Only one oral submission was presented in the public hearings on the Mental Health Amendment Bill, from the South African Military Health Service (SAMHS). The representative noted that he was also a past President of the South African Society of Psychiatrists (SASOP) and he would touch also on this organisation’s concerns. The changes that were requested were aimed at establishing clarity about, and improvements to the working relationship between the SAMHS and the Department of Health (DOH). By way of introduction, the hierarchical structure and the patients served by SAMHS were outlined. These included VIPs and some foreign personnel. The position of the Surgeon-General needed to be recognised, particularly since there was not clarity amongst others about the position of the military hospitals, and the fact that SAMHS must comply with all directives and policies of the DOH. Because the previous legislation had not been clear, the regulations took exceptionally long to be finalised, and the procedures were bound by red tape, many mental health practitioners operated, in practice, under the provisions of the old Mental Health Care Act, although they were aware that this was not correct. He urged that the position of the SAMHS in relation to observation of patients should also be clarified. At the moment, SAMHS itself would put patients under 72-hour observation but when they were referred to the appropriate institution, the 72 hours observation was repeated instead of the patients being put immediately under treatment, which was obviously to their detriment. The representative urged that there needed to be a clear agreement as to the role of the provincial hospitals and SAMHS.
Members noted that these concerns did not directly address the content of the Bill, but the Chairperson was happy that the issues were raised and said that Members should also ask wider questions if they wished. The intention behind the amendments, namely to clarify the delegation of authority and to amend the position of the Board, was noted, but the Committee would consider whether it was possible to address the concerns of SAMHS. Members asked about the protocol and lines of authority, the working relationship between the SAMHS and DOH, whether it was necessary to introduce more military hospitals, and asked about the consultation done by the DOH and where these public hearings were advertised, in view of the limited number of submissions. They asked how representative SASOP was of all practitioners in the field, and wondered if SANHS needed to be specifically named, as they believed that SAMHS must comply with DOH policies and procedures.
The Department commented that although there was at some stage a Memorandum of Understanding drawn up, the position of SAMHS was similar to that of Department of Correctional Services, which would refer patients and be billed by the provincial hospitals. Reference was made to the National Health Council, on which SAMHS was represented, and that had approved the legislation, so the processes were in place. The DOH was reluctant to specify the SAMHS in any written certification, as it was recognised as a self-standing entity under the DOH, but it would be useful to clarify its purpose and relationships through collaborative partnerships.
Mental Health Care Amendment Bill: Public Hearings
The Chairperson noted that only one oral submission had been requested. He noted the presence of the Department of Health (DOH) officials.
South African Military Health Services submission
Dr Thabo Rangaka, Principal Psychiatrist, South African Military Health Services, said that he was also at one stage the President of the South African Society of Psychiatrists (SASOP) and he would touch also on this organisation’s concerns about the Mental Health Amendment Bill (the Bill). He was putting forward the viewpoint of the Surgeon-General, and was requesting changes that would enable better working between the Department of Defence (DOD) and Department of Health (DOH).
He noted the DOD vision to have a healthy military community, which included soldiers, dependents and military veterans. The organogram of the South African Military Health Services (SAMHS) was tabled, noting the representation of both the current forces and military veterans, since SAMHS had responsibility for ensuring medical support to the members of the Navy, Air Force and Army. The "secondary clients" would also include the ex-President and other VIPs, and other members from provincial or local government departments who chose to attend the military health facilities, and clients as approved by National Treasury from other countries, such as VIPs who required stringent security measures.
He explained a little more about the structures and said that the Tertiary Military Health Formation comprised of three hospitals. In fact, however, many of the DOD personnel were treated at the private sector and were not fully treated by SAMHS. There was also a mobile health formation, which visited the borders and organised external missions. The Training Formation focused on training nurses and other staff, and there was also a supply sector for beds and equipment.
The Surgeon-General, from 1901 to the present, had a position in the DOD similar to that of the Minister of Health. The Commander in Chief (the President) could instruct the military to assist the Department of Health to keep health services going, should there be strike action. However, the position of the military, and particularly the Surgeon-General, vis a vis the DOH, as set out in the existing Mental Health Act was not clear. The responsibilities of the Surgeon-General (who had always been a male) had to be fully appreciated.
Practitioners in the mental health field had welcomed the Mental Health Care Act of 2002, because it had been protective of patients' rights and care. From the doctors' point of view, specifically psychiatrists, there was, however, a problem in the length of time that it took for the passing of regulations to put the legislation fully into effect. This had created confusion in the transition from the 1973 to the 2002 legislation, with the result that many private practitioners in reality had reverted to using the old legislation in order to get patients admitted, although this was not actually correct.
SACOP recommended changes to the regulations to ease the process of certifying a person as mentally ill. General practitioners should not be able to shy away from their responsibilities because they did not understand the legislation.
SAMHS main concern related to the lack of clarity about the position of SAMHS in the whole health sector structure. Its existence was not covered in terms. This resulted in the DOD tending to behave as "a tenth province"; it was aware of the legislation and regulations, but operated almost independently, knowing that it may be in contravention of the strict tenets of the legislation, but also recognizing that, for practical purposes, there were special requirements for dealing with the military and VIPs. This included the need for extreme secrecy, especially as many of the more prominent people - like VIPs - may need to be "hidden" away in private institutions. When SAMHS practitioners handled such cases, the patients were often dealt with as general health users, rather than mental healthcare users. Dr Rangaka therefore asked that specific mention be included, in the definitions section, of the SAMHS and that there should be a specific acknowledgment of the role of the Surgeon-General.
He also wanted to speak to the designation of health establishments. There were questions as to whether military health services in general, including clinics and hospitals, were "state" institutions. He was sure that they were, but noted that others did not necessarily agree with him. He noted that clause 1 of the Bill required the consent of the "head of the relevant provincial department". He suggested that this should be amended to include a reference to “or Surgeon-General of the DOD”. Alternatively, it should be clarified somewhere that the Surgeon-General was the head of the national military health structure, although he recognised that this might be problematic and cause confusion as to how exactly this post fitted into the hierarchical structure of health services in general. Whatever way was chosen, SAMSH should be specifically stated as included.
The present uncertainty in the Act and regulations meant that military patients were not handled with sufficient speed. SAMHS did its own patient observations for 72 hours, but instead of these patients then being admitted to the appropriate institution for treatment, in practice they would be sent to the provincial hospitals, which undertook their own 72-hour observation in addition to that done already by SAMHS. This delayed their treatment.
Dr Rangaka also noted that violence was an ever-present problem, given the nature and stress of the military services. Although soldiers tended to show better discipline and more restraint when they were with their supervising officers, they may not be able to contain their violence and aggression in a civilian situation, and it was certainly not easy to contain them when they were under observation in a hospital, so that the further 72-hour observation period served little purpose.
The majority of the patients under the SAMHS were families of soldiers. SAMHS offered several programmes that attempted to counter the disruptions that active service caused. These patients should be able to be treated in military hospitals in the same way as in the regular provincial hospitals.
The Chairperson noted the comment that the old legislation had been very cumbersome and had caused problems to the Director General of the Department of Health. The amendments contained in the Bill were largely intended to allow delegation of authority, in order to improve service delivery, and the other substantive matter in the Bill related to amendments of the Boards. He explained the purpose of the public hearings. The comments from SAMHS seemed to be focusing not on the wording of the Bill as it stood, but on the concerns that SAMHS had not been included or factored into the system, or that there was misunderstanding about the military health environment. The Committee would need to consider whether further amendments could be crafted to answer these concerns.
Ms Precious Matsoso, Director General, Department of Health, at the request of the Chairperson, introduced her team, and said that they could respond.
Ms M Dube (ANC) asked for clarity on the point that the Minister of Health had authority for health in general. She asked how the protocols applied to the military, and was not clear about the relative positions of the military and general health services.
Ms M Segale-Diswai (ANC) enquired about the working relationship between the military and DOH. She would have thought that, similar to Department of Correctional Services, there should be operational links.
Ms H Msweli (IFP) asked if the SAMHS could introduce more military hospitals. Some provinces had none, although there were patients in every province.
Ms P Kopane (DA) said that although her question did not relate directly to the presentation, she wanted to know why there were not more submissions. She asked for an indication of who was consulted.
Ms D Robinson (DA) added to this, and asked where these public hearings were advertised. She had spoken to some people who seemed to be unaware of the Bill and she was concerned around the input.
The Chairperson noted that this question would be discussed in the Committee.
Ms C Dudley (ACDP) asked if Dr Rangaka was still directly linked to the Society of Psychiatrists, who had merely indicated that they reserved the right to make further comments. She also noted if SASOP was broadly representative of practitioners in public, private and military sectors, as the Committee needed to know if it was hearing the views of all concerned professionals.
The Chairperson commented that the discussion seemed to be spilling over into a more generalised debate about mental health matters. However, since there was sufficient time to deal with these concerns, he encouraged Members to ask such broader questions.
Ms T Kenye (ANC) referred to the "tenth province" of the SANDF and then the comment that SAMHS should be specifically named. She wondered if these were not contradictory statements.
Dr Rangaka noted that in 2005, the then-Ministers of Defence and Health had signed a Memorandum of Understanding, which had recognised that SAMHS and DOH were crucial partners in health services. However, there was no definite statement to the effect that SAMHS actually fell under the DOH. Just as nobody else could be expected to head up defence services, only DOH should head up health services. The "tenth province" would remain, because SAMHS was a permanent part of the nation, but the point was that it should be properly placed under DOH, and the responsibilities and lines of reporting made clear.
Dr Rangaka noted the comment on shortage of hospitals but did not necessarily agree that there was a need to establish more. He noted that in accordance with the previous agreements by the Ministers of Defence and Health, military patients, wherever situated, could be treated at local hospitals, who would then send an account to the Department of Defence. He agreed that there was no military hospital in KwaZulu Natal or Eastern Cape, which sometimes meant that patients were travelling far, to Pretoria or Free State, for care at another military hospital. There had been many attempts, since 2006, to bring the SAMHS hospitals on the same footing as other state hospitals, in relation to treatment.
Dr Rangaka said that SASOP was the only organised grouping of psychiatrists, with about 400 members. It therefore spoke with a unified voice, for psychiatrists in the private, public and military services. It was definitely keeping tabs on the developments and did interact with the DOH. Recently, it had held discussions with the Deputy Minister of Health about mental health issues. SASOP had an able group of managers to handle secretarial services, and it was via this organisation that he had received notification of the public hearings on the Bill.
The Chairperson asked the Department of Health to comment on how these health services fitted together.;
Ms Matsoso referred to the National Health Act, which established a National Health Council (NHC) and technical advice committee. The NHC was chaired by the Minister of Health and the members included provincial MECs, SAMHS and the South African Local Government Association (SALGA). Any proposal for new legislation would be endorsed in that Council. Since the Surgeon-General was a member of the NHC, he would have had an opportunity to give input on the position of SAMHS. The proper processes for this Bill had been followed.
Ms Matsoso agreed that the Department of Correctional Services (DCS) also rendered health services to its inmates and staff. The DOH and DCS had a draft Memorandum of Understanding. These services were run with the support of the provincial department, who would then bill DCS for any services that provincial hospitals rendered. SAMHS also had healthworker officials, who rendered services internally. DOH, in practice, would then collect the money on behalf of the provincial departments who had not been paid for services rendered to DOD or DCS.
The Acting Committee Secretary commented that the advertisements of the public hearings were published in four languages, although he still needed to check which newspapers were used.
The Chairperson explained that the Committee Secretary was currently on leave. He seemed to recall advertisements in the Daily Dispatch and Cape Argus, and he thought that radio notifications were also used, similar to what had been done before. However, before any bill was referred to Parliament, the DOH would also call for public comments. This was done in this case, and there were very few comments. This either indicated that people were supportive of the Bill and thought the amendments should have been done long ago, or that they felt they would not impact, or that the amendments were regarded as having a positive effect on service delivery.
The Chairperson noted the comments in relation to DOD and DCS and said that both had internal medical staff, although he did note that both military and non-military patients could be referred by SAMHS to the military hospitals. He asked if SAMHS billed “external” patients for these services.
Ms Agnes Mabotsha, Legislative drafter and researcher, DOH, noted that section 44 gave the national DOH broad powers to provide a legislative framework for provision of healthcare services in the country. It also, in terms of Schedule 4, had the power to draw a policy framework. No matter who offered the services, whether SAMHS or DCS or any other relevant health body, they would have to be guided by the broad legislative and policy frameworks of the DOH.
Ms Dube agreed fully with this statement. She felt that the submissions by SAMHS seemed to fall outside the ambit of the Bill. Clearly, there was a need to clarify the working relationship, but she believed that other legislation already clarified the position.
Ms Kenye urged again that the number of military hospitals had to be increased.
Dr Rangaka agreed that there was supposed to be a working relationship between SAMHS and DOH, so that the provincial hospitals could take on patients. For this reason, he reiterated that he did not agree that there was a need to increase the numbers of military hospitals. The World Health Organisation (WHO) was urging for a primary healthcare approach to patients globally, as opposed to a focus on tertiary services. The SAMHS was equipped to do this, although he conceded that perhaps the DOH needed to harness the energy of SAMHS and give more specific instructions to the provincial departments, and to the Surgeon-General.
Ms Kopane appreciated the remarks from the DOH, and thought that the NHC would have covered the consultation questions. However, there might be some doubt around whether the Surgeon-General had conveyed the SAMHS concerns clearly enough to this Council.
The Chairperson said that it would not be easy to confirm how the misunderstanding arose, and commented that correct exchange of information worked in two directions. He appreciated that it was very difficult for Dr Rangaka to comment on the performance or understanding of the Surgeon-General. The SAMHS and public health were both in the public service, but the difference was that when security was a major concern; SAMHS had to handle these patients.
The Chairperson reiterated that it seemed that the correct place for Dr Rangaka’s concerns to be noted was at the NHC. However, this Committee had noted his comments, and would still discuss his, and other written submissions, to try to craft a Bill that would answer as many of the concerns as possible.
Dr Rangaka said that the NHC should perhaps have already considered the problems that had arisen in the past. He suggested that section 5 of the Mental Health Act could be amended so that the phrase reading “with the concurrence of the head of relevant provincial departments” could also include some reference to the Surgeon-General. This would make it quite clear that he had the responsibility to act in a certain way. Alternatively, either the regulations, or even a Memorandum or certification from the DOH might be used to make it clear, in writing, that SAMHS was regarded in the same light as other state hospitals. Without that being clarified, the SAMHS was likely to continue to labour under misapprehensions.
Dr Rangaka finally noted that it was crucial for the DOH, when it introduced legislation, to communicate directly with the professional medical associations in specific fields as advertising in newspapers was really not so effective.
The Chairperson noted that the Committee would consider whether the contact with the stakeholders was adequate.
Ms Matsoso noted that SAMHS and SALGA were the only institutions mentioned directly as serving on the NHC, in the Mental Health Act. That vehicle must be recognised. If the NHC had passed a resolution, provincial health departments had to implement it. However, provincial departments and SAMHS had their own laws, and this must also be recognised. In some instances, the DOH did rely on SAMHS to provide support - for instance, during strikes, during major events such as the World Cup. SAMHS would in these cases bill DOH for the services it rendered. She cautioned that it was not proper for SAMHS to be stated as falling under DOH, because it was a self-standing organisation, established for a specific purpose, under the DOD. However, she agreed that it would be useful to clarify its purpose and relationships. She stressed that collaborative partnerships, rather than a strict hierarchal structure, were rather needed.
The Chairperson commented that there had not been a female Surgeon-General and said that this was something that needed to be looked into.
The Chairperson said also that there should be wider appreciation of the regulations. Although Parliament did rely on departments to prepare regulations, there was ongoing discussion about its role in this regard.
The meeting was adjourned.
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