Department of Health Presentation to the Portfolio Committee on Health State of Mental Health and Mental Health Services in SA Plans for way forward 12 June 2013

1
Department of HealthPresentation to the
Portfolio Committee on HealthState of Mental
Health and Mental Health Services in SAPlans for
way forward12 June 2013
2
Introduction

• Mental disorders are associated with significant
  distress and impairments of human functioning.
  This includes ability to work, learn and interact
  with people. Impacts are felt not only be the
  individual him/herself but by their family and
  community.
• The World Health Organization at the Alma Ata
  conference in 1978 defined health as a state of
  complete physical, mental and social well-being
  and not merely the absence of disease or
  infirmity. The message is that no health can be
  achieved without mental well-being.
• WHO has recently gone further than this by
  asserting that mental health is key to
  development.

3
Prevalence of mental disorder

• 12-month prevalence of adult mental disorders in
  South Africa -16.5 (SA National Stress and
  Health Survey 2002)
• 12-month prevalence of child and adolescent
  mental disorders in the Western Cape 17 (no
  national data)
• For People Living with HIV and AIDS the
  prevalence of mental disorder was found to be 43

4
1-2 of population suffer from severe mental
disorder ie schizophrenia, bipolar disorder. The
remainder suffer from common mental disorders
such as depression, anxiety disorder, substance
dependence.   Measuring diagnosable mental
disorder does not capture the disturbed psyche
of many people in SA. About 14 of the global
burden of disease has been attributed to
neuropsychiatric disorders and while this figure
is slightly lower in developing countries because
of the high burden from other diseases, the
numbers of people suffering from mental disorder
is very high. Around three quarters of people
in South Africa that suffer from a mental
disorder do not currently receive any mental
health intervention
5
(No Transcript)
6

• When looking at mental health in SA we must
  consider-
• - Association between poverty and mental health
• - Large numbers of children orphaned by AIDS and
  other diseases.
• - Militarized individuals that have returned to
  civilian life without psychological and social
  assistance.
• People that in their youth were part of
  liberation campaigns involving violence and in
  strategies such as freedom now, education later
  that excluded them from completing their
  education. We also now have the
  intergenerational impacts on the children of
  these individuals.
• A number of people were severely tortured under
  apartheid.

7

• Significant numbers of unemployed people who have
  become immobilized by their circumstances
• - Significant othering of people (race, class)
  both historical and current.
• -Infants and children that receive minimal
  bonding and love from parents.
• -People that work such long hours (or who are
  away from home for long hours) that have little
  interaction with their families.
• - Stigma and discrimination

8
Key impacts on mental (ill) health and suffering
9

• As citizens we are constantly bombarded with
  incidents of-
• - Rape, including rape of young children (as
  young as 2 years old), people with disability and
  older persons (even 90 year olds)
• - Gratuitous violence and murders
• - Family murders
• - Mass murders
• - Violence by police officers
• Violence by young men on other young men
• It is not possible to separate out the internal
  dynamics of individuals from their social and
  economic conditions, a history of Apartheid etc.
• The past and present conditions live in people.

10
Outside in and inside out!

• Social determinants of mental ill health.
• There can be little doubt that social and
  economic conditions impact on mental health and
  that changing this will improve mental health.
  (Outside in)
• Mental health determinants of social and economic
  development.
• On the other hand if peoples internal world is
  damaged it makes it very difficult for them to
  act on the world in a way that changes that world
  in a positive way. It is necessary to change the
  psyche to achieve better social and economic
  development. (Inside out)
• Our approach not only to mental health but to
  development as a whole
• has to involve both an Outside in and inside
  out

11
Mental Health Care Act of 2002

• 3. The objects of this Act are to-
• (1) regulate the mental health care environment
  in a manner that-
• (i) makes the best possible mental health care,
  treatment and rehabilitation services available
  to the population equitably, efficiently and in
  the best interest of mental health care users
  within the limits of the available resources
• (ii) co-ordinates access to mental health care,
  treatment and rehabilitation services to various
  categories of mental health care users and
• (iii) integrates the provision of mental health
  care services into the general health services
  environment

12

• (b) regulate access to and provide mental health
  care, treatment and rehabilitation services to-
• (i) voluntary, assisted and involuntary
  mental health
• care users
• (ii) State patients
• (iii) mentally ill prisoners
• (c) clarify the rights and obligations of mental
  health care users and the obligations of mental
  health care providers and
• (d) regulate the manner in which the property of
  persons with mental illness and persons with
  severe or profound intellectual disability may he
  dealt with by a court of law.

13
Implementation of policies and measures by State

• 4. Every organ of State responsible for health
  services must determine and co-ordinate the
  implementation of its policies and measures in a
  manner that-
• ensures the provision of mental health care,
  treatment and rehabilitation services at primary,
  secondary and tertiary levels and health
  establishments referred to in section 5( 1)
• promotes the provision of community-based care,
  treatment and rehabilitation services
• promotes the rights and interests of mental
  health care users and promotes and improves the
  mental health status of the population.

14
Current mental health services

• We are someway towards achieving the goals of the
  legislation (and policy), but there is no doubt a
  long way to still go!

15
(No Transcript)
16
(No Transcript)
17
(No Transcript)
18
Hospitals conducting 72 hour assessments
61 of total hospitals conduct 72hrs assessment
68 of district hospitals 72hrs assessment
31 of regional hospitals conduct 72hrs assessment
45 of tertiary hospitals conduct 72hrs assessment
100 of central hospitals conduct 72hrs assessment

19
Human resources in the country
STAFF CATEGORY AVAILABLE IN THE PUBLIC SECTOR (2010)
Psychiatrists 0.28 per 100 000 population
Psychologists 0.32 per 100 000 population
Nurses (in psychiatry) 10.8 per 100 000 population
Social workers 0.4 per 100 000 population
Occupational therapists 0.13 per 100 000 population
20

• There are 2692 clinical psychologists registered
  with the HPCSA (and 1619 Counseling). So only
  around 14 of registered clinical psychologists
  are in the public sector.

21
Prevention and promotion

• Up to now we have tended to place more emphasis
  on care, treatment and rehabilitation than
  prevention and promotion. Main resources in
  mental health go into hospital services.
• Examples of current actions-
• As part of Re-engineering of PHC we have included
  screening of emotional problems in school
  children.
• We transfer resources each year to the SA
  Federation for Mental Health for Advocacy and
  health promotion.

22
Substance Abuse

• Demand and harm reduction through DoH
  interventions are critical components to health
  and development.
• The DOH has its sector Mini-Master Plan that it
  is implementing as part of the Central Drug
  authority Master Plan

23
Drug Master Plan (Central Drug Authority)

• Health Mini-Drug master plan
• Warning labelling (Foodstuffs and Cosmetics Act)
• Screening focus on emergency rooms, Ante-natal
  services, HIV and TB services
• Detox in general hospitals (and in primary care
  for some people)
• Work with Social development (Welfare) in
  getting people into community rehab programmes.
• Specialist treatment centres should be restricted
  only to those that really need them.

24
THE EKURHULENI DECLARATION ON MENTAL HEALTH -
APRIL 2012 (following Mental Health Summit)

• Hereby commit to-
• Promoting mental health as an important
  development objective
• Eliminating stigma and discrimination based on
  mental disability and promoting the realisation
  of the United Nations Convention on the Rights of
  Persons with Disabilities (2006)
• Full implementation of the Mental Health Care
  Act, 2002 (Act No. 17 of 2002) and changing the
  legislation where this is needed
• Ensure collaboration across sectors and between
  governmental and non-governmental organizations,
  academics and with other stakeholders to improve
  mental health services

25

• Providing equitable, cost-effective and evidence
  based interventions and thereby ensure that
  mental health is available to all who need it,
  including people in rural areas and from
  disadvantaged communities.
• Integrating mental health and substance abuse
  services into the general health service
  environment.
• Providing mental health and substance abuse care
  to people within communities while referring to
  higher health care levels where clinically
  required.
• Ensuring that all users of mental health
  services participate in the planning,
  implementation, monitoring and evaluation of
  mental health services and programmes.
•  

26

• Fostering person-centred recovery paradigm that
  respects the autonomy and dignity of all persons
• Increasing human resources to address mental
  health needs throughout the country through
  additional training across sectors, integration
  into general health care and through the National
  Health Insurance System
• Developing and strengthening human capacity for
  prevention, detection, care treatment and
  rehabilitation of mental and substance use
  disorders and build links with traditional and
  complementary health practitioners.
• Providing physical infrastructure that is
  conducive to the needs and human rights of people
  with mental disorders and disabilities

27

• Reducing costs and increase the efficiency of
  mental health interventions, including making
  medicines more affordable, in order to provide
  essential health services
• Establishing comprehensive mental health
  surveillance mechanisms, health information
  systems and dissemination processes to assist
  policy and planning.
• Developing and supporting research and
  innovation in mental health.
• Using the outputs from the summit to finalise
  the Mental Health Policy Framework 2012-2016 and
  to assist with its implementation and monitoring

28
And consequently to 1)Develop and implement a
mental health service delivery platform based on
community and district based models to ensure
that prevention, promotion, treatment and
rehabilitation services meet the needs of all
2)Implement with vigour the Health Sector Mini
Drug Master Plan 3)Establish at least one
specialist mental health team in each
district 4)Adequately fund mental health
services as per WHO recommendations 5)Embed and
increase mental health human resources within the
National Human Resource Plan 6)Develop a fit for
purpose plan for mental health infrastructure at
all levels
29

• 7)Revise norms and standards in line with the
  service delivery platform
• 8)Strengthen Mental Health Review Boards
• 9)Establish a national surveillance system and
  appropriate monitoring and evaluation systems for
  mental health care integrated into the National
  Health Information System
• 10)Establish a national suicide prevention
  programme
• 11)Strengthen links with traditional,
  complementary and faith based healers and
  non-governmental organizations.

30
World Health Assembly Resolution 2013

• A resolution on WHOs comprehensive mental health
  action plan 2013-2020 sets four major objectives
• strengthen effective leadership and governance
  for mental health
• provide comprehensive, integrated and responsive
  mental health and social care services in
  community-based settings
• implement strategies for promotion and prevention
  in mental health, and strengthen information
  systems
• evidence and research for mental health.
• The plan sets important new directions for
  mental health including a central role for
  provision of community-based care and a greater
  emphasis on human rights.

31
Task team on mental health

• Subsequent to the summit, under the stewardship
  of the Deputy Minister, a working group of
  stakeholders met to draw an action
  plan/strategic plan to implement the resolutions
  from the Summit.
• Eight catalytic objectives were selected and are
  recommended by the task team for implementation.

32
Selected catalysts

33

34

35

36

37

38

39

40

41
Key challenges

• Inadequate community care. People roaming the
  streets with mental illness mostly do not need
  hospitalization but good community care.
  (Hospitalisation of such people may not only
  constitute an abuse of their human rights but is
  more expensive than providing good community
  care, including housing, social support etc).

42

• Stigma. People with mental disorder still are
  subject to discrimination and abuse. The answer
  to this is not to remove them from society (and
  thereby subject them to secondary punishment) but
  to integrate them through educating the public,
  providing facilities so that they do not cause
  harm to others etc.

43

• Human resources. There are far too few trained
  professionals to meet need. More professionals
  must be trained but also we need to make best use
  of health staff at all levels through integrated
  mental health care and greater use of community
  health workers we need more equitable care
  between the private and public sectors as part of
  the NHI. (For example its just not acceptable
  that only 14 of psychologists are available to
  treat nearly 85 of the population)

44

• Infrastructure. Some mental health facilities are
  not fit for human habitation and require
  revitalization or new facilities built. However
  we must balance this with establishing community
  based facilities.

45

• Prioritization of mental health in annual
  performance plans. Mental health needs to be
  prioritized so that it becomes part of not only
  the national but provincial annual performance
  plans. Without this mental health will remain the
  Cinderella of health.
• Neglect of mental health will impact negatively
  on physical health as well as mental health
  (given high co-morbidity). It will also impact on
  education, productivity, violence etc.

46

• Thank-you (and look forward to assistance in
  improving mental health and mental health
  services in SA!)