The Free State Department of Health presented on the state of mentally ill patients in the province. The private facilities that provided mental health care services were mainly based in the Mangaung District. A district mental health specialist team was appointed to enhance integration and implementation of mental health care services. Funds were allocated for compensation of employees and goods and services. Other districts had similar teams subject to funding. The Free State Psychiatric complex was the only specialised institution in the province. It provided inpatient and outpatient mental health services to communities and patients referred by the courts for psychiatric evaluation. It was not yet recognised as a Specialised Tertiary Hospital, which affected the funding allocated to it. There was no electronic system to capture patient information and mental health history. Facilities in the province were dilapidated and did not meet health standards. The Department was due to sign a MoU with the Department of Social Development. Staff retention and specialised psychiatric training remained a problem in the province.
Members asked questions about how many mental health facilities were in the province, were there day treatment centres and community residential facilities in the province? What was the categorisation of human resources challenges and how was it going to be addressed? Members questioned whether the effectiveness of the review board was measured on the number of meetings held and wanted to know about other functions stipulated by legislation? Ten members were appointed on the review board, when legislation provided differently. What was the reason for the deviation? What was the professional composition of the board?
Members asked what support was provided to the board if the directorate was not yet fully functional. Which systems were in place to monitor and evaluate to prevent challenges? What were the roles of outreach teams, and how was the promotion and prevention aspect addressed? Members wanted to know if research was conducted to show the causes of mental illness in the province. A budget was allocated in the past but there was no report on what it was used for and what the progress was. What were the incentives given to health professionals to work in rural areas? The NGO’s that were run by Social Development were servicing mental health patients which fell under the mandate of the Department. Members asked what the working relationship was between the Departments. Why were there no facilities catering specifically for children? Were there trained nurses that could pick up substance abuse at clinics?
Members questioned the support given to poor families in the province who had mentally ill family members. They wanted to know how long before the whole system was fully functional? Which diseases did traditional healers work with and did they operate within state facilities? Did the psychiatric complex’s non-recognition as a specialised tertiary hospital mean that there was no psychiatric hospital in the province? Members also wanted to know which programmes were in place to address the stigma surrounding mental illness in communities. There were a high number of patients from prisons, but there was no report on why they were defaulting on taking medication. What interactions took place with traditional healers, to empower them to encourage patients to take their medication?
The Limpopo Departments of Health and Social Development presented on the state of mental health care in the province. There were three residential health care facilities in the province, and only two of the general hospitals did not have psychiatric wards. A new state of the art psychiatric ward was being commissioned at Letaba hospital. The Departments were working together to address challenges of people with disabilities in the province, and overcrowding at facilities was as a result of the stigma attached to mental illness within communities. The province was assisting Mpumalanga as it did not have a residential mental health care facility. There were challenges with the filling of vacant posts and NPO’s within communities which were not fully compliant or met the minimum requirements. The Department had a plan to take over management of Shiluvana Frail Care Centre from Life Esidimeni in March 2018.
Members asked questions about the general hospitals which did not have psychiatric wards, the overcrowding at facilities and plans to extend facilities or build new ones. The patient that was at a facility since 1972, was he one of the patients whose relatives were untraceable? They wanted to know what was done about patients suffering from TB and their isolation from other patients. The facilities were unsuitable for patients and posed a health and safety risk to patients. If there was no forensic facility in the province, how did the Department deal with patients awaiting trial? Members sought clarity on the compliance of care facilities, and asked whether the province had a mental health care directorate. Was there a mental health care review board, and why were the salaries of the gardeners and administration staff so high? Mpumalanga did not having a psychiatric health care facility, yet a resolution was taken as far back as 2013 to build one. How far was the national Department with this process as it was putting pressure on other provinces which led to overcrowding in facilities?
Members felt that the promotion and prevention programmes in the province were not known which highlighted the main causes of mental illness in the province. Which districts were affected the most, so that advocacy programmes could be developed to specifically target problem areas? Which monitoring and evaluation systems were in place to avoid problems like those that happened in Gauteng? Was the Department taking over the function and management of Shiluvana frail care centre? What was the difference between outsourcing and the function of NPO run institutions? What was the comparative salary of workers at Life Esidimeni and those at NPOs? Why was the Department selectively dealing with the issue of NPO run facilities?
Presentation by the Free State Department of Health
Mr Butana Komphela, MEC, Free State Department of Health, thanked the Chairperson for the invitation to present on the state of mentally ill patients in the province. He introduced his delegation as Dr David Motau, the HOD; Dr Langa, Chief Director; Mr Basi Polelo, Deputy Director General; Professor Pretorius, Head of Psychiatry; Ms Seboko, CEO, Free State Psychiatric Complex; Ms Leshodo, Free State Psychiatric Complex and Ms Zukiswa Jaga, Private Secretary Office of the MEC.
Dr David Motau, HOD, Free State Department of Health, gave an overview of the environment within which the Department operated. The primary health care facilities were nurse-driven and district hospitals doctor-driven. The private sector substantially contributed towards health care in the province. There were many people who consulted traditional healers and the Department initiated plans to regulate this important service. The private facilities which were licensed to provide mental health services were mainly based in the Mangaung metro area. These were Bloemcare Centre, M-care Optima, and Nurture Hillandale. Welkom Medi Centre was based in Lejweleputswa District and Corona Medical Care at Thabo Mofutsanyana. He then gave an overview of the legislative mandate and norms and standards regulating mental illness in the province. Priority was given to establish a fully functional mental health directorate, and funds for the positions of Senior Manager, Deputy Director for community based mental health services, adolescent and substance abuse and Support were allocated as R3.9 million for compensation of employees and R2 million for goods and services. Vacant posts were in the process of being filled.
Mr Motau said that the district mental health specialist team consisting of a psychologist, occupational therapist, social worker and professional nurse with qualifications in psychiatry were appointed in Thabo Mofutsanyana to enhance mental health care services. Similar teams would be rolled out in the remaining four districts subject to funding availability. There were five district mental health care coordinators in each district to ensure integration and implementation of mental health programmes at all levels of care. There was an effective mental health review board for a period of three years.
He said that the Free State Psychiatric Complex was the only specialised psychiatric hospital in the province. It was also a care and rehabilitation centre for persons with severe intellectual disabilities and served state patients referred by the courts for psychiatric evaluation and treatment and mentally ill prisoners. There were a total of 877 beds, of which 760 were in use. The bed occupancy for the 2016/17 financial year was 91%. In-patient services included observation, forensic, acute, and long-term psychiatry, and care and rehabilitation. Outreach services included clinical psychology, occupational therapy, social work, child and mental health care, substance prevention and rehabilitation and adult outpatients.
District support services involved the multi-disciplinary team outreach to regional and district hospitals and identified clinics. There was a 24 hour telephonic consultation/ liaison service between health professionals. Therapeutic rehabilitation services were offered to promote and improve functioning. He said that Boitumelo Hospital offered psychiatric services with 47 commissioned beds, 20 of which were in use. Mofumahadi Manapo Mopedi Hospital had 30 commissioned beds. Fezile Dabi District, Lejweleputswa, Thabo Mofutsanyana, Xhariep and Mangaung had several hospitals which offered psychiatric serves to patients, but only had two beds in each hospital.
Mr Motau said that the Department had several challenges relating to servicing mentally ill patients; the first being infrastructure. The facilities were dilapidated, there was no provision for adults separate from adolescents and children and no facilities for disabled persons and physically ill persons. There were also security challenges. The recommended solution was to upgrade the facilities to comply with requirements and health infrastructure standards; budget was allocated to upgrade existing buildings.
Challenges related to funding included the fact that the psychiatric complex was not yet recognised as a tertiary specialist hospital. Current discussion of a service package was in progress. There was also no agreed billing system for forensic outpatient services, and the discussion of the national billing and revenue collection system was in progress. There was poor retention of social workers due to the Occupational Specific Dispensation (OSD) implementation, scarcity of professional nurses with advanced psychiatric qualifications, and a high vacancy rate of nurses and support staff. Posts were in the process of being filled and discussions with the provincial training institution to offer advanced psychiatric course was in progress. The patient care system was mostly manual, and a discussion on the establishment of patient electronic system was in progress.
Mr Motau explained that there was an effective mental health care review board which was appointed in 2014. Ten members were appointed and divided into two teams. One team was responsible for the Southern Free State i.e. Metro and Xhariep Districts, and the other team was responsible for north and eastern Free State i.e Fezile Dabi, Lejweleputswa and Thabo Mofutsanyana. A total of 39 meetings were held in the period April 2015 to March 2016, 1 405 documents reviewed, 404 periodic report documents reviewed and 8 M&E visits conducted. There were five private facilities licensed to provide admissions of voluntary mental health care users in the province. The facilities applied for approval to the HOD, and M&E assessments at such facilities included follow-up inspections annually and ad hoc inspections unannounced.
The Department was working together with the Department of Social Development to ensure effective mental health care services in the province. The MECs would meet to discuss and sign a MoU for collaboration to ensure provision and compliant mental health care services. The 40-bed half-way house in Clarens managed by Social Development would be catering for adolescents recovering from substance abuse, and would be opened in the new financial year. There were NPOs in the province which provided mental health care services. They obtained a license from the Department and were subjected to annual audits. There were 61 NGOs registered with the Department of Social Development in the province and the Department prioritised mental health in the province.
The Chairperson thanked the HOD and invited members to engage with the presentation.
Mr A Mahlalela (ANC) welcomed the presentation by the Department. He asked questions about how many mental health facilities were in the province, were there day-treatment centres and community residential facilities in the province? What was the categorisation of human resources challenges and how was it going to be addressed? The effectiveness of the review board was measured on the number of meetings held, what about other functions stipulated by the Act? Ten members were appointed on the board, when the Act provided differently. What was the reason for the deviation? What was the professional composition of the board? He also asked what support was provided to the board if the directorate was not yet fully functional. There were areas that had to be given special focus to according to the National Health Policy Framework, of which only two were addressed by the presentation. What about the other areas, and why has the monitoring and evaluation process been left to the board? Which systems were in place to monitor and evaluate to prevent challenges? What were the roles of outreach teams, and how was the promotion and prevention aspect addressed? Was research conducted to show the causes of mental illness in the province?
Dr W James (DA) said that the national framework was very good, but there was no common way of reporting for provinces to allow the Committee to compare provinces. The staffing and vacancy rates were not easy to assess based on the information in the presentation. There should be less board meetings held to allow more effectiveness. The challenges were noted but there was no detail about how they were going to be addressed. The infrastructure challenge was usually addressed by Public Works. What engagements took place with the Department and what was the progress? A budget was allocated in the past but there was no report on what it was used for and what the progress was.
Ms L James (DA) asked about the challenge of human resources and how it was being addressed. The directorate was important for addressing mental health challenges and needed to be fully functional. What were the incentives given to health professionals to work in rural areas? The NGOs that were run by Social Development were servicing mental health patients which fell under the mandate of the Department. What was the working relationship between the Departments? Why were there no facilities catering specifically for children? Were there trained nurses that could pick up substance abuse at clinics? What was the support given to poor families in the province who had mentally ill family members?
Dr P Maesela (ANC) asked what the process was in dealing with mental patients since the directorate was not fully functional. How long before the whole system was fully functional? Who did the board report to and who appointed them? Which diseases did traditional healers work with and did they operate within state facilities? Did the psychiatric complex’s non-recognition as a specialised tertiary hospital mean that there was no psychiatric hospital in the province? How was the retention of social workers being resolved? What role did the Department play regarding the NGOs run by Social Development?
The Chairperson said that presentations should not just be made for the sake of presentations. The presentation was bordering on technicalities with very little details which could be interrogated. Which district was affected by mental illness the most? Were there dedicated programmes to empower home-based carers and community based workers to detect mental illness? Which programmes were in place to address the stigma surrounding mental illness in communities? There were a high number of patients from prisons, but there was no report on why they were defaulting on taking medication. What interactions took place with traditional healers, to empower them to encourage patients to take their medication?
The HOD thanked members for the questions. He said that some of the clinics were able to detect substance abuse leading to mental illness, but more nurses needed to receive training on advanced psychiatry. The vacancies were a challenge and it was not specific to the province only. Posts were advertised and were being filled, but specialists remained a huge challenge. Mental health services were provided in the province even without a directorate. A summit was held in 2012 and one of the resolutions was to prioritise mental health services which led to the directorate being formed and the review board. There were coordinators in every district. The OSD matter that affected social workers was being addressed and aggressive recruitment was in progress. Nurses were going through training that enabled them to detect mental patients that consulted at the clinics.
The review board was appointed by the MEC, and the Department was aware of the provision of the Act relating to membership component. There were two advocates, four mental health practitioners, and three community members which were divided accordingly. The support structure was composed by clerks of the two hospitals where meetings were held together with a district coordinator. There was also support on a quarterly basis from the provincial office. They monitored the infrastructure, the admissions, discharge and transfers of patients and periodic reports of 72 hour facilities in the province.
The National Tertiary Services Grant was being engaged with to ensure that the psychiatric complex was fully compliant so that it could be recognised. The process of discharging patients at the complex involved the family. The patient was checked to see if he/she integrated back into the community. Some patients who committed serious crimes found it difficult to return to their communities because their families refused to accept them back. There were patients whose families could not be traced, and the Department had an agreement with Social Development to place these patients within NGOs. The Department paid a monthly stipend to these NGOs for the patients’ upkeep.
Presentation by Limpopo Department of Health
Dr Phophi Ramathuba, MEC, Limpopo Department of Health, thanked the Chairperson for the invitation to present. She said that she would be acting as the MEC for Social Development because the MEC was unwell and on sick leave. She introduced her delegation as Dr Kgaphola, HOD for Health; Ms Daphney Ramokgopha, HOD for Social Development; Ms Mashimbyi, Chief Director, Social Development, and Mr Norman Phophi, Parliamentary Officer.
The MEC handed over to the HOD to do the presentation.
The HOD said that the Department of Health rendered specific interventions for mental health care users which included care, treatment and rehabilitation through a multidisciplinary approach. The annual hospital admission rate for mental health in public health facilities was 300 per 100 000 of the population. There were six general hospitals with psychiatric wards, three specialised psychiatric hospitals and two general hospitals which had non-functioning psychiatric wards. A state of the art psychiatric ward was about to be commissioned at Letaba hospital.
All hospitals managed psychiatric patients and referred them to appropriate facilities where necessary. There were three community residential facilities under the Department of Social Development, and one licenced sub-acute psychiatric hospital with 38 beds. There was no licensed acute psychiatric hospital in the province. There were no child/adolescent outpatient clinics, and child and adolescent mental healthcare users were admitted to separate sections of the health care facilities, if they could not be managed as inpatients. Admitting children was the last resort. There were different services offered at health care facilities depending on the capacity of the facility. Half-way houses provide care, treatment and rehabilitation to patients who did not require hospitalisation. Evuxakeni utilised the old Nkhensani hospital as a half-way house in collaboration with Akaya Project funded by the national Department.
Hayani, Evuxakeni and Thabamoopo psychiatric hospitals were built in 1969, 1984 and 1972 respectively. Hayani had 390 commissioned beds, of which 234 were in use. Evuxakeni had 400 commissioned beds of which 354 were in use. Thabamoopo had 400 commissioned beds of which 365 were in use. Many of the patients could benefit from a step-down facility. Some of the patients’ relatives could not be traced and remained at the hospitals for a long time.
The 2016/17 allocated budget for the specialised psychiatric hospitals was outlined, and the reasons for patient admission. Some of the challenges relating to overcrowding at facilities were that families did not want the patients back, there was no one to take care of them at their homes, or relatives were untraceable. Co-morbidity clinics provided inpatient beds and were inside the hospitals. They dealt with medical conditions and provided HIV tests and medication on site. Treatment for diabetes mellitus, hypertension, asthma, epilepsy, tuberculosis, renal failure, arthritis, stroke and HIV was provided. The number of deaths and causes of death at the three hospitals were outlined. Thabamoopo hospital had one suicide case of a bipolar patient.
The vacancy rate within the facilities was high, ranging from a 60% to 100% vacancy rate. There were people acting in the positions while the recruitment process was on-going. There were functional mental health review boards in Capricorn, Vhembe and Waterberg districts. Mopani and Sekhukhune districts boards were being established. The biggest challenge with members was the issue of stipends versus professional fees. Forensic mental health services were provided at Hayani and Thabamoopo. Thabamoopo did not have an observation unit and relied on Hayani. There were 78 panel cases and 171 single psychiatric patients who were awaiting trial and under observation at Thabamoopo hospital. The Department had infrastructure challenges which were not suitable for psychiatric service, there were no child psychiatric units in the province, there were no forensic observation units in the province, and there was poor network connectivity at hospitals. Insufficient budgets, untraceable relatives, shortage of core and support staff and community stigma remained a problem for mental health care in the province. Overcrowding in facilities was also a result of the province accommodating patients from Mpumalanga province which did not have residential psychiatric facilities.
Presentation by Limpopo Department of Social Development
Ms Daphney Ramokgopha, HOD, Department of Social Development, presented on the integrated services to persons with disabilities in the residential facilities, protective workshops and stimulation or partial care sites. The interventions were rendered in partnership with the Department of Health and NPOs. There were 132 facilities providing services to persons with disabilities: four residential facilities, one outsourced by the government and three managed by NPOs, 27 partial care sites and 102 protective workshops managed by NPOs. The total allocated budget to services for persons with disabilities was roughly R68 million. The facilities rendering services for children with disabilities were conditionally registered as they were not fully compliant with norms and standards. Protective workshops and residential facilities did not have a legislative mandate, and the policy on transformation and management of protective workshops required the facility to comply with environmental and health and safety requirements. All residential facilities complied with the minimum norms and standards.
The Department faced challenges of facilities being established which did not meet the minimum requirements and policies. Inadequate infrastructure limited access and safety, there was a limited budget to cover the needs of persons with disabilities, lack of management and staff in NPOs and lack of identity documents for some beneficiaries.
Presentation on Shiluvana Frail Care Centre
Shiluvana was a frail care centre providing 24hour nursing care services situated in the Tzaneen municipality. The facility had a 160 bed capacity and admitted different types of disabilities of persons above 18 years. An EXCO decision was made for government to take over the management of the facility in March 2018. The facility catered for persons with mental disorder, cerebro-vascular accidents, physical conditions which included blindness, amputations and hearing impairment, cerebral palsy, neuro-degenerative conditions, brain trauma, epilepsy and the homeless. The major causes of death were pulmonary oedema, cardiac arrest and natural causes. The 2015/16 death toll stood at 35, and no deaths were reported since October 2016 to date.
The centre currently had a staff complement of 116 people costing R11.58 million. The proposed staff complement was 150 people which would cost R29.11 million. The centre offered social work services, occupational therapy, physiotherapy and community outreach among other services. Plans to take over the centre included a benchmark and feasibility study, stakeholder engagement, establishment of organisational structure, costing of structure and engagement with treasury.
The Chairperson thanked the presentations and invited members to engage with it.
Dr James commented on the vacancy rate at residential facilities and said that it was alarmingly high. The percentages meant that there was either one person running a unit or no people in the positions at all. On face value, the Department had no staff and it was a disaster waiting to happen. Why were the posts not filled?
Dr Maesela asked about the general hospitals which did not have psychiatric wards, the overcrowding at facilities and plans to extend facilities or build new ones. The patient that was at a facility since 1972, was he one of the patients whose relatives were untraceable? What was done about patients suffering from TB and their isolation from other patients? The facilities were unsuitable for patients and posed a health and safety risk to patients. If there was no forensic facility in the province, how did the Department deal with patients awaiting trial? He sought clarity on the compliance of care facilities, and asked whether the province had a mental health care directorate. Were there mental health care review boards, and why were the salaries of the gardeners and administration staff so high?
Ms James welcomed the presentation and asked about the two general hospitals with no functional psychiatric wards. How were the facilities run by communities to ensure compliance? The absence of outpatient child and adolescent centres was a problem, what was being done to address this? Were there plans of building outpatient rehabilitation clinics? What was the working relationship between the Departments to deal with persons with disabilities?
Mr Mahlalela asked about Mpumalanga not having a psychiatric health care facility when a resolution was taken as far back as 2013 to build one. How far was the national Department with this process as it was putting pressure on other provinces which led to overcrowding in facilities? The vacancy rate was too high. For how long was it this way and what was the progress in filling the posts? What were the exact challenges relating to the filling of posts? He said he expected that the presentation would be general, but would be guided by the strategic plan which had focus areas of which nothing was said. The promotion and prevention programmes in the province were not known which highlighted the main causes of mental illness in the province. Which districts were affected the most, so that advocacy programmes could be developed to specifically target problem areas? Which monitoring and evaluation systems were in place to avoid problems like those that happened in Gauteng?
Was a mental healthcare directorate established? The representation of the delegation did not represent people who were addressing mental health problems in the province. What were the key elements of performance targets to determine the functionality of the review boards? The issue of stipend was raised, why were magistrates not approached to serve on these boards as they were already government employees? Was the Department taking over the function and management of Shiluvana frail care centre? What was the difference between outsourcing and the function of NPO run institutions? What was the comparative salary of workers at Life Esidimeni and those at NPOs? Why was the Department selectively dealing with the issue of NPO run facilities?
Dr Kgaphola responded by saying that the human resources issues were a concern because of the organisational structures which dated back from the past. This led to problems with the filling of posts and matching posts with qualifications. A process was underway to rectify the situation. The three residential facilities were not intended to be mental health care facilities when they were built, that was why overcrowding was a problem. The patient that was in the facility since 1972 has lost his memory and as such his relatives could not be traced.
The directorate was in the process of being established and the position of the person tasked with coordinating the directorate did not know what she was doing. The position was in the process of being filled by a person who was both knowledgeable and qualified to perform the required tasks. The district coordinators received advance psychiatric training. Outpatient services were provided by the hospitals to avoid further overcrowding at residential facilities. The province continued to assist Mpumalanga province as patients could not be turned away. The Department worked closely with Social Development through the treatment centre that would be opened soon to address promotion and prevention of substance abuse. There was a team within the Department of Health that dealt with monitoring and evaluation at the three residential facilities to avoid the Gauteng situation. The functionality of the review boards was based on the meetings and review of documents.
Ms Ramokgopha responded by saying that there were many NPOs that were not complying and the plan going forward was to close them. The assessment was already done, but it would take a long time because there were many of them. Those which were meeting the minimum requirements would be assisted to meet the full requirements. Shiluvana frail care centre belonged to the Department after it was handed over to the Department of Health after a 25 year lease from the former Gazankulu government. It was now under Public Works as one of the government assets. There was a difference between the funding of Life Esidimeni and other NPOs because of the services that were offered and the formula for subsidising NPOs. It was a real challenge within the Department and there were complaints about the standardisation of salaries and organisational structure of posts. The Department partnered with South African National Council on Alcoholism and Drug Dependence (SANCA) to implement mobile outpatient services within the communities. The understanding of the services remained a challenge and more advocacy programmes were required to educate communities.
The MEC said that the stigma around mental illness within communities remained a serious challenge. Families expected their family members to be admitted, and only accepted them into their homes on the day when they received a grant. They exploited them which triggered the illness. Many of the patients in the residential facilities did not have traceable relatives, but after a tragedy many of these relatives came forward because there was a possibility of a civil claim. The review board reported directly to the MEC. There were campaigns run throughout the province to fight the stigma. The human resources challenges were linked to a culture of creating a directorate to deal with a particular outbreak, and when it passed the warm body was left in the position being paid a salary. There were a lot of nurses who were not trained in advanced psychiatry.
The Chairperson thanked the presenters for their inputs.
The meeting was adjourned.
- Mental Healthcare Services: Limpopo Department of Health presentation
- Mental Healthcare Services: Limpopo Department of Social Development presentation
- Mental Healthcare Services: Department of Health Free State presentation
- Progress Report on Shiluvana Frail Care Centre take over by Limpopo Department of Social Development