Health authorities in South Africa’s wealthiest province, Gauteng, have launched an investigation into the deaths of 37 people with chronic mental illness who died over a four-month period. The patients were part of a group of 1300 relocated from a mental health facility last December. Janine Bezuidenhoudt explains why mental health is still neglected in developing countries. South Africa is no exception.
There has been increased attention given to mental health as a global priority. Has the management of mental health changed as a result, particularly in developing countries?
Developing countries have unique challenges which either lead to or worsen mental health disorders. These include people experiencing trauma, injury, violence as well as the burden of infectious diseases, harsh economic circumstances and poor living conditions.
Depression is one of the most common mental health disorders in the world. According to the World Health Organisation more than 350 million people suffer from the condition globally.
But mental health care takes the backseat when it comes to the allocation of resources. This is due to the burden of infectious and non-communicable diseases which are given priority.
Yet, in developing countries, mental health should be given the same priority. Neuropsychiatric disorders – which include mental health and nervous system disorders – are the third largest contributor to the burden of disease after HIV/AIDS and other infectious diseases.
Another problem is that although policies have been developed for mental health care, implementation remains a challenge. This means that the management of mental health care in developing countries has not changed.
How does South Africa treat its mentally ill?
South Africa has a history of being unkind to its vulnerable populations. This includes those who have mental disorders. In terms of policies the situation has improved quite a bit in the last decade. Several are now in place to take care of people with a mental health conditions. These include:
These policies aim to ensure that people with disabilities enjoy the same rights as their fellow citizens and that all citizens and institutions share equal responsibility for building such a society.
But policies alone are not good enough, especially if they’re not enforced and there is no accountability.
There are a number of instances that illustrate the fact that policies aren’t yet having the desired effect. Possibly the most stark was the recent death of 37 patients over a four-month period.
A total of 1300 mental health patients were transferred from a mental health facility, the Life Esidimeni Healthcare Centre, to non-governmental organisations. Several organisations, including the South African Depression and Anxiety Group , Psychological Society of SA, human rights group Section27 and the South African Federation for Mental Health warned against the move.
But the government went ahead and transferred patients to organisations that were not equipped to manage and care for them. The deaths were shocking. And there are still concerns about the quality of care and living conditions for the rest of the patients.
What particular challenges does South Africa have?
Mental health care is underfunded and under-resourced.
There are are not enough trained mental health professionals. In 2010, South Africa had 1.58 psychosocial providers for every 100,000 people. In the same period, Argentina had 13.19 psychosocial providers for every 100,000 people. The World Health Organisation recommends that South Africa increase its psychosocial professionals by 2937.
There has been a heavy reliance on psychiatric hospitals to care for and manage mentally ill patients. But public sector mental health care services are not accessible to the country’s most vulnerable populations. The hospitals also don’t have enough trained mental health professionals.
This means there is a large treatment gap. About 75% of people with mental health illness do not access mental health care.
In addition to this Western psychological models are used. These are not representative of the South African population. South Africa’s high prevalence of HIV/AIDS and TB means that specific mental health screening tools and treatment care models need to be developed. And the country isn’t using indigenous knowledge systems for primary prevention, such as making use of traditional healers.
More generally, mental health care management and treatment is not integrated into other health care programmes.
People with mental health illnesses are also often discriminated against and are stigmatised. This means they don’t access the health care they need. If they do they often fail to get the quality of care they need.
What needs to be done?
Mental health care management and services need to made a priority. And mental health care must be de-institutionalised so that community-based care can be set up in a systematic way. This would entail first strengthening and then expanding community-based care.
Mental health screening must also be integrated with care and management at primary care level – especially for people who have TB, are living with HIV or AIDS, are pregnant or who recently gave birth.
The country should also develop indicators to ensure the provision of quality mental health care management and services. These indicators must be monitored and evaluated.
Human resources also need to be tackled. This needs to happen at a number of levels. At the health care professional level, all should be trained on how to manage mental health disorders. At the management level, managers need to be trained in mental health management, care and treatment to ensure mental health care is treated as an essential part of health care delivery. It should be integrated into routine health care delivery. Mental health care management should not be a specialist field. It should be introduced into the broader curriculum for students and covered as routine care management for health care workers.