The long-awaited new National Mental Health Policy Framework and Strategic Plan 2023-2030 took centre stage recently at the two-day SA Mental Health Conference in Johannesburg, the old policy framework having technically expired in 2020 – but experts are frustrated by delays in implementation.
While they have welcomed the new policy framework, they are not happy about the time lags, writes Thabo Molelekwa from Spotlight.
“We’re now sitting in 2023, three years late,” said Cassey Chambers of the South African Depression and Anxiety Group (SADAG).
What that means, she said, is that civil society did not have a working document with which to engage government at provincial or district level.
Bharti Patel of the South African Mental Health Federation expressed similar concerns. “We are disappointed it has taken this long for the policy to be reviewed, given that the initial policy was launched in 2013.
“We had a crisis from 2013 to 2020. We have witnessed mental healthcare users losing their lives during Life Esidimeni. The (Health) Ombud report, the South African Human Rights Commission Report, have all given recommendations,” said Patel, arguing that those recommendations should have informed policy and implementation more quickly.
However, Health Minister Dr Joe Phaahla said that despite the three-year gap since the previous policy framework expired, it doesn’t mean there has been a gaping chasm in the period between.
“Every either three or five years, we revise the policy. So, it is not that there has been a gap. There has been a policy, which has been guiding,” he said.
“But in each cycle of the strategy and planning, we have a timeframe … so now we have evaluated, we are adding (additional things) we learned from the previous implementation.”
Gaps in the country’s mental health services were not due to a lack of policy and plans but rather, to implementation issues – and sometimes the shortage of resources and psychiatrists, he said.
“If you look at the area of psychiatrists, it is just the two-tier system of our health service, which makes it difficult because …we can’t match with the public sector salaries generally,” he said.
Psychiatrists, he added, who mostly work in the private sector, were typically trained at public-sector teaching hospitals. “But once they’re qualified, they stay for one year or so, then they are attracted by better income,” he told Spotlight.
To deal with the shortage in provinces like the Northern Cape, where there are only three psychiatrists, the department plans to contract from other provinces. “We can have part-time psychiatrists, maybe take some from Gauteng where the majority are, and in
Western Cape, and contract them to provide services in Northern Cape. Even if it’s on a weekly rotation,” he said.
Concerns over delays
Chambers described the previous strategic policy framework as a “very good document”. The problem came in the implementation, she said.
“And I think perhaps this is (why there was a) delay in having an updated document that is now running from 2023 to 2030. It is because the document was good, the policy was good. However, how it was implemented was not happening,” she said.
Professor Crick Lund, co-director of the Centre for Global Mental Health at King’s College London, said various factors create implementation challenges.
“One is ignorance on the part of senior decision-makers about mental health, ignorance about the scale of the problem, and ignorance about the fact that something can be done about it,” he said.
Lund said the new policy framework has stronger implementation monitoring mechanisms and implementation can be tracked in a much clearer way over time.
However, for it to work better than the previous one, Lund believes there is a need to create greater public awareness about mental health and the mental health policy.
“We need to get all the sectors involved working together – the Department of Health, Education, Social Development, the criminal justice system, and also the NGO sector.”
Along similar lines, Patel stressed the importance of involving more government departments. “While the policy is developed at the national level, the Department of Health is responsible for training the provinces, and not only the Department of Health; they need to train all government departments within the province who have bought this policy,” she said.
“You can’t have the Department of Health alone implement a policy. This requires inter-sectoral collaboration so everyone can also put budgets towards implementation.”
Budgets and human resources
While there seems to be consensus on the need for more training and more buy-in, there is also a shared awareness that successful implementation will depend on the availability of funds and human resources.
“We need to see structured action plans in the provinces with budgets allocated so that we can hold the government departments accountable,” said Patel.
Chambers agrees that to get the implementation right, the budgets also need to be right, “especially because our previous policy framework was not implemented”.
“So, we have to compensate for that now, which is concerning because this year, the health budget has been reduced,” she said.
According to the new policy framework, the case for investing in mental health is strong. It states that at a societal level, lost income associated with mental illness far exceeds public sector expenditure on mental healthcare – in other words, it costs South Africa more to not treat mental illness than to treat it.
The impact of mental illnesses like depression and anxiety has been estimated to cost the economy more than R61.2bn in lost earnings per year. Certain conditions such as perinatal depression and anxiety have lifelong cost consequences, amounting to R47.6bn per annual cohort of births in SA.
Chambers also highlighted the shortages of human resources and appropriate facilities. “We don’t have the human resources or the capacity to fulfil that implementation plan and that’s a worry and a concern,” she said.
NHI and provincial plans
According to the new policy framework, mental health will be financed according to the principles adopted for all health financing in the country, and people will be protected from the catastrophic financial consequences of mental ill-health.
The financing of the National Health Insurance (NHI) system provides for mental health services to be given parity with other health conditions, in proportion to the burden of disease and evidence for cost-effective interventions.
NHI will specifically include packages of care for mental health…and private medical aid schemes should be required to provide similar parity between mental health and other health conditions.
“At provincial level, mental health budgets will be reviewed annually to align mental health with national priorities…,” the framework reads.
All provinces are to develop provincial strategic plans for mental health, in keeping with national policy, which outlines specific strategies, targets, timelines, budgets and indicators in 2023 and annually thereafter, informed by specific unique local challenges.
NMHP-FINAL-APPROVED-ON-30.04.2023
See more from MedicalBrief archives:
Mental healthcare resources dire in some provinces, says Phaahla
Mental health still last in line seven years after Life Esidimeni
Psychiatrists group urges government to spend more on mental healthcare