In the face of a mental health pandemic in South Africa, the share of the national public health budget allocated to mental healthcare is not only woefully inadequate but could be better invested in prevention and care at primary healthcare and community level.
Responding to Finance Minister Enoch Godongwana’s 2023 Budget tabled yesterday (22 February), the South African Society of Psychiatrists (SASOP) said it was concerning that mental healthcare continued to be under-funded while common mental health conditions including anxiety and depression were on the rise.
“Mental healthcare continues to be allocated only 5% of the national public health budget and since the health budget itself is declining in real terms, the mental health portion is actually declining in monetary terms,” SASOP public sector national convenor Dr Kagisho Maaroganye said.
One in three South Africans suffer from mental illness, with 75% unable to access treatment,[i] while Dr Maaroganye said mental healthcare professionals had seen a significant increase in common mental health problems “after Covid-19 ran through the country and caused both documented and untold misery for all citizens”.
Common and treatable mental health disorders have overtaken physical illnesses and injuries as the leading cause of medical disability claims in South Africa.[ii]
However, the focus of the mental healthcare system is skewed towards more severe mental health conditions that affect less than 1% of the population, he said.
The latest Mental State of the World report[iii] rated South Africans’ mental wellbeing the lowest in the world, with the country’s “mental health quotient” (MHQ) at 46/100, a decline of 3% from 2020. South Africa also had the highest percentage (36%) of people experiencing emotional distress or struggling with mental health, an increase of 8% from 2020.
“The combined effects of the Covid-19 pandemic – social isolation, job losses, illness and threats to people’s physical health, deaths of family members – have caused widespread emotional distress and mental illness.
“Treatment rates fell due to lack of access to mental healthcare facilities during lockdowns and patients may have had relapses, while those who did not previously experience mental health problems now find themselves with anxiety, depression and sleep disorders,” Dr Maaroganye said.
Meanwhile, he said, under-funding of mental healthcare hampered prevention and diagnosis of mental illness, and limited access to treatment.
“Shortages of mental health clinicians, a lack of experienced practitioners and , insufficient resources to follow up and ensure compliance with treatment, all contribute to a persistent treatment gap.
“In addition to the factors that put the general population at risk of mental illness, there are specific populations that are particularly vulnerable to mental illness, specifically the maternal population and children and adolescents,” he said.
Insufficient attention to the mental health needs of expectant and new mothers, and of children and adolescents, suggests that the prevalence of mental illness is likely higher than indicated in surveys.
“South Africa’s mental healthcare budget, as a percentage of the overall health budget, is at the lower end of international recommendations for mental health spending, but it is also mis-directed. Budget allocations are hospital-centric and reactive, with 86%[iv] of the budget allocated to inpatient care, and almost half that on specialised psychiatric hospitals.
“The focus is on treating the most severe conditions, which have a prevalence of less than 1%, rather than preventing or providing early intervention and treatment for widespread and common mental health conditions of anxiety and depression before they escalate into more serious mental illness.
“Almost 20% of the mental healthcare budget is spent on hospital re-admissions.[v] This ‘revolving door syndrome’ is a costly reflection of a highly inefficient system with an inability to optimise care at primary and community level,” he said.
While only 8% of the mental healthcare budget is allocated to primary healthcare,[vi] SASOP argues that it is at this level that community psychiatry can work to prevent mental illness and ensure early treatment that prevents mental health conditions becoming disabilities.
Dr Maaroganye said that community psychiatry offers the best prospects of optimal care for a stabilised mental healthcare patient in the community and preventing the costly “revolving door” of repeated hospital admissions.
“While specialised psychiatric hospitals, and psychiatric wards in general hospitals, do serve a purpose, the success of a health care system ultimately depends on the extent to which we can prevent illness, and on treating illness effectively to prevent relapse. The aim is to improve quality of life by enabling persons with mental illness to maintain their dignity, obtain or re-obtain independence, and return to being productive members of society,” Dr Maaroganye said.
Within the budget limitations for mental healthcare, SASOP has called on the government to focus investment in mental healthcare at the community psychiatry level.
The organisation proposes the following as more appropriate investments in mental healthcare:
Development of IT systems that hold and distribute psychiatric information between community-based psychiatric facilities and psychiatric units/hospitals to facilitate continuity of carea , better understanding of care outcomes, and inform service planning.
Strengthen child and adolescent mental healthcare through the establishment of more community-based mental health facilities and provision of treatment and rehabilitation for children and adolescents.
Expansion of the substance abuse helpline set up in Gauteng, that gives substance use help-seekers access to human and physical resources to manage their substance use disorders.
Improve mental healthcare for expectant and new mothers by investing in the mental healthcare education of all primary care nurses and healthcare workers, not only antenatal care nurses and midwives, to bolster early detection and treatment of depression and other psychiatric conditions that have a high prevalence in South Africa during pregnancy and after childbirth.
Increase expenditure on Community Psychiatry through 1) hiring of psychiatrists, psychiatric medical officers, mental health nurses and allied professionals with interest and expertise in mental health, 2) renovating or expanding primary healthcare clinics to accommodate mental health clinics, and 3) facilitating the training of generalist clinical staff to manage patients’ mental illness independently or with support from psychiatric clinicians.
[i] Herman AA, et al. The South African Stress and Health (SASH) Study: 12-month and lifetime prevalence of common mental disorders. SA Medical Journal, Vol 99, No. 5. 2009. http://www.samj.org.za/index.php/samj/article/view/3374 [ii] Sumaiyah Docrat, Donela Besada, Susan Cleary, Emmanuelle Daviaud, Crick Lund. (2019) Mental health system costs, resources and constraints in South Africa: a national survey. https://academic.oup.com/heapol/article/34/9/706/5572608?login=false [iii] Mental Health Million Project, Sapien Labs. March 2022. Mental State of the World 2021. https://mentalstateoftheworld.report/ [iv] Reference ii. [v] Reference ii. [vi] Reference ii.