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: Assessment of progress in scaling up mental health services worldwide using a systematic review of literature and a survey of key national stakeholders in mental health suggested that successful strategies can be adopted to overcome barriers to scaling up.
549 citations
TL;DR: There remains widespread inequality between provinces in the resources available formental 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.
Abstract: Background
There 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.
212 citations
Cites methods from "Planning for district mental health..."
...It is clear that an instrument of this nature is not designed to provide detailed analyses of political and cultural factors, and in the case of South Africa, we have used qualitative methodologies to explore these aspects in other papers [41, 42]....
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TL;DR: Perceptions of service users and providers of current interactions between the two systems of care and ways in which collaboration could be improved in the provision of community mental health services are explored.
Abstract: The majority of the black African population in South Africa utilize both traditional and public sector Western systems of healing for mental health care. There is a need to develop models of collaboration that promote a workable relationship between the two healing systems. The aim of this study was to explore perceptions of service users and providers of current interactions between the two systems of care and ways in which collaboration could be improved in the provision of community mental health services. Qualitative individual and focus group interviews were conducted with key health care providers and service users in one typical rural South African health sub-district. The majority of service users held traditional explanatory models of illness and used dual systems of care, with shifting between treatment modalities reportedly causing problems with treatment adherence. Traditional healers expressed a lack of appreciation from Western health care practitioners but were open to training in Western biomedical approaches and establishing a collaborative relationship in the interests of improving patient care. Western biomedically trained practitioners were less interested in such an arrangement. Interventions to acquaint traditional practitioners with Western approaches to the treatment of mental illness, orientation of Western practitioners towards a culture-centred approach to mental health care, as well as the establishment of fora to facilitate the negotiation of respectful collaborative relationships between the two systems of healing are required at district level to promote an equitable collaboration in the interests of improved patient care.
180 citations
Cites background from "Planning for district mental health..."
...One important finding from the MHaPP situational analysis at district level in South Africa (cf. Petersen et al., 2009) was the need for the establishment of a multisectoral mental health advisory group to plan and facilitate the integration of mental health services at district and sub-district…...
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...In this regard, primary health care nurses and doctors provided care for users with mental health needs but had very little training in mental health and the requisite supervision structure was deemed inadequate (Petersen et al., 2009)....
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...As a consequence, the mental health care provision focused predominantly on emergency and symptom management of serious mental illnesses, particularly psychotic and mood disorders requiring hospitalization and psychopharmacological care (Petersen et al., 2009)....
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TL;DR: The research programme undertakes an analysis of existing mental health policies in four African countries, 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.
Abstract: 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.
155 citations
TL;DR: There has been some progress in the decentralisation of mental health service provision, but substantial gaps in service delivery remain and intervention research is needed to provide evidence of the organisational and human resource mix requirements and cost-effectiveness of a culturally appropriate, task shifting and stepped care approach for severe and common mental disorders at primary healthcare level.
Abstract: In 2000, Rita Thom published a systematic review of mental health services research in southern Africa, conducted from 1967 to 1999. 1 The review suggested a need to shift from centralised institutional care, which characterised apartheid South Africa, towards decentralised, integrated and community-based services provided within a human rights framework. The use of trained non-specialists to provide mental healthcare was also suggested as a strategy to increase access in the context of a shortage of mental health specialists. Research gaps identified included the need for accurate epidemiological studies; intervention studies demonstrating the efficacy of sustainable models of service delivery in line with policy imperatives for deinstitutionalised and integrated primary mental healthcare; and economic evaluation studies of service delivery models. 2 The latter included cost-effectiveness, cost-benefit and cost-utility analyses. Policies and legislation in post-apartheid South Africa have been consistent with the suggestions emanating from this review in a bid to increase access and quality of care within a human rights framework. 3,4
155 citations
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TL;DR: In contexts where specialized psychological services are lacking, the demand for mental health services includes that of psychometric assessment services for mental retardation and/or scholastic problems, and it is suggested that in South Africa, such a 'package' could be provided by the new professional category of 'counsellor'.
Abstract: Care for common mental health problems in medium-resourced countries has been conceptualized by the World Health Organization as needing to be provided by primary health care personnel, in particular primary health care nurses This study, which comprised a file audit of a psychological referral service at primary level in South Africa, suggests that in contexts where specialized psychological services are lacking, the demand for mental health services includes that of psychometric assessment services for mental retardation and/or scholastic problems It is argued that in these contexts, third generation health systems reforms should be applied to the provision of care for more common mental health problems as well as mental retardation and/or scholastic problems in medium-resourced countries This would require the insertion of a 'package' comprised of both psychological assessment and intervention services It is suggested that in South Africa, such a 'package' could be provided by the new professional category of 'counsellor', which the Professional Board of Psychology of the South African Health Professions Council has recently accredited
54 citations
"Planning for district mental health..." refers background in this paper
...…as part of the professional practice framework for Psychology in South Africa in 2003, in response to the unmet need for psychological services in South Africa, with the view to providing counselling and preventive services at the primary level of care (Petersen 2004; Elkonin and Sandison 2006)....
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TL;DR: The authors survey the experiences of the entire first group of community service clinical psychologists in South Africa and find that more than half the respondents experienced difficulty in finding accommodation and office equipment, psychological tests and play therapy materials were not available in many cases.
Abstract: The year 2003 saw the introduction of community service for all graduating clinical psychologists in South Africa. While this year of compulsory service in government health facilities brought the promise of much-needed mental health care to underserved areas, the incumbents' experiences and feedback are a vital source of information for the further development and improvement of this innovation. The present study attempted to survey the experiences of the country's entire first group of community service clinical psychologists. Over two-thirds (n = 52) of the group responded to the mail survey. Among the findings was that more than half the respondents experienced difficulty in finding accommodation. Office equipment, psychological tests and play therapy materials were not available in many cases. About half the sample felt their role was unclear to them and to others, and more than half the respondents were not proficient in the primary language spoken by their patients. Nearly three-quarters of the res...
45 citations
Journal Article•
TL;DR: Community/hospital staff distribution indicates an overemphasis on centralised hospital-based care in most provinces and inadequate hospital care in certain provinces, and patterns of patient service utilisation indicate an over-reliance on central hospital- based services and substantial unmet need.
Abstract: Background: The need to balance resources between community and hospital-based mental health services in the postdeinstitutionalisation era has been well-documented. However, few indicators have been developed to monitor the relationship between community and hospital services, in either developed or developing countries. There is a particular need for such indicators in the South African context, with its history of inequitable services based in custodial institutions under apartheid, and a new policy that proposes the development of more equitable community-based care. Indicators are needed to measure the distribution of resources and the relative utilisation of community and hospital-based services during the reform process. These indicators are potentially useful for assessing the implementation of policy objectives over time. Aims of the Study: To develop and document community/hospital indicators in public sector mental health services in South Africa. Methods: A questionnaire was distributed to provincial mental health coordinators requesting numbers of full-time equivalent (FTE) staff who provide mental health care at all service levels, annual patient admissions to hospitals and annual patient attendances at ambulatory care facilities. The information was supplemented by consultations with mental health coordinators in each of the 9 provinces. Population data were obtained from preliminary findings of the 1996 census. The community/hospital indicator measuring staff distribution was defined as the ratio of staff employed in community settings to all staff, expressed as a percentage. The community/hospital indicator measuring patient service utilisation was defined as the ratio of the annual ambulatory care attendance rate per 100 000 population to the sum of this rate and the annual hospital admission rate per 100 000 population, expressed as a percentage. Results: Of psychiatric public sector staff, 25% are located in community settings in South Africa (provincial range: 11-70%). If hospital outpatient services are included in the definition of ‘‘hospital’’, this figure is reduced to 17% (provincial range: 3-56%). In terms of service utilisation, 66% of patient contacts with mental health services occur through ambulatory care services in South Africa (provincial range: 44-93%). Discussion: Community/hospital staff distribution indicates an overemphasis on centralised hospital-based care in most provinces and inadequate hospital care in certain provinces. Patterns of patient service utilisation indicate an over-reliance on central hospital-based services and substantial unmet need. The findings draw attention to problems in information systems for mental health care in South Africa. Implications for Health Policies: The community/hospital indicators developed for this study form a useful measure for assessing the implementation of mental health policy over time. For the South African context, the community/hospital indicators are a measure of the extent of resource redistribution from hospital to community services and changing patterns of service utilisation over time. Currently, patterns of resource distribution and service utilisation are inconsistent with government policy. Implications for Further Research: Further research is needed into the development of mental health information systems, refining service indicators and improving methodologies for assessing the implementation of mental health policies in service delivery.
37 citations
TL;DR: In this article, the current political changes in South Africa and the realization that there is a need to transform many institutions have resulted in strident calls for changes to mental health policies.
Abstract: The current political changes in South Africa and the realization that there is a need to transform many institutions have resulted in strident calls for changes to mental health policies. However,...
34 citations
"Planning for district mental health..." refers background in this paper
...Given that the majority of psychologists in South Africa have been trained to employ individually oriented treatment modalities (Pillay and Petersen 1996), utilizing these specialist mental health practitioners in training, supervisory and consultant liaison roles would, however, require substantial revisions to existing training programmes to include community psychology theory and practice, as has been suggested by Pillay and Harvey (2006)....
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...Given that the majority of psychologists in South Africa have been trained to employ individually oriented treatment modalities (Pillay and Petersen 1996), utilizing these specialist mental health practitioners in training, supervisory and consultant liaison roles would, however, require…...
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