Review Boards in all provinces: These are quasi -judicial bodies established in terms of the Mental Health Care Act, 2002 to protect the human and health rights of people with mental illness and intellectual disability.
- Establishment of a Ministerial Committee on Mental Health to advise the Minister (composed of both experts and representatives of civil society organisations)
- Established an intersectoral committee on mental health composed of government departments and civil society organisations as directed by the SA Human Rights Commission
- Integration of mental health into primary health care to ensure that all health care providers at PHC level are able to detect, support and refer people with mental health conditions
- Established district teams composed of mental health professionals in 17 districts whose role is to strengthen mental health services at primary health care level; going forward teams will be established in all districts
- Strengthening of infrastructure for mental health. In the current financial year, 21 mental health infrastructure projects form part of the infrastructure revitalization projects. Plans are underway to construct mental observation units at Hayani and Thabamoopo Hospitals in Limpopo Province, Weskoppies Hospital in Gauteng Province and Umzimkhulu Hospital in KwaZulu-Natal province.
- Trained more than 900 doctors and nurses working in primary health care and district hospital levels in the treatment of acute psychiatric conditions
- In addition to commissioning an investment case for mental health, the Department also commissioned a review of community based mental health services
- Commissioned work to review the efficiency of psychiatry hospitals (where 45% of all mental health expenditure takes place)
- Stabilised the backlog even as the number of psychiatric forensic referrals by the Courts have increased and extinguished the backlogs in Hayani Hospital in Limpopo, Komani Hospital in Eastern Cape and Mpumalanga Province.
- Increased output for mental observations to 66% of 2 740 referred cases concluded over the past 12 months.
- Provided funding to the South African Federation for Mental Health to support advocacy on mental health.
- Provincial Departments of Health are innovating as well and some of these innovations include: deployment of e-psychiatry; centralised waiting lists to ensure efficient referrals; deployment of psychiatric registrars to support outreach services and redeployment of some social workers and psychologists from psychiatric hospitals to primary health care; establishment of mental health forums at district level to strengthen accountability; digitisation of patient files; and decentralisation of psychiatric forensic services.
Is this sufficient? Of course not! We have much more to do to ensure that everyone who needs access to quality mental health services is able to receive it without delay and without the need to pay for it at the point of delivery. Under National Health Insurance we must clearly define the package of mental health services that will be provided at each level of care, ensure that there are mental health professionals able to provide this package and that this package is fully funded. Given the increasing burden of diseases attributed to mental disorders the work to strengthen preventive, treatment and rehabilitative services are critical. All available resources must be utilised in creative ways to meet these needs.
- Pillay is the deputy director general of communicable and non-communicable diseases at the national health department.