South Africa’s policy framework and strategic plan has lapsed, so what happens next?

Once widely hailed, South Africa’s Mental Health Policy Framework and Strategic Plan 2013 — 2020 lapsed last year, with mixed reviews on its implementation from mental healthcare stakeholders.

Bharti Patel, National Executive Director of the South African Federation for Mental Health (SAFMH), commends the framework’s emphasis on generating scientific evidence and best practice underscored by a deep commitment to human rights and serving vulnerable populations. “However, there is still a long way to go to improve access to quality mental healthcare to meet the needs of people throughout South Africa,” she says.

Patel says it is very concerning that we are heading towards the end of 2021 and are having these conversations about a ‘lapsed mental health policy’ when Covid-19 has brought about an increase in mental health problems globally over the past 18 months. “The review and update of the policy framework should have commenced long before its ‘expiry date’, and the fact that we are seeing a retrospective review and scrambling to update it now speaks — once again — about the continued neglect of mental health in South Africa,” she says.

What the policy framework set out to do 

The 62-page document (which is both a policy framework and a strategic plan) set out ambitious objectives with timelines for mental health staff training and mental health financing, among others. For example, the framework said that by 2014 “mental health will be financed according to the principles adopted for all health financing in South Africa and people will be protected from the catastrophic financial consequences of mental ill-health”.

By 2015, the policy aimed that “mental health will be integrated into all aspects of general healthcare, particularly those identified as priorities within the 10-point plan, for example, TB and HIV”. By the same year, all health staff working in general health settings were meant to have received basic mental health training and ongoing routine supervision and mentoring. The expansion of the mental health workforce was to be “actively pursued by all provincial Departments of Health”.

Assessing policy implementation: Hits and misses

While the aims of the policy framework were widely welcomed, Crick Lund, Honorary Professor at the Alan J. Flisher Centre for Public Mental Health in the Department of Psychiatry and Mental Health at the University of Cape Town, says it has unfortunately not been well implemented.

“A key priority was the establishment of district mental health teams to support the implementation of the mental health policy, including training primary care workers in mental health and coordinating the various sectors involved in mental health at a district level. Very few of these district mental health teams have been appointed,” he says. “A key barrier has been the lack of budget priority for mental health at the provincial level. Other urgent priorities highlighted by the policy framework included strengthening of community-based mental health services, including residential care and day-care. “[But],” he says, “there has unfortunately been very little progress in this area.”

Dr Mvuyiso Talatala, board member and past president of the South African Society of Psychiatrists (SASOP) doesn’t mince his words. He says provinces failed to implement the framework and points to a Human Rights Commission report published in 2018 that came to the same conclusion.

He says it seems it is not the policies that are a problem but the lack of will by authorities to implement the policies. “Some provinces never even prioritised the appointment of provincial mental health directorates,” he says. He also points out that the Gauteng provincial government prioritised deinstitutionalisation despite the framework having warned against further deinstitutionalisation. The consequence, he says, was the Life Healthcare Esidimeni Tragedy.

Lesley Robertson, Adjunct Professor at the Department of Psychiatry at the University of Witwatersrand and head of the clinical unit for community psychiatry in the Sedibeng District of Gauteng, doesn’t think the policy framework received much attention until recently. “I think it came into a stronger awareness with the Life Esidimeni Ombudsman Report and the Life Esidimeni Arbitration Hearings, which referred extensively to this policy framework. Before that, the department of health, the healthcare funders, decision-makers were very focused on the national health strategy (a more general health strategy),” she says.

No implementation plan?

One concern is that officials may not have been given enough guidance on how to implement the policy.

Robertson points out that it is not straightforward for officials such as directors, or even heads of departments, to know what exactly to do to implement the action points mentioned in the strategic plan section of the policy framework. She argues that the policy should have been accompanied by a detailed implementation plan.

Shortage of mental health staff

The policy acknowledged the shortage of mental health practitioners and that there was a need for additional training, but progress in this area also seems at best patchy.

Talatala says the country has about 600 psychiatrists. “There have been lots of deaths of psychiatrists since the Covid-19 pandemic reached South Africa. Some psychiatrists continue to emigrate. The number of training posts has not significantly increased. The human resources situation has not significantly improved since the framework was published,” he says.

According to Robertson, the training of primary healthcare practitioners happened in pockets and it was not an initiative from the department of health as stated in the policy framework. “I don’t think the emphasis came from the department of health. I think the emphasis came from various psychologists and psychiatrists employed at universities linked to hospitals who have been motivated to offer training.” She says it is a major problem that this didn’t come from the department of health.

Rural Health Advocacy Project (RHAP) project officer Lungile Gamede, says studies in South Africa reveal that some patients presenting for mental health services are managed by registered nurses who do not have qualifications in psychiatric nursing science and posit that this practice may result in misdiagnosis and a possible relapse of mental illness.

“If nothing is done, this will pose a significant threat to the successful integration of mental health in primary healthcare in the future, where communities living in rural areas will bear the brunt. It is also vital that nursing education plays a role in closing the mental health treatment gap through social accountability in nursing education and producing nurses whose competencies align with disease burdens as healthcare workers who are mostly the first point of contact for patients at primary healthcare centres,” says Gamede.

A protester outside St Georges Mall on 10 July 2013 in Cape Town, South Africa, during Psychiatric Disability Awareness Month. (Photo: Gallo Images / The Times / Halden Krog)