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: There were low levels of inpatient service provision in South Africa, and there was considerable variability between provinces, giving further support to the need to develop acute inpatient psychiatric services, reduce levels of chronic care where appropriate, and redirect resources towards the development of community-level residential and day-care services.
Abstract: Background In post-apartheid South Africa, mental health service planners face critical decisions regarding appropriate and affordable inpatient care. Before a fashion of deinstitutionalisation is followed blindly in South Africa, effective community services should be in place and sufficient psychiatric beds should remain in hospitals for those who cannot be catered for in the community. In order to maintain the delicate balance between hospital and community-based services, it is essential that useful indicators of inpatient care are established. This study documents current bed/population ratios per 100 000 population in public sector mental health services in South Africa. Method A questionnaire was distributed to provincial mental health coordinators requesting psychiatric bed numbers in acute and medium-long stay facilities across all service levels. The information was supplemented by consultations with mental health coordinators in each of the nine provinces. Population data were obtained from preliminary findings of the 1996 census. Results For acute facilities, the mean bed/population ratio was 13 (provincial range: 6–18) per 100 000 population. For medium-long stay facilities, it was 16 (provincial range: 0–29) excluding contracted facilities, and 35 (provincial range: 0–83) including contracted facilities per 100 000 population. Conclusions There were low levels of inpatient service provision in South Africa, and there was considerable variability between provinces. This study gives further support to the need to develop acute inpatient psychiatric services, reduce levels of chronic care where appropriate, and redirect resources towards the development of community-level residential and day-care services. It is crucial to develop accurate indicators to monitor this process.
34 citations
"Planning for district mental health..." refers background in this paper
...…staff/population ratios, admission rates and community/hospital ratios (Lund and Flisher 2001; Lund and Flisher 2002a; Lund and Flisher 2002b; Lund et al. 2002; Flisher et al. 2003; Lund and Flisher 2003; Dawes et al. 2004; Lund and Flisher 2006), the mechanisms for monitoring…...
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...While there has been extensive work on the development of norms and standards for integrated primary mental health care such as bed/population, staff/population ratios, admission rates and community/hospital ratios (Lund and Flisher 2001; Lund and Flisher 2002a; Lund and Flisher 2002b; Lund et al. 2002; Flisher et al. 2003; Lund and Flisher 2003; Dawes et al. 2004; Lund and Flisher 2006), the mechanisms for monitoring service delivery remain weak, particularly at district level....
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TL;DR: The rationale and sense behind the Mental Health Care Act is outlined, the problems encountered at the 'rock face', and solutions to the problem of translating principles into practice are offered.
Abstract: Legislation prior to 2002 tended to reinforce the alienation, stigmatisation and disempowerment of mentally ill patients in South Africa. In line with international developments in mental health legislation, the Mental Health Care Act (2002) was promulgated in South Africa. Its core principles--human rights for users; decentralisation and integration of mental health care at primary, secondary and tertiary levels of care; and a focus on care, treatment and rehabilitation--are progressive and laudable. However, the task of implementing the requirements of the Act at community and district hospital levels is fraught with problems. Lack of infrastructure, inadequate skills and poor support and training undermine its successful implementation. Health workers already burdened with enormous workloads and inadequate resources struggle to manage mentally ill patients at district hospitals. The 72- hour observation is a particular area of difficulty throughout the country. This paper outlines the rationale and sense behind this legislation, discusses the problems encountered at the 'rock face', and offers solutions to the problem of translating principles into practice.
34 citations
"Planning for district mental health..." refers background in this paper
...The protection of society prevailed over the human rights of the individual (Burns 2008)....
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Journal Article•
TL;DR: Although the national mean bed occupancy is compatible with international figures, there is considerable discrepancy between provinces, indicating both over- and under- utilisation of inpatient resources.
Abstract: Background: In post-apartheid South Africa the organisation and delivery of mental health care is undergoing significant change. With the heritage of an under-resourced, fragmented, racially inequitable service, heavily reliant on chronic custodial treatment in large centralised institutions, this change is long overdue. New policy has set out a vision for a community-based, comprehensive, integrated mental health service. In order to realise this vision a review is required of the way in which care is currently delivered, or the “process” of mental health care. To date, no national research has been conducted regarding process of care indicators in South African mental health services. Aims of the Study: This study documents four public sector mental health service process indicators in South Africa: bed occupancy rates, admission rates, average length of stay and default rates. Methods: A questionnaire was distributed to provincial mental health co-ordinators, requesting numbers of occupied and available beds in psychiatric inpatient facilities, annual mental health admissions, average length of stay (ALOS), and default rate in ambulatory care settings. The information was supplemented by consultations with mental health co-ordinators in each of the 9 provinces. Results: The national bed occupancy rate is 83% (range: 63-109%). The national annual rate of admission to psychiatric inpatient facilities is 150 per 100 000 population (range: 33-300). The national average length of admission is 219 days in psychiatric hospitals, 11 days in general regional hospitals and 7 days in general district hospitals. On average 11% of psychiatric patients who attend ambulatory care services on a monthly basis fail to keep their appointments. Discussion: Although the national mean bed occupancy is compatible with international figures, there is considerable discrepancy between provinces, indicating both over- and underutilisation of inpatient resources. Admission rates are low, relative to developed countries, though comparable to developing countries. Low admission rates are associated with a range of factors including inadequate service provision, unmet need, inaccessible services, cross-border flow between provinces and custodial patterns of care. There is evidence of long periods of admission relative to international settings. There is also considerable diversity between provinces, with certain institutions continuing to provide long term custodial patterns of care. Default rates are low relative to international settings and past reports default in South Africa. Implications for Health Policies: In keeping with current policies there is an urgent need for local level evaluation and reform of chronic custodial care. The ongoing monitoring of process indicators is important in the transition to community-based mental health care. Implications for Further Research: Limitations of the data, and problems of collecting information on mental health care within an integrated health system indicate the need for further research in this area. There is also a need for further research into unmet need for mental health care in South Africa.
28 citations
Journal Article•
TL;DR: Staff/bed ratios in South African mental health care are low relative to developed countries, and staff/DPV ratios highlight both the need to develop ambulatory care personnel formental health care, and problems associated with monitoring the delivery and utilisation of mental health services within an integrated health system at primary level.
Abstract: Objectives. To document staff/bed and staff/patient ratios in public sector mental health services in South Africa.
Design. Cross-sectional survey.
Method. A questionnaire was distributed to provincial mental health co-ordinators requesting numbers of full-time equivalent (FTE) staff who provide mental health care at all service levels; numbers of psychiatric beds; and numbers of patients who attend outpatient departments, clinics and community health centres. The information was supplemented by consultations with mental health co-ordinators in each of the nine provinces.
Results. The staff/bed ratio for the country as a whole was 0.3 staff per bed. For the provinces, the staff/bed ratios were as follows: Eastern Cape 0.30, Free State 0.50, Gauteng 0.22, KwaZulu-Natal 0.34, Mpumalanga 0.89, North-West 0.27, Northern Cape 0.26, Northern Province 0.26, and Western Cape 0.59. For the country as a whole, the staff/bed ratios for each category of staff were as follows: total nursing staff 0.25, occupational therapists 0.01, occupational therapy assistants 0.01, social workers 0.01, community health workers 0.00, psychologists 0.00, intern psychologists 0.00, psychiatrists 0.00, psychiatric registrars 0.01, and medical officers 0.00. The ratio of ambulatory psychiatric service staff to daily patient visits (DPV) for the country as a whole was 0.6.
Conclusions. Staff/bed ratios in South African mental health care are low relative to developed countries. Staff/DPV ratios highlight both the need to develop ambulatory care personnel for mental health care, and problems associated with monitoring the delivery and utilisation of mental health services within an integrated health system at primary level.
S Afri Med J 2002; 92: 157-161.
26 citations
TL;DR: The professional category of Bachelor of Psychology (B.Psych.) Registered Counsellor was created in order to deliver psychological services at a primary health care level to previously disadvantageing individuals.
Abstract: The professional category of Bachelor of Psychology (B.Psych.) Registered Counsellor was created in order to deliver psychological services at a primary health care level to previously disadvantage...
21 citations
"Planning for district mental health..." refers background in this paper
...This category of mental health professional was officially introduced 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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...…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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