By Hannah Zhihan Jiang

Policies without adequate funding will have no impact on improving mental health services in South Africa. Mental health medical practitioners and advocates warn the newly approved National Mental Health Policy Framework and Strategic Plan 2023-200 will be ineffective unless it is properly funded. 

During the recent Mental Health Conference, the University of Cape Town Department of Psychiatry chair  Prof Dan Stein pointed out that although the previous framework from 2013 to 2020 was excellent, it did not lead to increased funding.

“We always get the money last. We always get the least amount of funding,” says Prof Stein. 

Over 700 delegates met in Gauteng last week to discuss the urgent need to scale up mental health resources in South Africa. But the government signalled it will not be increasing funding, with Deputy President Paul Mashatile emphasising that “all partners” should address the issue.

“There’s often a tendency of leaving this challenge to the Department of Health. We should ensure that there’s broader participation to seek adequate funding,” Mashatile says.

South Africans are struggling

The Mental State of the World in 2022 surveyed 64 countries and found South Africa with the highest percentage (36%) of people feeling distressed or struggling with mental health.

As of April 2019, the World Health Organisation’s Global Health Observatory recorded only 850 psychiatrists in South Africa, which means every 100 000 population gets 1.52 psychiatrists, based on the population of 55.6 million people generated by the 2016 census.

“We really as South Africans are not doing as well. Compared with others, globally, we rank the lowest insofar as mental health status,” says Professor Olive Shisana, conference chair, during the opening session.

Not enough mental healthworkers

Despite comprehensive policies on paper such as the National Mental Health Policy Framework and Strategic Plan 2013-2020, participants say mental health has been underfunded. Gross ignorance of mental health allowed tragedies like Life Esidemini to happen. 

In the 2016-2017 financial year, the public mental health expenditure was R7.8 billion, accounting for less than 4.6% of the national budget. Among the expenditures, 86% was devoted to inpatient care, which provides care in a hospital or other type of inpatient facility where one spends at least one night. This left R1 billion in funding or R17 per South African for outpatient care that involves counselling, community mental health outreach, etc. 

In 2019, then-Health Minister Zweli Mkhize revealed that Mpumalanga had only three psychiatrists and seven clinical psychologists, while Western Cape had 37 psychiatrists and 31 clinical psychologists.

The number has not improved significantly. Health Minister Dr Joe Phaahla revealed at the conference that while Western Cape and Gauteng Provinces have 50 and 72 psychiatrists working in the public sector respectively, Northern Cape and Mpumalanga respectively have three and four psychiatrists working in the public sector. 

“Implement policies instead of reinventing them”

The minister highlighted that the government established a Mental Health Service Grant in 2018. It integrated mental health assessments, referrals and intervention into primary health care as well as contracting more psychiatrists, psychologists and social workers. But the minister did not point to any data that proves the effectiveness of this program.

“Why are we reinventing the policy when it’s there? Why are we not implementing it?” says Christine Nxumalo, who lost her sister in the Life Esidimeni tragedy. 

“I generally don’t like conferences. Because in South Africa, we’re pretty good at doing conferences. That’s where the anger is. The amount of money that is spent on conferences versus what they could be doing just for one school and district,” Nxumalo told Health-e News.

In the first half of 2016, mental healthcare users were discharged from Life Esidimeni, a private healthcare provider, to NGOs and other care centres. Many of the centres were later found to be unlicensed and under-resourced. Patients were being loaded onto trucks during the transfer. 144 people died as a result of the chaos. 

Innovative approaches needed

With deficient political will and strained public health resources to tackle mental health issues, researchers at the conference say innovative approaches are needed. Many mentioned that the country should learn from the successful model of cross-sectoral efforts to combat the HIV epidemic in the past 20 years. 

Prof Dan Stein says the mental health movement should develop a slogan or a target for which policymakers are held accountable. For the HIV epidemic, the “95-95-95” target is known to call for 95% of people living with HIV to be aware of their status, 95% of those aware of their status to be on antiretroviral therapy (ART) treatment and 95% of those on ART to achieve viral load suppression. 

Additionally, Prof Melvyn Freeman, a consultant on non-communicable disease and professor extraordinaire at the University of Stellenbosch, says people with severe mental conditions should be added into the Key Populations category in the HIV/STI/TB National Strategic Plan, which historically gets more attention and funding. Research has shown that mental health disorders increase the risk of HIV acquisition by four to tenfold.

The Foundation for Professional Development (FPD), which hosted the conference, launched the Masiview campaign to strengthen and monitor Health Department’s mental health policies, to build healthcare workers’ capacity to assess and refer mental health patients, to improve referral networks by providing digital screening tools and to destigmatize mental health by creating multimedia storytelling content. 

One concept many researchers raised was “task-sharing” – equipping primary healthcare providers with the ability to assess and refer mental health patients. The goal is to help relieve the stress of the lack of human resources in mental health, especially tertiary mental health practitioners such as psychiatrists and psychologists. 

The Masiview movement is funded by The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), Grand Challenges Canada (a Canadian NGO) and AngloGold Ashanti, a global gold mining company. FPD is actively seeking more investment and partnerships.

“Only get a social worker when a kid is about to jump off the roof”

According to the World Health Organisation, globally, one in seven 10-19 year-olds experience a mental disorder. Suicide is the fourth leading cause of death among 15-29 year-olds. WHO says adolescence is a crucial period for developing social and emotional habits important for mental well-being. 

Dr Rita Sonko-Najjemba, director of the Body Mind Wellness Clinic, surveyed 3 417 learners in schools across four districts of the Eastern Cape. She found 23% of the students surveyed seriously considered attempting suicide in Buffalo and Nelson Mandela Bay, 17% in Oliver Tambo and 13% in  Alfred Nzo. 

She also found that screening services were not available in most schools at the time of the study and most schools were not actively referring and linking children to mental health services.

“We only get a social worker when a kid is about to jump off the roof,” says Sonko-Najjemba, stating there are inadequate social workers employed in school systems to support youth and children. 

Mental Health of Healthcare workers

The COVID-19 pandemic shined a light on the issue of mental health of healthcare workers that has long stayed unrecognised. Long working hours, strained health resources and stigma attached to health workers seeking help left many health workers burnout and suffering from substance abuse as well as mental health issues. 

A study showed that the global prevalence rate of depression and anxiety was 25% among healthcare workers and 43% among frontline professionals during the COVID-19 pandemic. Dr Antoinette Miric, the founder of Healthcare Workers Care Network, presented that across different professionals in the healthcare industry, 59% of doctors in KwaZulu-Natal (2020), 67% of rural doctors (2021) and 67.7% of psych registrars have reported feeling burnout. 

Although public healthcare workers could refer to employee wellness programs for help, FPD has found that healthcare workers don’t utilise the service because of a lack of confidentiality and stigma around health workers seeking help. 

“Yes, healthcare workers need to be appreciated for what they do. But the “hero” narrative delegitimises some of their concerns,” says Dr Miric.

FPD recommends implementing validated burnout screening tools for health workers and appointing mental health champions among healthcare workers to destigmatize the issue. – Health-e News