Introduction

1. Department of HealthPresentation to the Select Committee of Social ServicesState of Mental Health and Mental Health Services in SAPlans for way forward30 July 2013

2. Introduction • Mental disorders are associated with significant distress and impairments of human functioning. This includes ability to work, learn and interact with people. Impacts are felt not only be the individual him/herself but by their family and community. • The World Health Organization at the Alma Ata conference in 1978 defined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. The message is that no health can be achieved without mental well-being. • WHO has recently gone further than this by asserting that mental health is key to development.

3. Prevalence of mental disorder • 12-month prevalence of adult mental disorders in South Africa -16.5% (SA National Stress and Health Survey 2002) • 12-month prevalence of child and adolescent mental disorders in the Western Cape – 17% (no national data) • For People Living with HIV and AIDS the prevalence of mental disorder was found to be 43% • More than 25% of people develop one or more mental or behavioural disorder in their lifetime

4. 1-2% of population suffer from “severe mental disorder” ie schizophrenia, bipolar disorder. The remainder suffer from “common mental disorders” such as depression, anxiety disorder, substance dependence. Measuring diagnosable mental disorder does not capture the disturbed “psyche” of many people in SA. About 14% of the global burden of disease has been attributed to neuropsychiatric disorders and while this figure is slightly lower in developing countries because of the high burden from other diseases, the numbers of people suffering from mental disorder is very high. Around three quarters of people in South Africa that suffer from a mental disorder do not currently receive any mental health intervention

6. Distribution of South African injury Mortality by Cause, 2000 INJURY MORTALITY BY CAUSE, 2000 Distribution of Global Injury Mortality by Cause, 2000

7. Costs The indirect cost of mental disorders outweighs direct treatment cost by two to six times in developed countries and may be even higher in developing countries. In the first nationally representative survey of mental disorders in South Africa, lost earnings among adults with severe mental illness during the previous 12 months amounted to R28.8 billion.29This represented 2.2% of GDP in 2002, and far outweighs the direct spending on mental health care for adults (of approximately R472 million). In short, it costs South Africa more to not treat mental illness than to treat it.

8. When looking at mental health in SA we must consider:- • - Association between poverty and mental health • - Large numbers of children orphaned by AIDS and other diseases. • - Militarized individuals that have returned to civilian life without psychological and social assistance. • People that in their youth were part of liberation campaigns involving violence and in strategies such as “freedom now, education later” that excluded them from completing their education. [We also now have the intergenerational impacts on the children of these individuals]. • A number of people were severely tortured under apartheid.

9. Significant numbers of unemployed people who have become immobilized by their circumstances • - Significant “othering” of people (race, class) both historical and current. • -Infants and children that receive minimal bonding and love from parents. • -People that work such long hours (or who are away from home for long hours) that have little interaction with their families. • - Stigma and discrimination

10. Key impacts on mental (ill) health and suffering

11. As citizens we are constantly bombarded with incidents of:- • - Rape, including rape of young children (as young as 2 years old), people with disability and older persons (even 90 year olds) • - Gratuitous violence and murders • - Family murders • - Mass murders • - Violence by police officers • Violence by young men on other young men • It is not possible to separate out the internal dynamics of individuals from their social and economic conditions, a history of Apartheid etc. • The past and present conditions live “in” people.

12. Outside in and inside out! • Social determinants of mental ill health. There can be little doubt that social and economic conditions impact on mental health and that changing this will improve mental health. (Outside in) • Mental health determinants of social and economic development. On the other hand if people’s internal world is damaged it makes it very difficult for them to act on the world in a way that changes that world in a positive way. It is necessary to change the psyche to achieve better social and economic development. (Inside out) Our approach not only to mental health but to development as a whole has to involve both an “Outside in and inside out”

13. Mental Health Care Act of 2002 • 3. ’The objects of this Act are to- • (1) regulate the mental health care environment in a manner that:- • (i) makes the best possible mental health care, treatment and rehabilitation services available to the population equitably, efficiently and in the best interest of mental health care users within the limits of the available resources; • (ii) co-ordinates access to mental health care, treatment and rehabilitation services to various categories of mental health care users; and • (iii) integrates the provision of mental health care services into the general health services environment;

14. (b) regulate access to and provide mental health care, treatment and rehabilitation services to- (i) voluntary, assisted and involuntary mental health care users; (ii) State patients (iii) mentally ill prisoners; • (c) clarify the rights and obligations of mental health care users and the obligations of mental health care providers; and • (d) regulate the manner in which the property of persons with mental illness and persons with severe or profound intellectual disability may he dealt with by a court of law.

15. Implementation of policies and measures by State • 4. Every organ of State responsible for health services must determine and co-ordinate the implementation of its policies and measures in a manner that- • ensures the provision of mental health care, treatment and rehabilitation services at primary, secondary and tertiary levels and health establishments referred to in section 5( 1); • promotes the provision of community-based care, treatment and rehabilitation services; • promotes the rights and interests of mental health care users; and promotes and improves the mental health status of the population.

17. Current mental health services • We are someway towards achieving the goals of the legislation (and policy), but there is no doubt a long way to still go!

21. Hospitals conducting 72 hour assessments

22. Human resources in the country

23. There are 2692 clinical psychologists registered with the HPCSA (and 1619 Counseling). But only around 14% of registered clinical psychologists are in the public sector.

24. Prevention and promotion • Up to now we have tended to place more emphasis on care, treatment and rehabilitation than prevention and promotion. Main resources in mental health go into hospital services. • Examples of current actions:- • As part of Re-engineering of PHC we have included screening of emotional problems in school children. • We transfer resources each year to the SA Federation for Mental Health for Advocacy and health promotion.

25. Substance Abuse • Demand and harm reduction through DoH interventions are critical components to health and development. • The DOH has its sector Mini-Master Plan that it is implementing as part of the Central Drug authority Master Plan

26. Drug Master Plan (Central Drug Authority) • Health Mini-Drug master plan • Warning labelling (Foodstuffs and Cosmetics Act) • Screening – focus on emergency rooms, Ante-natal services, HIV and TB services • Detox in general hospitals (and in primary care for some people) • Work with Social development (Welfare) in getting people into community rehab programmes. • Specialist treatment centres should be restricted only to those that really need them.

27. THE EKURHULENI DECLARATION ON MENTAL HEALTH - APRIL 2012 (following Mental Health Summit) Hereby commit to:- • Promoting mental health as an important development objective; • Eliminating stigma and discrimination based on mental disability and promoting the realisation of the United Nations Convention on the Rights of Persons with Disabilities (2006); • Full implementation of the Mental Health Care Act, 2002 (Act No. 17 of 2002) and changing the legislation where this is needed; • Ensure collaboration across sectors and between governmental and non-governmental organizations, academics and with other stakeholders to improve mental health services;

28. Providing equitable, cost-effective and evidence based interventions and thereby ensure that mental health is available to all who need it, including people in rural areas and from disadvantaged communities. • Integrating mental health and substance abuse services into the general health service environment. • Providing mental health and substance abuse care to people within communities while referring to higher health care levels where clinically required. • Ensuring that all users of mental health services participate in the planning, implementation, monitoring and evaluation of mental health services and programmes.

29. Fostering person-centred recovery paradigm that respects the autonomy and dignity of all persons; • Increasing human resources to address mental health needs throughout the country through additional training across sectors, integration into general health care and through the National Health Insurance System; • Developing and strengthening human capacity for prevention, detection, care treatment and rehabilitation of mental and substance use disorders and build links with traditional and complementary health practitioners. • Providing physical infrastructure that is conducive to the needs and human rights of people with mental disorders and disabilities;

30. Reducing costs and increase the efficiency of mental health interventions, including making medicines more affordable, in order to provide essential health services; • Establishing comprehensive mental health surveillance mechanisms, health information systems and dissemination processes to assist policy and planning. • Developing and supporting research and innovation in mental health. • Using the outputs from the summit to finalise the Mental Health Policy Framework 2012-2016 and to assist with its implementation and monitoring;

31. And consequently to: 1)Develop and implement a mental health service delivery platform based on community and district based models to ensure that prevention, promotion, treatment and rehabilitation services meet the needs of all; 2)Implement with vigour the Health Sector Mini Drug Master Plan; 3)Establish at least one specialist mental health team in each district; 4)Adequately fund mental health services as per WHO recommendations; 5)Embed and increase mental health human resources within the National Human Resource Plan; 6)Develop a fit for purpose plan for mental health infrastructure at all levels;

32. 7)Revise norms and standards in line with the service delivery platform; • 8)Strengthen Mental Health Review Boards; • 9)Establish a national surveillance system and appropriate monitoring and evaluation systems for mental health care integrated into the National Health Information System; • 10)Establish a national suicide prevention programme; • 11)Strengthen links with traditional, complementary and faith based healers and non-governmental organizations.

33. World Health Assembly Resolution 2013 A resolution on WHO’s comprehensive mental health action plan 2013-2020 sets four major objectives: • strengthen effective leadership and governance for mental health; • provide comprehensive, integrated and responsive mental health and social care services in community-based settings; • implement strategies for promotion and prevention in mental health, and strengthen information systems; • evidence and research for mental health. The plan sets important new directions for mental health including a central role for provision of community-based care and a greater emphasis on human rights.

34. Task team on mental health • Subsequent to the summit, under the stewardship of the Deputy Minister, a working group of stakeholders met to draw an “action plan/strategic plan” to implement the resolutions from the Summit. • Eight catalytic objectives were selected and are recommended by the task team for implementation.

35. Selected catalysts

44. Key challenges • Inadequate community care. People roaming the streets with mental illness mostly do not need hospitalization but good community care. (Hospitalisation of such people may not only constitute an abuse of their human rights but is more expensive than providing good community care, including housing, social support etc).

45. Stigma. People with mental disorder still are subject to discrimination and abuse. The answer to this is not to remove them from society (and thereby subject them to secondary punishment) but to integrate them through educating the public, providing facilities so that they do not cause harm to others etc.

46. Human resources. There are far too few trained professionals to meet need. More professionals must be trained but also we need to make best use of health staff at all levels through integrated mental health care and greater use of community health workers; we need more equitable care between the private and public sectors as part of the NHI. (For example its just not acceptable that only 14% of psychologists are available to treat nearly 85% of the population)

47. Dealing with “common mental disorder” and addressing the “disturbed society” needs far greater attention. This could include a strategy of shifting psychologists from hospitals into the community (without additional costs) and/or contracting private sector and/or more posts for mental health practitioners in communities.

48. Infrastructure. Some mental health facilities are not fit for human habitation and require revitalization or new facilities built. However we must balance this with establishing community based facilities.

49. Prioritization of mental health in annual performance plans. Mental health needs to be prioritized so that it becomes part of not only the national but provincial annual performance plans. Without this mental health will remain the “Cinderella” of health. • Neglect of mental health will impact negatively on physical health as well as mental health (given high co-morbidity). It will also impact on education, productivity, violence etc.

50. Thank-you (and look forward to assistance in improving mental health and mental health services in SA!)