Parliament commemorated World Mental Health Day on 10 October 2013. The Portfolio Committee on Health invited the Department of Health (DOH), the Program for Improving Mental Health Care (PRIME) and other organizations and individuals to speak on the issue of mental health and the related issues that need to be addressed.
The Department of Health presented its report on scaling up investment in mental health. Only 25% of those with a mental disorder have access to formal mental health services. Mental health system challenges include weak institutional capacity, old infrastructure, inequity in the distribution of resources among and within provinces, over-reliance on specialized psychiatric hospitals, limited investment in community-based mental health care and primary mental care, limited information on mental health, challenges with the production, supply and retention of mental health practitioners, and problems with access to mental health technology, equipment, and medicines.
The provisional figure of psychiatrists and psychologists in the public sector is 70. The Department of Social Development (DSD) had inaugurated a drug authority in March 2013. President Jacob Zuma had proclaimed the Prevention of Treatment of Substance Abuse Act. The Minister of Social Development had made the regulations for this Act.
The National Drug Master Plan approved this year, which will run from 2013-2017, has 3 pillars: demand reduction, supply reduction (law enforcement) and harm reduction (prevention and treatment). The DSD is embarking on an Awareness Campaign with the DOH, the NGO sector and community-based organizations. Treatment centres have been established around the country, especially in the rural areas. There are 47 private treatment centres, and government funds 25 of these. Government has gone further to combat substance abuse with an inter-ministerial committee. Government is dealing with alcohol outlets around the country to fight alcohol abuse in South Africa.
Currently, 2 135 beds are available for psychiatric patients in the Western Cape. There are plans to provide more 216 more beds over the next two years. South African Federation for Mental Health (SAFMH) said that mental health gets a small proportion of the health budget when in actual fact psychiatric disorder is the third highest cause of the health burden in South Africa. The South African Depression and Anxiety Group (SADAG) offers volunteer calls for mental therapy. The group receives a lot of suicide calls on its help line. 22 people commit suicide, and 220 attempt suicide, per day in South Africa..
Members and other stakeholder asked about supporting churches which have been helping people with mental health prevention and treatment. They also asked if government can provide licensed traditional and divine healers for patients who prefer to be treated by them. They asked what government will do with financial policies in cases of suicide, as they do not release financial support, even though suicide is a mental health problem. They asked what criteria are used in determining how much money is allocated to each province. The panel responded to the questions and highlighted that steps are being taken to address the issues, and a report will be provided to give information on progress.
The Chairperson said that mental health is a functional problem. People tend to shy away from mental health issues. One cause is a cultural issue, resulting from the diversity in South African society -- what is normal to one culture is abnormal to another. There are divine healers and traditional doctors in some cultures. South Africa’s past also affects how mental health services are handled.
The Chairperson said that from reading the National Development Plan, he noted that South Africans did not trust one another as a result of what had happened in the past. There was no trust between the private sector and the public sector, between communities and the private sector, and so on. This affected the status of mental health and must be dealt with. Mental health is harder to address than physical illness. He referred to the migrant labour system. Families were broken as kids grew up in fatherless homes and became more prone to psychopathic behaviour. These were some of the challenges South Africans face. Psychologists and psychiatrists needed to intervene.
Department of Mental Health
Mr Sifiso Phakathi, Director of Mental Health and Substance Abuse in the National Department of Health (DoH), made a presentation titled ‘Scaling Up investment in Mental Health’. The Department of Health is busy in October. The director general was in Geneva and excused from this meeting. The DOH had last presented to the Committee on 12 June 2013. The DoH aimed to update the Committee on their plans by providing an overview of the key findings of the review of mental health services initiated by the Minister of Health in 2011.
Mr Phakathi described priority actions/interventions that are being implemented to further transform the mental health system. In 2011, the National Health Council (NHC) had resolved that mental health services be reviewed. Provincial summits led by MEC’s had been held in all nine provinces. The National Summit was based on the theme “Scaling up investment in mental health for a long and healthy life for all South Africans.” The Summit had reviewed quantity and quality of mental health services provided, identified key challenges in the mental health care system, provided information on best practices, and agreed on priorities that must be implemented as part of the re-organization and further strengthening of the health system. The Summit had adopted the “Ekurhuleni Declaration” which consisted of 11 action areas. The Summit had committed to using the outputs to finalise the “Mental Health Policy Framework 2013-2020”. There has been good progress made in enacting mental health policy, but there were still many challenges, especially with implementation.
Neuro-psychiatric disorders ranked third in their contribution to the overall burden of disease in South Africa – after HIV and AIDS and other infectious diseases. The most common mental health disorders are depression, anxiety, and substance abuse. There is an intersection between mental health and other health priorities and outcomes. There exists a gap between demand for and supply of mental health services. Only 25% of those with a mental disorder had access to formal mental health services. Mental health systems’ weaknesses include weak institutional capacity, old infrastructure, inequity in distribution of resources among and within provinces, over-reliance on specialized psychiatric hospitals, limited investment in community-based mental health care and primary mental care, limited information on mental health, challenges with production, supply and retention of mental health practitioners, and challenges with access to mental health technology, equipment, and medicines. The provisional figure of psychiatrists and psychologists in the public sector is 70. The migration of psychiatric nurses adversely affected mental health environment.
There is a prevalence of stigma and discrimination surrounding mental health. There is also public ignorance about mental health. Evidence shows that mental health interventions have been effective. What is being done is that subsequent to the summit, a working group of stakeholders drew up a strategic plan adopted for implementation by the NHC. The eight catalytic objectives were aligned with the World Health Organisation (WHO) comprehensive mental health action plan for 2013-2020. A substantial amount of money is allocated to long-stay facilities and specialist psychiatric services (top tier). The bottom tier is self-care – there is limited investment in community-based health care facilities. The DoH aims to redistribute the allocation of funds. Families need self-agency in dealing with problems. The DoH aims to develop community facilities for vagabonds and families who choose to use mental health care facilities. It is critical and urgent that services for intellectual disabilities and related facilities be revitalized.
The first catalyst is to implement a district-based mental health service and align this with the primary health care, with the initial focus on National Health Insurance (NHI) pilots. This involves establishing one specialist mental health team in each district, and designating selected health centres and clinics to provide psychological services, including mental health, as part of chronic care. As a priority, the National Health Council has decided to introduce specialized mental health teams in each of the districts and implementation will start off with the 11 NHI pilot sites, where mental health has already been included as part of chronic health care in primary health care services. All nine provinces have review boards. There are plans to establish a way of collecting mental health data for future planning. The Department hopes that funding to role this out will be available.
The second catalyst is institutional capacity building, which includes establishing and appropriately staffing mental health directorates in each of the nine provinces and establishing functional Mental Health Review Boards, in keeping with the Mental Health Care Act. Currently there is a big question mark regarding the functionality of Mental health Review Boards.
Under catalyst three -- which is surveillance, research, and innovation -- there is a plan to develop and implement a monitoring and evaluation system to track and report progress with the implementation of the “Health Sector Drug Master Plan.”
Catalyst four is infrastructure and capacity of facilities, which involves the Council for Scientific and Industrial Research (CSIR) being appointed to provide design specifications to comply with the Mental Health Care Act, and to establish a specialised psychiatric hospital in Mpumalanga province. The plan includes revitalizing dilapidated health facilities in all provinces and developing community residential care facilities to provide accommodation for deinstitutionalised service users.
Catalyst five is mental health technology, equipment, and medicines, to make all psychotropic medicines available and to equip clinics and health centres with psychology infrastructure and equipment.
Catalyst six is inter-sectoral collaboration, where mental health will be included on the agenda and mental health representation will be assured on the newly established National Health Commission.
Catalyst seven is human resources for mental health, which involves training health professionals who will rotate through psychiatric units in district and regional general hospitals, and selected key staff in every primary health facility will receive basic mental health training. Primary Care 101 guidelines and language competency of all mental health professionals will be improved, particularly in indigenous African languages.
Catalyst eight is advocacy, mental health promotion and prevention of mental illness, where a national public education programme for mental health will be established, including knowledge about mental health and illness, stigma and discrimination against people with mental illness, and services that are available. As a way forward, road shows on the Mental Health Policy Framework and Strategic Plan will be held to popularize the plan and to support provinces develop provincial plans, secure funding and implement the plan. Periodical reports on progress will be submitted to the National Health Council.
Mr Mogomotsi Modimo, the Director for Substance Abuse and chairperson of the Central Drug Authority in the Department of Social Development (DSD) said there is a need to acknowledge drug and alcohol abuse have a negative impact on mental health. The DSD had inaugurated a drug authority in March 2013. President Jacob Zuma had proclaimed the Prevention of Treatment of Substance Abuse Act. The Minister of Social Development had made the regulations for this Act.
The National Drug Master Plan approved this year, which will run from 2013-2017, has 3 pillars: demand reduction, supply reduction (law enforcement) and harm reduction (prevention and treatment). The DSD is embarking on an Awareness Campaign with the DOH, the NGO sector and community-based organizations. The DSD can handle treatment only to a certain level – reducing the harm of substance abuse. Beyond that they have to hand over to the rest of DOH to treat more severe cases. Treatment centres have been established around the country, especially in the rural areas. There are 47 private treatment centres, and government funds 25 of these. Government has gone further to combat substance abuse with an inter-ministerial committee. Government is dealing with alcohol outlets around the country to fight alcohol abuse in South Africa.
Mr Frank Makwa, assistant parliamentary officer in the Ministry of Health, from the Western Cape Department of Health, spoke about the problem of the substance abuse epidemic. In the Western Cape, there were 255 000 mental health visits to the clinic, 6 000 in-patient admissions and 28 000 out-patient visits. The Department wants to strengthen and have more community-based households and assertive community teams to improve service for mental health uses. The Department will increase the number of nurses to strengthen service at the primary care level.
There is a need to provide more regional hospital-level beds in the province. At the moment, 2 135 beds are available for psychiatric patients. The Department aims to provide 216 more beds over the next two years at Valkenberg Hospital, a key psychiatric institution. In 2014 the Department aims to have 30 new beds at Mitchell’s Plain Hospital and 64 beds at regional hospital level. The Department will also focus on providing beds in rural areas. The challenges the province face are the pressure of dealing with drug abuse, as poverty and violence are also increasing problems. Child and adolescent services are the most vulnerable and neglected.
Ms Samantha Hanslo, Adherence and Psychological Advisor for the South to South at Stellenbosch University, shared her own experience and said the way her psychiatrist had treated her had made her experience more bearable. She is now a qualified psychologist working in an HIV unit, and is passionate about working with health care workers.
Ms Bharti Patel, National Director of the South African Federation for Mental Health (SAFMH) said that mental health gets a small proportion of the health budget, when in actual fact psychiatric disorders are the third highest cause of South Africa’s health burden. 75% of people with mental health problems in the country do not receive the care that they need. She had emphasized need to raise awareness about this at the 2012 Mental Health Summit. SA mental health services are fragmented. The SAFMH is an NGO that focuses on capacitation, research and human rights awareness, consumer advocacy movements, and awareness campaigns to remove stigma. She spoke of the decreasing amount of money received from the government by the Federation. She recommended that mental health is included in national health care decisions. Government must partner with NGOs to make mental health a priority for all.
Ms Elizabeth Matare, CEO of South African Depression and Anxiety Group (SADAG), talked about what the group does and the challenges it faced. The group offers volunteer calls for mental therapy. This call centre receives about 400 calls per day. The group receives a lot of suicide calls on the help line. In South Africa, 22 people commit suicide per day, and 220 attempt suicide per day. On behalf of SADAG, she asked for a National Suicide Prevention surveillance programme from the Department.
SADAG gives suicide prevention talks to children at schools. They run a 24/7 substance abuse helpline. They carry out a door-to-door campaign in all provinces, with promotional materials. They distribute wristbands, advertising the helpline number. The booklets SADAG hands out address the language issue, as they are in the 11 official languages. It also distributes “speaking books” for people who cannot read.
SADAG runs 238 support groups in SA. Mental health, HIV/AIDS and substance abuse are linked and SADAG is dealing with this. Ms Matare expressed concern about access to quality mental health care and said that action needs to be taken immediately. She is also concerned about financing, as less than 4% of the health budget is for mental health care. She asked that mental health be given the attention it deserves.
Ms Elsabe Brits, science journalist from Die Burger, has bipolar mood disorder and wrote a book about her illness. There are not enough psychiatric hospitals in SA. Mental illness can be treated. Non-communicable illnesses are on the rise and the effects are dreadful. With the right treatment, patients can contribute to society. She closed with the sentence, “Please treat us with dignity and help to treat our illness”.
Prof Crick Lund, Director of the Centre for Public Mental Health at the University of Cape Town, said that one in six South Africans per year will have a diagnosable mental health disorder. He spoke about the Global Mental Health Action Plan between 2013 and 2030, adopted by the WHO, which will scale up mental health services. The plan will work with government to develop monitoring systems to ensure deliverables are delivered. He described PRIME – the Programme for Improving Health Care -- which works in five countries and is funded by the Department for International Development in the UK (UKAID).
Prof Inge Peterson, Principal Investigator of PRIME SA, congratulated the DoH on the Mental Health Action Plan. PRIME is taking some of the DoH objectives and trying to implement them in collaboration with the DoH. PRIME is working at one of the NHI sites. Two million people in SA use anti-retrovirals (ARV’s). With the roll out of ARV’s, HIV is moving towards an integrated chronic disease model. Schizophrenia, depression, and alcohol use disorder are the top three mental problems. Psycho-social rehabilitation for people with schizophrenia is lacking. Depression interferes with the prevention of treatment efforts. People with depression are less likely to engage in healthy behaviour and adhere to self-care and register for treatment. This affects the impact of ARV treatment. It is crucial to integrate depression care with chronic disease care. She explained how this can be done in partnership with DoH and existing HIV counsellors.
Mr Oscar January, Mental Health user and Advocate from the Centre of Mental Health, said that there has been an improvement in the mental health sector, but more still needs to be done as there are still insufficient resources and services in the community. He said that alcohol and drug abuse adds to the mental health care burden.
Ms Jabu Zulu, Research Co-ordinator from the University of the Western Cape School of Public Health, asked about what the government is doing to support churches which have been helping people with mental health prevention and treatment. She asked Mr Phakathi if government can provide licensed traditional and divine healers for patients who prefer to be treated by them. She also asked Ms Matare what government will do with financial policies in cases of suicide, as they do not provide financial support if a person has committed suicide, when a suicide is a mental health problem.
Ms M Segale-Diswai (ANC) asked Mr Phakathi about progress with fixing dilapidated buildings, prioritizing mainly on general hospitals.. She asked what the exact timelines are for all their objectives. What would be done to improve mental health services in the communities, especially in the clinics and health centres? What criteria are used in determining how much money is allocated to each province? Lastly, she referred to the Comprehensive Nursing Diploma and said that not enough emphasis is placed on psychiatric nursing.
Ms Ingrid Daniels, Director of Cape Mental Health, thanked the DoH for their plans. She asked about the factoring in of salaries and transport costs, as well in the projected costs for the establishment of district specialist mental health teams at NHI sites. She asked how the Department was planning to work with NGO’s in the projected plans.
Mr Phakathi responded, mentioning that Mr Lund and Ms Patel had participated with the DoH in finalising the mental health policy and plan. Many of the other costs will be included as the plan is piloted. There is a task team to help scale up the project. Detailed targets are contained in a policy framework, with timelines for when they aim to achieve targets. A public health approach is being used in looking at mental health care. Particular districts and priorities are being considered, and this determines how much is allocated to each district. The Ekurhuleni Declaration contains pronouncement on what they plan to do with traditional and faith-based healers. A system to register these groups is being developed.
Prof Lund talked about referral pathways for a system of treatment, and about providing access to basic counselling for all.
Ms Patel highlighted that whatever existing services are available will be adequately resourced.
Ms Matare emphasized her recommendation of establishing a South African National Suicide Prevention Programme to monitor number of suicides that take place.
Dr Simone Honikman, from the Perinatal Mental Health Project (PMHP), a partner of PRIME, spoke about maternal mental health. She hopes that early childhood development will be recognized and communities will be strengthened in this regard.
The Chairperson thanked Amit Makan, who is the PRIME Research Uptake Officer for organizing the event. He commented that mental health cannot be dealt with until mental health problems are addressed directly. He said that society must continue to remove the stigma surrounding mental health.
The meeting was adjourned.
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