Mental Health Care Status in South Africa: Impumelelo Social Innovations Centre; Department of Health briefing

Meeting report

The Chairperson began the meeting by wishing former President Mandela a speedy recovery. The agenda originally included a round table discussion with a delegation from Uganda, but owing to passport problems, they were not able to attend. The new agenda included a briefing by the Department of Health on the status of mental health care in South Africa, as well as a last-minute brief presentation by the Impumelelo Social Innovations Centre. This group had done much work nationally and internationally, so it was important for Parliament to learn more about it.

Impumelelo
Ms Rhoda Kadalie, Executive Director of Impumelelo, introduced it as an organization that had started in 1999 as a part of an innovative international network. It was funded mainly by the Ford Foundation, the Open Society Foundation for South Africa and the Canadian International Development Agency, and had sister organizations in the United States, Chile, Brazil, Peru, Philippines, China, Mexico and Kenya. The mission of Impumelelo was to use innovative service delivery, reward those with successful innovative ideas, and then to inspire people to replicate what worked and adopt the innovations. Initially, the organization was an awards programme, as awards were, and remained, the fulcrum around which all the projects revolved. Some pictures of previous award ceremonies, as well as different workshops and projects, were presented to the Committee (see attached document).  It was indicated that the ceremonies were always very well received by the people. Annually, Impumelelo had submitted the top projects to the United Nations (UN) and South Africa had won almost every year. In the past year, South Africa had five projects shortlisted by the UN, which indicated that South Africa had created homegrown solutions to its own problems.

Impumelelo was currently using the award winners to train public officials on the new innovative service delivery methods. The award winners had been taken around the country and had presented their projects so they could be replicated.   A map system had been created to track the progress of different projects in each province.

Ms Kadalie presented the Ndlovu Care Group project as an example of an award-winning project that had been highly successful. This project had been started in Limpopo, where a man had taken out a bond on his home in order to open up a clinic for the local community, run by the locals. The project had a human resource strategy, in that it aimed to provide the local people the skills and knowledge to run the clinic.  This also motivated rural doctors to stay in the rural areas. As a result of this clinic, many other entrepreneurs had emerged from the community to create other projects such as a petrol station, internet café, nappy factory and a successful car wash. A very significant outcome for the community had been the boreholes that had been dug by the community to alleviate their lack of water supply. The community currently had four boreholes, which allowed them to control their own supply of water.

ART clubs
Dr Lynne Wilkinson, project coordinator from Doctors Without Borders, introduced an HIV/AIDS treatment project, ART clubs, that had been piloted in Khayelitsha.  According to the provided statistics, it was said that South Africa had the largest number of people infected with HIV/AIDS, as well as the most people on treatment in the world.  In South Africa, there was a strong focus on starting people on treatment, but maintaining long-term care for those patients wasd largely neglected. The goal was to ensure that 70% of people who started treatment, remained in care after five years, but South Africa was doing very poorly in this regard. The increase in the number of those infected had put great pressure on clinics, as they struggled to find the time and space for all the patients. There was also some frustration shown by those on treatment who were responding very well, yet had to keep coming back to the clinic very often for a long day in order to receive treatment.

As a result, the ART club model had been created to provide quick service options. 30 stable patients would be grouped together and would then arrange to meet at any location outside of the clinic for 45 minutes. At these meetings, they received their pre-packaged treatment and as result were required to go to the clinic only once a year for check-ups. These meetings provided the patients with the opportunity to meet at a time best suited to their schedule and needs, and also to discuss any issues that may have come up. The person who was bringing the medication from the clinic to the groups was also responsible for ensuring that all was going well with the patients and if any issues were noted, they were responsible for having the patient seen at the clinic. The project had been highly successful in Khayelitsha, with 97% retention of patients in the clubs. The model had been looked at by the Western Cape Department of Health, and had been adopted at the provincial level. A team had been developed, and currently there were 670 clubs in the Cape metro region and 17 685 patients enrolled in ART clubs.

Discussion
The Chairperson said the presentation provided an opportunity to show that South Africa had unique challenges but was also unique in finding innovations to deal with such issues.

Ms B Ngcobo (ANC) asked about Impumelelo’s relationship with provincial legislatures. How was the organization working with the National Department of Health since it had started working with the Department of the Western Cape? How did you ensure that the medication was not abused, as there had been incidences where the drug had been sold for profit by patients. Where did the data presented come from?

Ds Wilkinson replied that the statistics used in the presentation were national statistics confirmed by the Department of Health, as well as the World Health Organisation (WHO). Although the data had been proven to be relatively reliable, however, it was known that statistics could not be perfect. On the issue of drug control, she replied that the medicines were pre-packed and labeled per patient, according to script. If the patient was not at the meeting for whatever reason, the medication would be immediately returned to the clinic. There was no need for concern.

Ms D Robinson ((DA) was impressed by the work that was being done and was interested in seeing projects that were being done all over South Africa. Why were African countries not more prevalent as sister organizations? Did the organization expect to be reimbursed or paid when doing training?

Ms Kadalie replied that the Canadian Development Agency (CIDA) had been supporting the training that Impumelelo had done for the past two years. Once a training opportunity became available, they submitted a proposal to CIDA and the process went on from there. Aside from CIDA, the Open Society and the Ford Foundation had been among the highest funders.

Department of Health: State of mental health and mental health services in South Africa
Prof Melvyn Freeman, Chief Director of  Non-Communicable Diseases (NCDs) at the Department of Health, provided a detailed presentation that consisted of an overview of mental health in South Africa, as well as an outline of the mental health services offered.  The World Health Organization (WHO) had recognized mental health as not just a health concern, but also a key towards development. With regard to the prevalence of mental health issues in South Africa, the National Stress and Heath Survey conducted in 2002 had been the last, and probably the only one, done to establish statistical data. There was a need for statistical data, and an understanding of what the numbers meant and their impact on society.  It was strongly emphasised that roughly three-quarters of people with mental health issues in South Africa were currently not receiving any treatment. The shortage of treatment among patients was closely related to the associated high costs incurred.   It had been found that indirect costs resulting from the lack of treatment outweighed the treatment costs by two to six times in developed countries, and even higher in developing countries.

There were many other factors involved when looking at mental health, which included the association between poverty and mental health, the large numbers of children orphaned by AIDS and other diseases, militarized individuals who had returned to civilian life without psychological and social assistance, torture under apartheid, large numbers of unemployed people who had become immobilized by their circumstances, infants and children that received minimal bonding and love from parents, people that worked such long hours that they had little interaction with their families, and stigma and discrimination

Prof Freeman went on to indicate that the past and present were both a part of us, and if those two were not optimal, then one could not function at optimal levels.  If mental health was to be changed, then the conditions that were not optimal to health also had to be changed. In particular, factors of social and economic development were detrimental to the prospect of change in mental health. In other words, the internal factors impacted the external, and vice versa. The Mental Health Care Act of 2002 was provided in detail in an attached document, and was briefly mentioned in the presentation. It was emphasized that mental health needed to be acknowledged as a dimension of health that was dealt with as a condition at all levels, as indicated in the Act. The Act also described when one was legally allowed to assist a person in giving consent for treatment.

Work was needed to improve and increase the number of hospitals that could deal with psychiatric patients.  Psychiatric hospitals should not be seen as the only ones responsible for mental health issues, but also general hospitals and community clinics.  Community healing was also strongly emphasized as an integral part of improving the state of mental health.

The four objectives of the World Health Assembly Resolution 2013 were to strengthen effective leadership and governance for mental health, to provide comprehensive, integrated and responsive mental heath and social care services in community-based settings, to implement strategies for promotion and prevention in mental health, and to strengthen information systems,
and to conduct research for mental health

Prof Freeman presented a list of key challenges facing the country.  These were:

Inadequate community care. People roaming the streets with mental illness mostly did not need hospitalization, but good community care.  Hospitalisation of such people may not only constitute an abuse of their human rights but was more expensive than providing good community care, including housing, social support, etc.

Stigma. People with mental disorders were still subject to discrimination and abuse. The answer to this was not to remove them from society (and thereby subject them to secondary punishment), but to integrate them through educating the public, and providing facilities so that they did not cause harm to others.

Human resources. There were far too few trained professionals to meet the need. More professionals had to be trained, but there was also a need to make the best use of health staff at all levels through integrated mental health care and greater use of community health workers.  There should be more equitable care between the private and public sectors.

Infrastructure. Some mental health facilities were not fit for human habitation and required revitalization or new facilities built. However this had to be balanced with establishing community- based facilities. 

Prioritization of mental health in annual performance plans. Mental health needed to be prioritized so that it became part of not only the national, but also provincial annual performance plans. Without this, mental health would remain the “Cinderella” of health. Neglect of mental health would impact negatively on physical health as well as mental health, given the high co-morbidity. It would also impact on education, productivity, violence etc.

Discussion
Ms M C Dube (ANC) wanted clarity regarding the voluntary, compared to involuntary, committing of patients. Where did one draw the line of who should be admitted involuntarily and how did one decide who had to be treated within the community and who should be institutionalized?

Prof Freeman replied that Chapter Five of the Act was fairly clear about the difference between voluntary and involuntary admission. If a patient had identified that they had a mental health issue, they were able to self-admit at a facility. In South Africa, roughly 80% of the people treated were categorized as involuntary patients who did not agree to treatment. If admitted involuntarily, the patient was required to undergo a 72-hour assessment by two health care practitioners. Involuntary admission was also used in times where patients were admitted due to fear of doing harm to themselves or others.

Ms Ngcobo wanted elaboration regarding the statistic that three-quarters of South Africans who suffered from a mental disorder did not receive treatment. What was the Department doing to reduce that number? What was the relation between poor nutrition and mental illness? How can the structures at a local level be strengthened to have all departments involved in a forum that addressed mental health in the community? What was the protocol on referrals and transporting of mentally ill patients from one location to another? Who should be responsible for transporting the patient?

Prof Freeman replied that the statistic of “three-quarters” was established in a study based on the people who met the diagnostic criteria. There was a need to create a way to assist those included in this statistic, because the majority of them suffered from everyday illnesses, such as depression and anxiety. He replied to the question of nutrition by referring to the ‘outside in story’, in which people were affected by what they eat (or do not eat), as nutrition impacted on both the physical and mental development of people.

Ms P Kopane (DA) asked for a breakdown by provinces of the 16.5% prevalence rate of adult mental disorders. Why was no national data available?  Had a specific study been done on the impact of people in liberation movements in relation to mental health? According to the map in the document, about five provinces did not have child and adolescent clinics -- how was this dealt with? What proportion of the health budget was allocated to mental health?   What was the Department doing to ensure that the budget was actually being used appropriately? How many psychiatrist nurses were there, how many were still in training and how many worked in the departments they were supposed to?

Prof Freeman replied that there was little to no difference in the prevalence rate of adult mental disorders between the provinces.

Dr Precious Matsoso, Director General: Department of Health, replied that the allocation of budget for health services was determined at the national level, after which the provincial level determined the budget of the different health services. There was a concern about priority areas, and the Department had therefore established non-negotiable factors to identify priority areas. There was a monitoring and tracking process to check how the provinces had arranged their budget allocation according to the priority areas. Mental health services had often not received proper attention, and there had also been some abuse of funds in the past.

Ms Robinson thanked the presenters for the thorough and in-depth presentation. How did the Department deal with the lack of funding in order to achieve all the objectives? How did the Department ensure that community care was properly initiated and effectively implemented? Could there be more assistance from the provincial or national level? What did one do to deal with people living in the streets? How could a place be found for them? Had the department come up with any solution for the link between HIV and mental health?

Prof Freeman said there were certain checks and balances that had to be followed with regard to cleaning up the streets. Mental health institutions could not be used to get all the people off the streets, as this was a social development issue. This was primarily why the 72-hour assessment period had been enacted.

Ms T Kenye (ANC) asked what the Department’s plan was to deal with the external factors like apartheid?   Were there any support centres for counselling so that patients had on-going care after rehab to maintain the recovery process? How could a national suicide prevention plan be achieved?

Ms H Makhuba (IFP) asked what the challenges were in working with the Department of Social Development to provide social support to families of patients?  Were there forensic psychiatric units in all of the nine provinces?

Ms M Segale-Diswai (ANC) asked for clarity on the people who used ambulances to travel from one province to another.

The Chairperson said that due to time constraints and the large number of questions, answers would have to be submitted in writing.

The meeting was adjourned.