South Africa faces severe psychological distress, compounded by a chronic shortage of mental health workers in the public sector. (Photo: / Wikipedia)

South Africa is facing severe psychological distress, which is exacerbated by a chronic shortage of psychosocial professionals in the public sector. According to a national survey, over 30% of the population living in South Africa have experienced depression, anxiety disorder or substance use disorder at some point in their life. However, studies show that only 15% of people with mental illness are treated.

Part of this is due to differences in mental health staff across provinces. According to a 2019 report, the availability of psychiatrists across the country is between 0.08 and 0.89 per 100,000 uninsured. According to the World Health Organization (WHO), the average number of mental health professionals worldwide is nine per 100,000 population.

“There just aren’t enough psychiatrists,” says Professor Crick Lund, director of the Alan J Flsher Center for Public Mental Health at the University of Cape Town (UCT) and one of the authors of the report.

Some of Lund’s work examines the role of Community Health Workers (CHWs) in closing this gap. The theory is that CHWs can provide an inexpensive, localized option for mental health support. Called task sharing, it is a model supported by the National Mental Health Framework and Strategic Plan 2013-2020.

“CHWs play a potentially valuable role in identifying and delivering mental health interventions mild to moderate disorders such as depression, anxiety and substance abuse, and in monitoring people with severe illness for relapse, ”says Lund.

A community-based approach to mental health services is also supported by WHO. The guideline on this practice published by the panel in June 2021 calls it “a vision of mental health care with the highest standards of respect for human rights, and gives hope for a better life to millions of people with mental illness and psychosocial disabilities. and their families around the world. ”

Pilot projects of this model in South Africa were encouraging, showing both the willingness of CHWs to use mental health services and potentially positive results with their users. However, experts say the model can only work with a mental health policy that includes dedicated budgeting and an overall strengthening of the public health landscape.

Mental health spending in all provinces of South Africa in 2016/17 was around 8.4 billion rand. At the national level, this represented 5% of the total health budget. The spending itself, however, was heavily skewed: 86% was used for inpatient hospital services and the remaining 14% was used for outpatient care.

This expenditure is enormous when you consider that over 24% of inpatients took three months Re-hospitalized after discharge, which is 1.5 billion rupees, compared to only 616 million rupees of total primary mental health expenditure.

CHWs are already very stretched. The concern is that if they take on a mental health role they need to be compensated and supported for it

The lack of competencies and skills at community and primary care level adds to these costs and puts a strain on specialized services, where qualified practitioners are located, says Goodman Sibeko, director of the South Africa International Technology Transfer Center (ITTC) and director of addiction psychiatry at the University of Cape Town.

For example, CHWs in the Western Cape, where Sibeko’s pilot study was conducted, can read and write, but do not require any additional educational qualifications. They are then trained in basic medical care for conditions such as high blood pressure, diabetes, HIV and TB. They don’t get standard mental health training, however.

“In many cases, cases that reach the specialist level would have been treated appropriately further down the treatment and referral pathway,” he says. “There is strong evidence that CHWs can be successfully trained to identify and support community-level mental health services.” In fact, Lund says CHWs could play a role in helping users manage mild cases of anxiety and help depression by referring only those with advanced symptoms to specialists or hospital services. CHWs could also monitor those with known serious illnesses such as psychosis or bipolar disorder to lower readmission rates.

“If we had CHWs in the community who knew about those suffering from these disorders, it would just be one monthly home visit to check them out to avoid crises and to check medication compliance, ”he says. However, the model requires adequate training and support for CHWs.

How this training can be developed was examined by Sibeko in a pilot study that Lund co-authored. It introduced CHWs with some mental health background to the cultural implications of mental health, characteristics of common disorders, and the role of health workers in the community. At the end of an eight-day training phase, case study vignettes were used to test how well the CHWs had taken up what they had learned.

“Our study found that CHWs successfully improved their knowledge of mental health when they were exposed to structured interactive training in mental health which aimed to raise their awareness of the major concerns in the communities in which they work, ”says Sibeko.

CHWs improved their ability to identify and identify mental health problems and were able to address their own prejudices face issues such as suicide and substance abuse. “This enabled them to face the reality that anyone can become a mental health care user,” says Sibeko.

Some CHWs also discovered personal challenges during training that they hadn’t felt comfortable with seeking help , like anxiety and depression. “This underscores the importance of providing a safe and supportive environment for CHWs, especially as we continue to empower them to offer more mental illness detection and support services,” says Sibeko.

We need a new policy framework, accompanied by a budget that shows what it costs to run high quality mental health services and what needs to be set up. And those resources need to be allocated at the provincial level, with reporting to the government.

Raquel Maart, a 24-year-old CHW who provides mental health services in Cape Town’s Lavender Hill, was trained on one of Lund and CHW research programs her employer, the NPO Compassion Action Trust (CAT).

She says it has helped her better cater for all of her users. “I see new mothers, those with TB and HIV, and I use these skills. The training definitely improved the way I work. ”

It also helped her manage her own feelings of depression after the birth of her first child. “I know now that I wasn’t being silly, I was depressed. Now I know exactly what a depressed person is feeling and I can use my experience to help someone. ”

Although Maart is part of a support team, she says that there are times when the workload is too heavy. “Sometimes I feel like I’m doing too much. I’m overwhelmed and tired, “she says.

There is a risk of overloading CHWs who take on psychiatric care, says Lund. “CHWs are already very stretched. The concern is that if they take on a mental health role, they will have to be compensated and supported, ”he says.

Most CHWs are poorly paid and have historically had little job security. While health departments have standardized their pay at R3,500 per month for the most part in recent years, a study in counties in Gauteng and KwaZulu-Natal shows that community-based care accounts for less than 5% of primary health expenditure.

CHWs are only part of a decentralized strategy based on strong primary health care, said Donela Besada, a senior scientist with the South African Medical Research Council. “We can’t let CHWs examine people and then refer them to a system that can’t perform,” she says.

“If we get CHWs to do something, it has to be related to significant Investments are made in strengthening public health services, including training generalist cadres who are currently uncomfortable with diagnosing and managing mental health. ”

The decentralization of mental health services has been central to the mental health policy framework 2013-2020. However, the practice was introduced before the infrastructure was ready and added to the tragedy, says Leon de Beer, deputy director of the South African Federation for Mental Health.

In 2016, the Gauteng Ministry of Health relocated over 2,000 users of the mental health Health care from inpatient care at Life Esidimeni Hospital to poorly equipped and undocumented NGOs. The result was the death of 144 people and numerous human rights violations.

“As a country and as a sector, Life Esidimeni taught us the hard way how not to decentralize,” says De Beer. “We cannot get people out of hospitals without preparing the infrastructure for them and unless we have invested heavily in community-based psychiatric care.” expired in 2020. De Beer says that urgent action is now needed to address the future of mental health services in the country.

“We need a new policy framework with a budget attached that shows what it costs to provide quality services for mental health practice and what needs to be implemented. And those resources need to be allocated at the provincial level, with reporting to the government, ”he says.

At the request of the Treasury Department, Besada and colleagues, including Lund, are developing a mental health investment case targeting the “Our work identifies at different levels of care what package of mental health services can be provided and at what cost in order to plan a transition to a more decentralized model,” says Besada.

“It builds on the previous guideline to say with this budget request that we are buying this and we have been advocating earmarked funding over a period of time before the NHI (National Health Insurance) is phased in.”

It is to be released in October and contains recommendations for CHWs who are involved in the NHI in carrying out basic counseling for light bi s to provide moderate depression and anxiety, drug monitoring for psychosis, and counseling for pregnant women and young mothers.

Besada hopes the investment case will guide a new policy framework. But she is careful not to overemphasize the role of the CHWs. “CHWs are a very important part of the picture, but they cannot fill the mental health void in South Africa,” she says.

Several attempts by Spotlight to get a Health Department comment on its plans for a new policy Mental health frameworks and where CHWs and the investment case would fit were not answered. DM / MC

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