Bridges Mental health policy vs practice

The Mental Health and Poverty Project (MHaPP) has just released a major report on the current state of mental health policy and service provision in South Africa. This is the first time that a comprehensive situation analysis of the mental-health system in SA has been conducted.

There is growing recognition that mental health is a crucial public health and development issue in SA. According to the Medical Research Council, neuropsychiatric conditions rank third in their contribution to the burden of disease in this country. The South African Stress and Health survey found that 16.5% of South Africans suffered from common mental disorders such as depression, anxiety and substance use disorders in the past year.

There are no differences between racial or ethnic groups in the prevalence of mental illness. Mental ill-health is strongly associated with poverty and social deprivation in low- and middle-income countries: poor people tend to have more mental health problems, and people living with mental disorders tend to have lower levels of education, employment and income.

However, mental health is not at the forefront of policy development and implementation in the health, education, employment, social development or other key sectors, and there is little co-ordination of mental health across these sectors. Furthermore, there is generally poor implementation of existing mental health policy and legislation at provincial and district level.

Some important steps have been taken to develop policy and legislation for mental health in South Africa. The Mental Health Care Act (2002) was praised by stakeholders from a wide crosssection of South African society for its human-rights orientation and promotion of communitybased care. The intention of this Act is to promote and protect the human rights of people with mental disorders. New mental health care policy is in the process of being drafted for South Africa, the most recent draft dated April 2006.

However, there are major gaps between policy and practice. There is wide variation between provinces in the level of mentalhealth resources and service provision. For example, the number of psychiatrists varies from one psychiatrist per 5 000 000 people (in North-West Province) to one psychiatrist per 111 111 people (in the Western Cape) - a 45-fold difference.

Only three of the nine provinces were able to report on health expenditure on mental health care: Northern Cape spends 1%, Mpumalanga 8% and North-West 5% of their health budgets on mental health care.

There is also continued dominance of mental hospitals as a mode of service provision: 56% of mental health beds are located in these institutions. This conflicts with policy and legislation that promotes the integration of mental health services into primary health care, and the establishment of mental health units in general hospitals and community-based residential care to supplement mental hospitals.

The Mental Health and Poverty Project (MHaPP) report has recommended the following actions to promote the prioritisation of mental health as a public health issue and improve implementation of mental health policy and legislation in South Africa:

• Finalise and adopt a new national mental health policy, and ensure that it is disseminated widely.
• Ensure adequate financial provision for mental health services in the provinces, particularly for communitybased care, which includes primary mental health care, community-based residential services and day-treatment facilities. Financial allocations should be appropriate to the burden.
• Develop mental health plans in Provincial Departments of Health, with clearly identifiable budget allocations to mental health care.
• Increase collaboration between sectors such as health, education, labour, social development and criminal justice.
• Develop information systems according to World Health Organisation guidelines, with nationally-agreed indicators, in order to monitor implementation of policy and legislation.
• Increase involvement of consumer, family and other organisations working on behalf of people with mental disorders, in order to raise public awareness, prevent stigma, discrimination and human-rights violations associated with mental ill-health, and lobby for political support for the prioritisation of mental health on the public agenda.
• Integrate mental health into wider poverty alleviation and development policies, in order to address the vicious cycle of poverty and mental ill-health. For example, include people with mental disabilities in the Expanded Public Works Programmes.
• Broaden the scope of mental health interventions to include prevention of mental disorders and mental health promotion.
• Develop a national mental health research agenda through collaboration between researchers and government, to promote the translation of research into policy and practice.

Issued by: The MHaPP, a groundbreaking research consortium that aims to provide vital evidence on what policies are needed to break the vicious cycle of poverty and mental ill-health and to ensure that the poorest communities have access to mental health care. The findings of the Mental Health and Poverty Project are based on a large research report, released by staff at the Department of Psychiatry and Mental Health at UCT. Partners include the Human Sciences Research Council, the University of KwaZulu- Natal, the University of Leeds, and the World Health Organisation. Data was collected from a national survey of mental health services and interviews with a wide range of stakeholders from government, NGOs, academics and mental health user groups.