South Africa’s critical shortage of psychiatrists and specialised staff in the field is not only a public health issue, according to experts, who say the treatment and care of people with schizophrenia, for instance, is also under pressure in the private sector, where it is additionally undermined by insufficient coverage from medical schemes.
In Spotlight, Thabo Molelekwa writes that Minister of Health Dr Joe Phaahla last year disclosed that South Africa had only 451 public sector psychiatrists and that there were 187 psychiatric vacancies.
The numbers differed drastically between provinces – the Western Cape had 99 public sector psychiatrists and one vacancy, while the entire Eastern Cape had only two public sector psychiatrists and 10 vacancies.
Apart from underlining large disparities between provinces, the numbers also suggest that in much of the country, the public sector simply lacks the specialised staff required to provide quality treatment and care for people with potentially severe mental health conditions, like schizophrenia.
But the private sector is equally hamstrung – by inadequate medical aid coverage.
‘An illness of young people’
Dr Mvuyiso Talatala, of the South African Society of Psychiatrists (SASOP), said although schizophrenia affects only around 1% of the population (rates are relatively similar between countries), it is quite severe for those affected by it.
Psychiatrist Dr Eugen Allers agreed, calling it “one of the most serious psychiatric disorders we get”. Allers is in private practice and a board member of PsychMG.
He described schizophrenia as a disease of young people, with around 90% of people with the disease first showing signs before 25. “So their whole careers, their whole lives are ahead of that,” he said.
Young people with schizophrenia also often become psychotic – hearing voices, seeing things, their thought processes confused, and being unable to distinguish between what is reality and what is not. “They get paranoid, they believe people want to kill them. So
it’s a very serious mental illness,” he said
However, with treatment, most symptoms of schizophrenia will greatly improve and the likelihood of a recurrence can be diminished.
Although hearing voices and behavioural problems are some of the most concerning aspects of schizophrenia, Talatala said the biggest problem was a decline in cognition, which happens in the first two years. “And if you lose that cognition, you’ve lost it. It’s difficult to recover. You have to prevent it upfront,” he said.
Allers said when the illness starts, people typically require medication and hospitalisation.
“We usually have to admit them to hospital in that state and from there, we medicate them. We also do psychotherapy to make them understand what the illness is all about.
“The new medications are very successful. We also have a long-acting injectable which lasts for two weeks, a month, three months, or six months.” (Although he clarified that the six-month formulation is not yet available in South Africa.)
The initial first six months to a year of treatment are critical. “The sooner you get them out of the psychosis, the better they do long term. They can function, go to university, (and) study. If you don’t do that, they become chronically disabled patients.”
Talatala also stressed this point. “If it’s not treated early, it’s going to drain the resources because the person who’s affected will stop working or studying, and become a burden to the state. They’re likely to end up in hospital care, which is more expensive.”
The answer was treating people early. “Remember, this starts in your adolescence, late adolescence, and young adulthood. If we treat these people when they’re at school, they’ll complete their studies (and there are) those who (can) start work. And we’ve seen this in our practices – where we treat patients and they continue working without anyone noticing or picking up any problems.”
Private sector problems
In the public sector, early treatment can be hard to come by if there is poor mental health screening and referral at clinics as well as a lack of beds in mental healthcare facilities and a shortage of psychiatrists.
But appropriate early treatment also poses challenges in the private sector.
Talatala said one was that regulations enacted under the Medical Schemes Act on how preferred minimum benefits (PMBs) must be funded are not “crystal clear” regarding schizophrenia.
“In the regulations, one needs to go and dig it out of the treatment algorithms that show some stages that should be followed in treating schizophrenia,” he said. “The regulations were not written in a way that would make it easy to comply or easy for patients to fight for the funding.
“As a result, you end up with patients who struggle to get funding to see psychiatrists or special therapists – everything that you need for treating schizophrenia.”
What’s clear enough is that medical schemes are obliged to cover three weeks of hospitalisation for patients with schizophrenia.
Allers said that usually, three weeks is enough, but in some instances, not.
It is the question of what else besides these three weeks should be covered that Allers and Talatala suggest is the rub.
For example, appointments with psychiatrists are not covered by default. Allers aid it takes six months to a year for people with schizophrenia to become really well, and to get there requires intensive treatment after hospitalisation.
PMBs do not cover this (outpatient) phase of treatment, so patients are at risk of relapse. “Psychiatry is really more about outpatient treatment than inpatient treatment. We want to keep patients out of the hospital, not in the hospital,” he said.
This lack of treatment and care beyond hospitalisation means some private-sector patients end up being treated in the public sector.
As stated in a paper published last year in the journal Schizophrenia Bulletin, of which Talatala was a co-author, “people with schizophrenia have minimal access to care in the private sector because of this restricted funding for mental healthcare. Most people with schizophrenia are therefore treated in the public health sector.”
Talatala said the regulations for schizophrenia are poorer than those for depression.
“Depression has an option of having 15 psychotherapy sessions. I’m not saying it’s adequate for depression either. And bipolar disorder has an option as well, 21 days in the hospital or 15 psychotherapy sessions. So depression or bipolar disorder are better covered than schizophrenia.”
Schizophrenia affects a small population, but the impacts were severe because people end up in chronic care facilities or on the streets, or in psychiatric hospitals, he said, and it should get the same level of attention as heart attacks or strokes or any of other severe illnesses.
“We need to treat it aggressively. To prevent heart attacks, we advertise better lifestyle care, monitoring low blood pressure, checking your blood, checking your digits, your cholesterol, and taking medication early. We need to have the same attitude for schizophrenia – look for early screening for the illness and early intervention with the medication that is effective from the beginning.”
Role of the CMS
In 2020 the Council for Medical Schemes published a PMD benefit definition guideline for schizophrenia, to, among other things, “guide the interpretation of the PMB provisions by relevant stakeholders” and to “improve clarity in respect of funding decisions by medical schemes”.
But the guideline was far from the end of the matter. Allers said they (South African Society of Psychiatrists and Psychiatry Management Group) have had numerous meetings with the CMS and particularly its clinical review committee, to raise concerns.
A circular from earlier this year suggested the CMS was listening. “Since the publication of the mental health definition guidelines, several stakeholder groups have commented on poor interpretation and application of the guidelines and advised on the need for revisions. The CMS is preparing a discussion document to revise these previously published mental health benefit guidelines,” the CMS circular reads.
Once inputs are collated, said CMS spokesperson Stephen Monamodi, “they will be assessed and used to create an updated benefit definition guideline”.
CMS perspective
Monamodi confirmed schizophrenia was a PMB condition as it is part of the Diagnostic and Treatment Pair (DTP) Code 907T and also one of the conditions included in the Chronic Disease List treatment algorithms. The specific DTP code refers to “Schizophrenic and paranoid delusional disorders”.
“The DTP treatment component, as well as the treatment algorithm, outline the minimum level of care that should be funded by medical schemes for any medical scheme member or beneficiary,” he said.
“Medical schemes may also develop formularies and clinical protocols to assist in funding decisions.
Apart from hospitalisation, follow-up treatment, meds, blood tests, and other tests related to schizophrenia must be paid in line with the PMB Regulations.”
The regulations stipulate that PMB level of care for DTP907T is hospital-based management for up to three weeks annually. The medical treatment algorithm for schizophrenia outlines various medical treatment options that should be available when someone is treated both in and out of hospital.
While this is the minimum care any medical scheme member or beneficiary to which someone with schizophrenia is entitled, Monamodi added that schemes can actually fund admissions for longer than three weeks or medications not on the treatment algorithm as per their protocols and formularies.
Study details
Addressing the Needs of People with Schizophrenia in South Africa During the COVID-19 Pandemic
Lindokuhle Thela, Mvuyiso Talatala, Bonginkosi Chiliza
Published in Schizophrenia Bulletin Open in January 2022
Abstract
Research indicates that most people with Schizophrenia from low to middle-income countries do not receive adequate healthcare. Inadequate policies, lack of funding, poor service planning and neglect are some barriers to adequate care. Intrinsic barriers to care include stigma, lack of insight, and pathways to care that are often driven by cultural beliefs, and many systemic challenges. South Africa was not spared from the scourge of COVID-19, hosting a third of all reported cases in Africa. In a country with disparities, it would be of interest to get insight into the situation concerning the healthcare needs of people with Schizophrenia during the pandemic. A pandemic such as COVID-19 placed enormous strains on already limited and unequally distributed health care resources. In this paper, we discuss: (1) The South African healthcare system (with respect to Schizophrenia care). (2) COVID-19 policies related to the care of people with Schizophrenia (testing, access to vaccine). (3) Managing people with Schizophrenia amid the COVID-19 pandemic. (4) Recommendations.
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