Decentralising mental healthcare

South Africans suffer from mental trauma because of their experiences under apartheid and their continuing struggles with poverty and HIV and AIDS. There is a serious need for mental healthcare. INGE PETERSEN and ARVIN BHANA look at policy that has focused on decentralising and integrating mental health services into district primary healthcare, but say more focused investment is necessary. 

Decentralisation in rural districts

What progress has been made in decentralising mental healthcare in a rural district in South Africa, and how has decentralisation affected the allocation of resources?

To be effective, integrated primary mental healthcare also needs measures for prevention and mental health promotion, and access to care for common mental health disorders such as anxiety and depression...

The decentralisation of mental health demands much more than simply taking patients out of mental health institutions (de-institutionalisation). It should include community-based rehabilitation programmes that help patients live in the community. To be effective, integrated primary mental healthcare also needs measures for prevention and mental health promotion, and access to care for common mental health disorders such as anxiety and depression, for children and adolescents as well.

In the study site located in the northern KwaZulu-Natal magisterial sub-district of Hlabisa (with a population of approximately 168 500 people), decentralisation focused on emergency management of psychiatric patients and ongoing drug treatment of patients with chronic but stabilised mental disorders. The mental health budget was not enough to cover promotion and prevention programmes, community-based rehabilitation or the costs of training primary healthcare staff in mental healthcare.

Study findings

A key finding was that the district lacked specialist mental health staff, having no psychiatrist and only one psychologist: this falls far below the suggested targets for middle-income countries. Further, due to staff shortages, the technical adviser for mental health was required to manage other programmes.

Nurses at the primary healthcare clinic level complained about lack of support and time to adequately assess, manage and refer patients with common meantal health disorders.

Another finding suggested that while there were more psychiatric nurses than the suggested target, overall staff shortages meant they had to work in general healthcare as well as mental health. Nurses at the primary healthcare clinic level complained about lack of support and time to adequately assess, manage and refer patients with common mental health disorders.

The research also showed that the scope of community rehabilitation programmes was limited to using general community health workers to help psychiatric patients take their medication properly. And although two-thirds of the service users interviewed reported using both traditional and Western medicine, there was little interaction between the two systems.

Recommendations

The researchers call for more resources to be earmarked for mental healthcare, and stress the need for more efficient use of existing resources. They suggest that policy-makers expand the role of mental health professionals, such as clinical psychologists, to play a training and consultant liaison role to help staff at primary healthcare level.

Other recommendations include:

  • fund more trained community-based workers dedicated to mental health;
  • employ psychological counsellors to provide a referral service for people with common mental health disorders as well as support and supervise community-level workers;
  • set aside resources for mental health services alongside measures to address the human resource crisis within the general healthcare service; and
  • fund training for both traditional and Western practitioners to exchange understandings and treatment of mental illness, and establish mutual referral systems.

The researchers call for more resources to be earmarked for mental healthcare, and stress the need for more efficient use of existing recources.

This article is based on a more comprehensive analysis that appeared in the journal Health Policy and Planning Vol.24, under the title, Planning for District Mental Health Services in South Africa: A Situational Analysis of a Rural District Site, by Inge Petersen (UKZN), Arvin Bhana (HSRC), Victoria Campbell-Hall (UKZN), Sithembile Mjadu (UKZN), Crick Lund (UCT), Sharon Kleintjies (HSRC), Alan Flisher (UCT) and the Mental Health and Poverty Research Programme Consortium.

The HSRC Press has also just published: Promoting Mental Health in Scarce-Resource Contexts: Emerging Evidence and Practice, which is available for free download or to order from http://www.hsrcpress.ac.za/