Mental health policy development and implementation in ...

1 Mental health policy development and implementation in South Africa: a situation analysis Phase 1. Country report Crick Lund Sharon Kleintjes Victoria Campbell-Hall Sithembile Mjadu Inge Petersen Arvin Bhana Ritsuko Kakuma Beauty Mlanjeni Philippa Bird Nathalie Drew Edwige Faydi Michelle Funk Andrew Green Mayeh Omar Alan J. Flisher 31 January 2008 2 Table of Contents Acknowledgements .. 6 Executive 8 1. 14 2. Methodology .. 18 Introduction .. 18 WHO AIMS .. 20 Sample and procedure .. 20 Analysis .. 21 Semi-structured interviews and focus group discussions .. 22 Instrument development .. 22 Sample and procedure .. 22 National and provincial level .. 23 District 25 Analysis .. 27 WHO Mental health policy and Legislation Checklists .. 28 WHO Mental health policy and Plan 28 WHO Mental health Legislation Checklist .. 29 Document analysis .. 29 Research ethics.

2 30 3. 32 Context .. 32 The political 32 policy implementation challenges .. 32 Human resource challenges .. 33 Rural development .. 34 The role of local government and civil 35 Poverty .. 37 Unemployment and job creation .. 38 Social 40 The impact of 41 Crime and violence ..44 Mental health 47 Public attitudes to Mental 47 Low priority given to Mental health .. 48 Poverty and Mental health .. 49 Stigma in Mental health .. 52 Current status of stigma .. 52 Impact on policy development and implementation .. 55 Reducing stigma .. 57 Strategies to address 59 Participation of Mental health care users in policy making .. 62 Support for Mental health care user 63 3 The development of a Mental health care user lobby .. 65 Support for Families ..66 General policy making processes in South 68 policy making in South Africa post-1994.

3 69 Stages of the policy -making process in South African Government .. 69 Documentary stages of policy development .. 71 Insiders and Outsiders in the policy making process in South 71 Process of Mental health policy and law development .. 72 Mental health policy development .. 72 Stages of Mental health policy development in the Department of 72 Current status of Mental health policy in South 74 Areas of action for policy development .. 77 Mental health law development .. 80 Content of Mental health policy and law .. 81 Content of the 1997 Mental health policy 81 Appropriateness of current Mental health 82 Links with other relevant policies .. 82 White paper for the transformation of the health System in South Africa (1997) .. 82 United Nations Convention on the Rights of Persons with Disabilities 85 National Disability Strategy .. 85 Areas to be addressed in the new Mental health 85 Child and adolescent Mental health .

4 85 Gender 86 Intellectual disability .. 86 HIV/AIDS and Mental 87 Poverty and Mental health .. 87 Content of the Mental health Care Act (2002).. 89 Links with other relevant legislation .. 90 Areas to be addressed in further legislation 90 policy and legislation development : recommendations for intersectoral approaches to specific user groups .. 95 Mental health policy implementation at national and provincial level .. 98 National and provincial structures and plans .. 98 Financing of Mental health services .. 98 Human rights 100 Mental health 100 Mental health outpatient facilities .. 100 Day treatment 101 Psychiatric inpatient units in general 101 Community residential facilities .. 102 Mental hospitals .. 102 Forensic and other residential facilities .. 104 Human rights and equity .. 104 Summary Charts: Mental health 104 Mental health in Primary health Care (PHC).

5 106 Training in Mental health care for primary care staff .. 106 Service provision in primary Mental health 107 4 Prescription in primary health 108 Human Resources .. 108 Number of human resources in Mental health care .. 108 Training professionals in Mental 110 Consumer and family associations .. 111 Public education and links with other 112 Public education and awareness campaigns on Mental 112 Links with other 113 Monitoring and evaluation of services .. 114 Mental health policy implementation at district level .. 117 Overview of facilities, resources, services provided and service usage from 118 District .. 118 Sub-district .. 118 Structure of Services at the District and 119 District Management .. 120 Sub-District 122 Primary health Care Clinics .. 128 Involvement of other Government Sectors in Mental health .

6 140 Community health workers .. 148 Community - 149 Key issues in current Mental health service provision in South Africa .. 166 Integration of Mental health with general health .. 166 District and regional hospital services .. 169 Deinstitutionalisation and the need for community-based Mental health services .. 170 The role of the national and provincial structures for Mental health , Department of health .. 172 Intersectoral 176 Research .. 181 4. Discussion .. 185 Context .. 185 Mental health 185 General policy making processes .. 187 Process of Mental health policy and law development .. 188 Appropriateness of Mental health policy and 192 Mental health policy implementation at national and provincial levels .. 193 Mental health policy implementation at district level .. 194 Key 194 Implications and Recommendations for district level 197 Conclusion: district level.

7 203 Research .. 204 Limitations of the study .. 204 5. Conclusion and Recommendations .. 205 Strengths and Weaknesses of the Mental health System in South Africa 205 5 Recommendations to strengthen the Mental health system and promote Mental health in South Africa .. 206 Strengthening the Mental health 206 Promoting Mental 207 6. References .. 209 7. Glossary: definitions .. 216 8. Annexures .. 221 Annex 1. Sample of SSI and FGD 221 Annex 2. Coding framework for qualitative data analysis .. 265 Annex 3. WHO Mental health policy and Legislation Checklists .. 281 WHO Checklist for evaluating a Mental health policy .. 281 WHO Checklist on Mental health Legislation .. 300 Annex 4. Ethical clearance .. 349 Letter of support: Minister of health , South Africa .. 349 Research ethics approval: University of Cape Town .. 351 Annex 5. Key resources for policy 352 6 Acknowledgements This report has been made possible through the contribution of many individuals and organisations.

8 We are grateful for the support of the Minister of health , Dr Manto Tshabalala-Msimang, and the Director-General in the national Department of health , Mr Tamsanqa Mseleku. Access to health services for the purpose of data gathering was granted through the permission of the national Department of health and heads of the provincial departments of health . We would like to thank the Director of Mental health and Substance Abuse, Mr Sifiso Phakathi, and the Deputy Director, Ms Evah Mulutsi for their ongoing support and assistance. We are grateful to the Provincial Mental health Coordinators, the Directors of the 17 Mental health Societies and the national Executive Director of the South African Federation for Mental health , Mr Solly Mokgata who contributed their time and expertise to the gathering of data. We would like to thank all those interviewed in semi-structured interviews and focus group discussions, who cannot be acknowledged individually for reasons of confidentiality.

9 At the District site in KwaZulu-Natal, we would like to thank the following people: for help with permission and gaining access to the community, Dr Marie-Louise Newell and the Community Liaison Office - Africa Centre; for permitting us to conduct interviews with health staff and facilitating the research, Miss Maoela, Mrs Mkhwanazi and Miss Mtimkulu (District health Office) and Mrs Zungu, Dr Adam and Jon Piku Yaku (District Hospital); and for facilitating the discussions with traditional healers, Mr Mbokazi (Traditional Healer's Council). In addition, we would like to thank all the other participants in both the government sector and civil society for their kind cooperation. We would like to thank the members of the South African Mental health Advisory Committee (MHAC) who assisted in reviewing progress of the study and providing comment on the design and methodology of the study: Ms Evah Mulutsi, Ms Hasina Subedar, Dr Irwin Friedman, Prof Melvyn Freeman, Mr Moosa Salie, Mr.

10 Solly Mokgata, Dr Connie Kganakga, Mrs. Gloria Mhlaluka and Ms. Seitisho Rammutla. We would also like to thank independent reviewers from the University of Cape Town: Ms Madeleine Duncan, Ms Phyllis Orner, Dr Pete Milligan, Ms Annie Leatt, who provided comment early in the methodological design of the study. We would like to thank members of the international Consortium Advisory Group, who assisted in reviewing the study and providing input on the methodology: Dr Yogan Pillay (chair), Prof Vikram Patel, Prof Haroon Bhorat, Ms Elaine Mckay, Mr Isaac Mwendapole, Ms Christina Ntulo and Dr JB Asare. This report was made possible by funding provided by the Department for International development (DFID) for a Research Programme Consortium entitled The Mental health and Poverty Project (MHaPP): Mental health policy development and implementation in four African countries (DFID contract number: RPC HD6 2005 2010).