Planning for district mental health services in South Africa: a situational analysis of a rural district site
TL;DR: It is suggested that, in a similar vein to other low- to middle-income countries, deinstitutionalization and comprehensive integrated mental health care in South Africa is hampered by a lack of resources for mentally health care within the primary health care resource package, as well as the inefficient use of existing mental health resources.
Abstract: The shift in emphasis to universal primary health care in post-apartheid South Africa has been accompanied by a process of decentralization of mental health services to district level, as set out in the new Mental Health Care Act, no. 17, of 2002 and the 1997 White Paper on the Transformation of the Health System. This study sought to assess progress in South Africa with respect to deinstitutionalization and the integration of mental health into primary health care, with a view to understanding the resource implications of these processes at district level. A situational analysis in one district site, typical of rural areas in South Africa, was conducted, based on qualitative interviews with key stakeholders and the World Health Organization's Assessment Instrument for Mental Health Systems (WHO-AIMS). The findings suggest that the decentralization process remains largely limited to emergency management of psychiatric patients and ongoing psychopharmacological care of patients with stabilized chronic conditions. We suggest that, in a similar vein to other low- to middle-income countries, deinstitutionalization and comprehensive integrated mental health care in South Africa is hampered by a lack of resources for mental health care within the primary health care resource package, as well as the inefficient use of existing mental health resources.
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TL;DR: The adoption of the concept of task shifting can substantially reduce the expected number of health care providers otherwise needed to close mental health service gaps at primary health care level in South Africa at minimal cost and may serve as a model for other middle-income countries.
Abstract: BACKGROUND A recent situational analysis suggests that post-apartheid South Africa has made some gains with respect to the decentralization and integration of mental health into primary health care. However, service gaps within and between provinces remain, with rural areas particularly underserved. Aim This study aims to calculate and cost a hypothetical human resource mix required to populate a framework for district adult mental health services. This framework embraces the concept of task shifting, where dedicated low cost mental health workers at the community and clinic levels supplement integrated care. METHOD The expected number and cost of human resources was based on: (a) assumptions of service provision derived from existing services in a sub-district demonstration site and a literature review of evidence-based packages of care in low- and middle-income countries; and (b) assumptions of service needs derived from other studies. RESULTS For a nominal population of 100 000, minimal service coverage estimates of 50% for schizophrenia, bipolar affective disorder, major depressive disorder and 30% for post-traumatic stress disorder and maternal depression would require that the primary health care staffing package include one post for a mental health counsellor or equivalent and 7.2 community mental health worker posts. The cost of these personnel amounts to £28 457 per 100 000 population. This cost can be offset by a reduction in the number of other specialist and non-specialist health personnel required to close service gaps at primary care level. CONCLUSION The adoption of the concept of task shifting can substantially reduce the expected number of health care providers otherwise needed to close mental health service gaps at primary health care level in South Africa at minimal cost and may serve as a model for other middle-income countries.
142 citations
Cites background from "Planning for district mental health..."
...Previous research suggests that they do not have the time to provide psychological treatment for service users with common mental disorders (Freeman and Pillay 1997; Petersen 2000; WHO and Wonca 2008; Petersen et al. 2009)....
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...2009), there is a need for dedicated CMHWs to undertake to deliver these specific packages as general CHWs reportedly do not have the time to provide specific treatment packages for mental disorders (Petersen et al. 2009)....
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...A recent situational analysis of mental health services in South Africa, conducted as part of the Mental Health and Poverty Project (MHaPP), suggests that while there has been progress towards decentralized integrated primary mental health care since 1997, there are still significant service gaps both within and across provinces (Lund et al. 2009a; Petersen et al. 2009)....
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...…as part of the Mental Health and Poverty Project (MHaPP), suggests that while there has been progress towards decentralized integrated primary mental health care since 1997, there are still significant service gaps both within and across provinces (Lund et al. 2009a; Petersen et al. 2009)....
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...…PHC system in South Africa as a result of high HIV prevalence (Chopra et al. 2009), there is a need for dedicated CMHWs to undertake to deliver these specific packages as general CHWs reportedly do not have the time to provide specific treatment packages for mental disorders (Petersen et al. 2009)....
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TL;DR: Opting mental health services in LMICs requires legislation, policies and plans that are enabling of the above strategies and actions, and best practices for strengthening mental health literacy and collaborative arrangements with community caregivers and other sectors can assist this process.
Abstract: Purpose of reviewAgainst the backdrop of a large burden and treatment gap for mental disorders in low-income and middle-income countries (LMICs), recently published articles were reviewed to assess strategies and actions for optimizing mental health services in LMICs.Recent findingsKey strategies an
116 citations
TL;DR: A common implementation framework incorporating a community collaborative multi-sectoral, task shifting and self-help approach to integrating mental health into primary healthcare holds promise for closing the treatment gap for mental disorders in LMICs at district level.
Abstract: Background
While decentralized and integrated primary mental healthcare forms the core of mental health policies in many low- and middle-income countries (LMICs), implementation remains a challenge. The aim of this study was to understand how the use of a common implementation framework could assist in the integration of mental health into primary healthcare in Ugandan and South African district demonstration sites. The foci and form of the services developed differed across the country sites depending on the service gaps and resources available. South Africa focused on reducing the service gap for common mental disorders and Uganda, for severe mental disorders.
115 citations
Cites background or methods from "Planning for district mental health..."
...In Uganda, where the focus was on SMDs, the training reportedly improved identification and referral of these disorders....
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...In contrast, decentralization efforts by the Department of Health in post-apartheid South Africa have focused largely on SMDs [11,13]....
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...This corroborates previous findings [4,13]....
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...CHWs present as a potentially important resource to be harnessed for strengthening mental health literacy and help seeking behaviour for CMDs and SMDs within the task shifting model....
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...Regarding the latter, an adequate supply of psychotropic medication at PHC level is an essential first step in the process of decentralization and re-integration of users with SMDs into society....
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TL;DR: Qualitative process evaluation suggests that improved social support, individual coping skills and improved personal agency assisted in the reduction of depressive symptoms in the group-based IPT intervention.
Abstract: Within the context of a large treatment gap for depression and a scarcity of specialist resources, there is a need for task shifting to scale up mental health services to address this gap in South Africa. This study assessed the feasibility of an adapted manualized version of grouped based Interpersonal Therapy (IPT) for use by supervised community health workers through a pilot study on 60 primary health care clinic users screened as having moderate to severe depression. Retention was good and participants in the group-based IPT intervention showed significant reduction in depressive symptoms on completion of the 12-week intervention as well as 24 weeks post baseline compared to the control group. Qualitative process evaluation suggests that improved social support, individual coping skills and improved personal agency assisted in the reduction of depressive symptoms.
102 citations
Cites background from "Planning for district mental health..."
...There is also increasing evidence that PHC nurses neither have the time, nor often the skills to provide psychosocial treatments given South Africa’s overstretched primary health care system (Petersen et al. 2009; WHO and WONCA 2008)....
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...Service gaps still remain with respect to community-based rehabilitation programmes for people with chronic mental illness, mental health promotion and prevention programmes, and access to care for more common mental disorders, such as anxiety and depression (Lund et al. 2009; Petersen et al. 2009)....
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TL;DR: This paper summarizes the findings for the European Region of the WPA Task Force on Steps, Obstacles and Mistakes to Avoid in the Implementation of Community Mental Health Care with some recommendations for the future.
101 citations
References
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09 Sep 2002
TL;DR: The last two decades have seen a notable growth in the use of qualitative methods for applied social policy research as discussed by the authors, which is underpinned by the persistent requirement in social policy fields to understand complex behaviours, needs, systems and cultures.
Abstract: The last two decades have seen a notable growth in the use of qualitative methods
for applied social policy research. Qualitative research is now used to explore
and understand a diversity of social and public policy issues, either as an
independent research strategy or in combination with some form of statistical
inquiry. The wider use of qualitative methods has come about for a number of
reasons but is underpinned by the persistent requirement in social policy fields
to understand complex behaviours, needs, systems and cultures.
7,396 citations
"Planning for district mental health..." refers methods in this paper
...A framework analysis approach (Ritchie and Spencer 1994) was used to analyse the qualitative data....
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...Framework analysis was specifically developed for qualitative data analysis in applied policy analysis research (Ritchie and Spencer 1994; Lacey and Luff 2001)....
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01 Jan 2007
TL;DR: The Nature of Qualitative Analysis Data Preparation Writing Thematic Coding and Categorizing Analysing Biographies and Narratives Comparative Analysis Analytic Quality and Ethics Getting Started with Computer Assisted Qualitative Data Analysis Searching and Other Analytic Activities Using Software Putting it All Together.
Abstract: The Nature of Qualitative Analysis Data Preparation Writing Thematic Coding and Categorizing Analysing Biographies and Narratives Comparative Analysis Analytic Quality and Ethics Getting Started with Computer Assisted Qualitative Data Analysis Searching and Other Analytic Activities Using Software Putting it All Together
3,790 citations
TL;DR: Every country can and should begin now to improve its efforts to treat people with mental illness, and 10 recommendations on how governments can strengthen their country’s mental health care are concluded.
Abstract: As I write these words in mid October I reflect on the way in which we have, during the past 4 weeks, expressed our shared grief in understanding, sympathy, and support for those affected by posttraumatic stress. We are reminded of the extraordinary ability of humans tocopewithextremesofemotion,tohelp each other, and to handle fear, pain, and loss. We work together to preserve our mental health. We see nothing wrong, or mysterious, in our coping mechanisms. But we do not expect people to have to cope alone, in isolation. We understandtheneedforhelpandguidance. As health care professionals, we know that mental illness is not a personal failure. If there is failure, it is in the way society in general and the health sector in particular have responded to people with mental and neurological disorders. By separating mental health care from physical health care—and often separating those who have mental illness from society—the health care profession has reinforced stigma, making successful treatment much harder. I see this as a time of opportunity for change, and I agree strongly with an earlier JOURNAL article by US Surgeon General David Satcher ( JAMA. 2001; 285:1697). Every country can and should begin now to improve its efforts to treat people with mental illness. A recent WHO global survey of mental health policy issues, Atlas of Mental HealthResources in theWorld2001 (http:// www.who.int/mental health/Publication Pages/Pubs 2001.html), found that 40% of the 185 countries surveyed have no national mental health policy, 30% have no programs to improve mental health conditions, and 25% have no specific mental health legislation. Well over one third (37%) of the countries have no community care facilities. The global toll of mental illness and neurological disorders is staggering. Neuropsychiatric disorders account for 31% of the disability in the world— and they affect rich and poor nations and individuals alike. According to the World Health Report 2001, Mental Health: New Understanding, New Hope (http://www.who.int/whr/), 450 million people have a mental or neurological disorder. Of these, 121 million have depression and 50 million have epilepsy. Every year, 1 million people commit suicide and 10 million to 20 million attempt suicide. A great deal of this suffering is unnecessary. We know, for instance, that 60% of those with major depression can fully recover if treated. However, in both industrialized and developing countries, less than 25% of those affected receive treatment, for reasons that include stigma, discrimination, scarce resources, lack of skills in primary health care, and deficient public health policies. The treatment gap is similar or greater for many other easily treatable mental and neurological disorders. Because people do not get the care they need, these disorders impose a range of social and economic costs on individuals, households, employers, and society, ranging from the cost of care to the cost of lost productivity. Solutions based on scientific evidence are available and affordable. Through recent advances in neuroscience, neuroimaging, genetics, and behavioral sciences, we know more about brain functioning and behavior than ever before. Breakthroughs in therapy and medication have occurred. In the World Health Report 2001, WHO summarizes current knowledge about mental and neurological disorders: the global burden, current level of care, latest knowledge about causes and treatment, and ongoing efforts to reform mental health care. The report concludes with 10 recommendations on how governments can strengthen their country’s mental health care: • provide treatment for mental disorders within primary care; • ensure that psychotropic drugs are available; • replace large custodial hospitals with community care facilities backed by general hospital psychiatric beds and home care support; • launch public awareness campaigns to overcome stigma and discrimination; • involve communities, families, and consumers in decision making on policies and services; • establish national policies, programs, and legislation; • train mental health professionals; • link mental health with other social sectors; • monitor community mental health; and • support more research. The report outlines three scenarios to help guide countries and population groups, depending on the resources available and the current status of mental health care in each country. Regarding treatment, for example, if even the poorest countries could ensure that the five most needed psychotropic drugs were available in all health care settings, we could ease the suffering of millions of people. If many middle-income countries could use the experiences of others as a guide and initiate pilot projects for community care, parts of or entire custodial institutions could be shut down, and the financial savings could strengthen further community care activities. If some of the richest countries could review their health care financing rules to ensure parity between mental and physical health problems, a major obstacle to treatment could be removed. We need to speed up and strengthen care for the mentally ill. —Gro Harlem Brundtland, MD, MPH Director-General World Health Organization FROM THE WORLD HEALTH ORGANIZATION
1,683 citations
TL;DR: The third in the Child Development Series as discussed by the authors assesses strategies to promote child development and to prevent or ameliorate the loss of developmental potential in developing countries by identifying four well-documented risks: stunting, iodine deficiency, iron deficiency anaemia, and inadequate cognitive stimulation, plus four potential risks based on epidemiological evidence.
927 citations