Homeless people are falling through the cracks due to gaps in the delivery of basic health services, especially mental healthcare, in South Africa.

Figures from 2020 suggest that at least 15 000 people don’t have a roof over their heads in Johannesburg. Numbers for the rest of the country remain unknown.

Access challenges

Michael Wilson, executive director of the Advanced Access and Delivery South Africa organisation, highlighted some of the obstacles the unhoused face when accessing healthcare.

“Traditional healthcare service delivery is just not convenient for people who are experiencing homelessness or transitioning in and out of homelessness.  Transport, getting time off, because a lot of them work informal jobs and interacting with staff that stigmatise them are some of the challenges to access,” he said. 

Wilson said that it is important to ask whether or not the systems that are there to provide medical care and psychosocial support are flexible in terms of where they meet people who are experiencing homelessness.

Advances Access and Delivery  is an organisation that provides medical care to people who are experiencing homelessness, substance users, and other socially marginalised groups. Their medical program includes services like regular screenings for TB, HIV, and Hepatitis, provision of free and clean injections and assessments.

‘Clinics that won’t chase us away’

*Thabiso Mametja, 27, originally from the North West, currently lives on the streets of Winterveldt, Pretoria North.

Mametja came to Pretoria to look for a job when he was 21 years old, but fell into a life of drugs after failed attempts and ‘bad influences’. He has not gone back home in the 6 years since. 

“I spend most of my time on this side and other times, I hustle in town or in the suburbs. I pick up plastic and cans, that’s how I make money,” said Mametja, who sleeps wherever he finds himself. 

Mametja admitted to using nyaope and drinking alcohol. He said he has tried going to a local clinic in Winterveldt, but was chased away. The second clinic he tried required a clinic book which he did not have. 

“There are days when I see taxi-like cars parked at random places – testing people, handing out medicine like panado, masks, and condoms. I always go and check it out because I need these services. Just because I look like this, it doesn’t mean that they should not help me. I am sick every day because of these drugs. I might get sick because I share injections with different people all the time, they think I don’t know that. We need clinics that won’t chase us away so that they can help us, like the mobile clinics,” he explained.

Homelessness and mental health 

Mary Gillert-De Klerk is the CEO of the Johannesburg Organisation of Services to the Homeless (JOSH) and also the Vice Chair of the Johannesburg Homelessness Network. She has been a social worker serving the homeless sector since 1982. 

Gillert-De Klerk noted that in some circumstances, mental illness can contribute to the reason why some people experience homelessness because the the person’s mental illness affects their ability to understand their surroundings and to be understood by their family members.

Research has shown that homelessness and mental illness are interdependent variables. This means that one could be responsible for causing the other and vice versa.  

Addressing the difficulties that homeless people go through when trying to access mental healthcare services, requires a combination of resources and services as well as a system that enables people to exit the street sustainably. 

“We’ve had over 15 000 people who are experiencing homelessness in Johannesburg before the pandemic, with shelter space for less than 1 000 people. We have critical bed shortages in shelters. This also affects the psychiatric institutions when patients have to go in for assessments, because there is no space to keep them there. So, it takes longer for them to get help, to get better, because they don’t have access to an entire range of services,” said Gillert-De Klerk.

“There is no known research that proves that people who are experiencing homelessness are more prone to mental disorders. The homeless are no different to any other population or grouping in society that we have. They are just people who don’t have homes, job and family support systems. Some have possibly resorted to substance use because of their life circumstances, but they are also just people,” said Gillert De-Klerk.

Discrimination at public health facilities

Similarly to other policies and legislation, there is a disconnect between what is written and the reality of service delivery. 

The South African Mental Health Care Act No 17 of 2002 states that the rights of persons with mental illness are to be protected from discrimination and that they are to receive care and services in the communities where they reside. 

The Disability Rights Charter of South Africa (2008) and the Bill of Rights of the Constitution of the Republic of South Africa (1996), also protect the rights of everyone to basic health care services.

According to a report compiled by Unotida Moyo and others titled “Homelessness and mental illness in Hillbrow, South Africa: A situation analysis”, the lack of access to service provision for homeless persons with mental illness is often related to the unwillingness of health care professionals to treat homeless people because they are ‘dirty’. 

The report cites a study that was conducted in South Africa by Zrinyi and Balogh which showed that student nurses would decline to care for homeless people in various situations. This reaction was the result of the way the homeless body has been stereotyped as unworthy and undeserving of medical services. This result supports that conclusion that “the inaccessibility of health care services is a key issue in understanding the high mortality rate among homeless people”.

The failure of homeless persons with mental illness to provide an address and to keep appointments was another alienating factor. 

Extra difficulties

Raymond Perrier is the Director at the Denis Hurley Centre. He said that people who are experiencing homelessness have extra difficulties facing them when using public health facilities.

“Just because they are not very well-dressed, may have an odour or may not be sober – they are seen as dirty when they walk in to a government clinic. We have dropped off patients at local clinics for further assistance and have had to actually walk in with them to make sure that they are not turned away. Otherwise, they just get ignored. The staff mistreating them is also a problem because this exacerbates their existing anxiety and paranoia from the constant survival mode they are in,” he said. 

The Denis Hurley Centre provides a primary health care clinic for refugees and homeless people in Durban. They  provide access to showers, ablutions and clean clothes, as well as a social worker and rehab programs. 

Access is not enough 

Homeless people usually don’t have a stable place to live and have to carry their belongings with them.

Vivien Pluddämen-Hobbs is a Social Worker at Streetscapes, in the Western Cape. Her organisation makes a difference by providing well-being and healthcare services to people who are experiencing homelessness. 

She said that this contributes to their difficulties in accessing mental healthcare because they have nowhere to keep their stuff safely. 

“Medication adherence is difficult. Even when people who are experiencing homelessness are able to access a local clinic, it is still difficult for them to get the help they need. Especially for mental health and people who need to see a psychiatrist, it takes so long. You have to first queue at the clinic for the whole day, just to see a doctor. He will then refer you to a psychiatric nurse, who will then refer you to a registrar – who’s who still like training to be a psychiatrist. At that point, you’ve had to go to the clinic three times and not have missed any appointments. This is often very hard for people who are homeless to do,” said Pluddämen-Hobbs.

Pluddämen-Hobbs added that a mental and substance use disorder is a common combination. People often land up on the streets again when they are not able to access the few services that are available.

“There are very few inpatient services for any kind of dual diagnosis. A lot of the time you’ll see homeless people having both a substance use disorder, and also some kind of mental health concern. There are very few facilities and healthcare workers who cater for both at the same time. So, even if you go in successfully, when you come out of a public institution, there isn’t any aftercare.” 

Public facilities should meet people halfway

Perrier said that the Department of Health supports their organisation.

“We get some of our medication from the department for our clinic. For example, at the moment we’re running a vaccination program for undocumented people. These are people who are experiencing homelessness and don’t possess IDs, and foreign nationals without passports. In that case, we’re not doing the vaccinations. It is the Department of Health and City Health, who are sitting outside the building to provide the vaccines.”

Perrier noted that more effective lines of referral are needed to help NGOs provide more effective primary health programs. This would make it easier for them to refer mental health patients to specialists in hospitals for further assessments. 

“With multi-drug resistant TB, we’ve been able to refer people into government wards. But we’ve had to negotiate every single one of those, and I’m afraid that it is linked to individuals and personalities. We always fear that if there’s a change of staffing, we lose the leverage. We have also struggled with the Casualty Department because we can’t find somebody who is willing to put in the effort to help the homeless,” he said.

Inpatient care facilities needed

Pluddämen-Hobbs added that inpatient care facilities are also needed at local clinics to make access less of a struggle.

“We need healthcare outreach workers to assist people to access mental healthcare. A space where medication can be stored, people are able to have access to drinking water and bathrooms. There are a lot of things you need when living on the street so that your life can be easier and you can start thinking about healthcare. When you’re not worrying about food, water and your belongings, then maybe you’ll be able to think about your health and appointments,” she said. – Health-e News

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