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Challenges faced by South African health services in implementing the Mental Health Care Act.

The World Health Organization (WHO) has drawn attention to the growing global burden of mental disorders, and to recent advances in our understanding of and ability to treat these disorders. (1) Mental disorders accounted for 12% of the global burden of disease in 2000. This figure will rise to 15% in 2020, when it is estimated that unipolar depression will be the second most disabling health condition in the world. (1) In South Africa, neuropsychiatric disorders account for the second highest proportion of the local burden of disease, after HIV/ AIDS. (2)

The Mental Health Care Act No. 17 of 2002 marks a significant step forward in addressing mental health as a major public health issue in South Africa and protecting the human rights of people with mental illness. Based on an extensive local consultation process, the new Act is consistent with international human rights standards. (3) The legislation is essential for monitoring mental health services, improving the quality of care and protecting the human rights of people with mental disorders, through compliance with the law. Congratulations are due to the legislators, to those who were consulted during the drafting process and to those who have begun the process of implementation, for example through the establishment of Mental Health Review Boards. The challenge is now to implement this legislation through the delivery of appropriate mental health services at provincial and district levels.

We believe that the implementation of the new Mental Health Care Act poses three challenges to health services in South Africa. The first challenge is to systematically address the lack of resources for mental health care, and begin to plan appropriate services for mental health. We know that there is widespread underresourcing of mental health services in South Africa, (4-6) with consequent underdiagnosis and undertreatment of mental illness. These difficulties reflect the historical legacy of mental health services in this country. The Mental Health Act provides an opportunity to remind decision-makers of the importance of mental health, and to ensure that appropriate resources are allocated to improve the quality of mental health services and protect the human rights of people with mental disorders now and in the future. While there are many claims on available health resources, the Act would seem to indicate that mental health services deserve parity.

The second challenge is for health services to develop information systems to monitor the mental health services that they do deliver and to become transparent and accountable in this regard. We recently conducted an audit in a collaboration between the Unit for Infection Prevention and Control at Tygerberg Academic Hospital, Stellenbosch University and the of Cape Town. The purpose of the audit was to assess the extent to which hospitals in the Western Cape are compliant with the provisions of the Act and report on some indicators of the quality of mental health care. Nineteen hospitals were audited by infection control nurses, of which 10 completed the mental health section of the audit.

The low response rate was found particularly among general hospitals, which completed the sections of the audit that did not relate to mental health, but did not answer the mental health questions. The low response rate by general hospitals may reflect the general lack of systems at such hospitals for gathering mental health data, a lack of transparency regarding mental health care within general hospitals, or the fact that mental health care has historically been offered only in psychiatric hospitals.

Clearly, any conclusions from this audit must be tempered by the inability to generalise from the data in the Western Cape to hospitals in other provinces. Nevertheless, we are aware from inspections of facilities in other provinces, that many provinces are experiencing similar difficulties in implementing the new mental health legislation. If the requirements of the new Mental Health Care Act are to provide mental health care in all 'health establishments', then both general and psychiatric hospitals need to develop information systems to monitor the care that they deliver. The audit we conducted indicated that many general hospitals are not able to provide mental health data, in compliance with the Act.

An immediate and practical solution to this problem is to expand current general health management information systems to include monitoring of mental health care. The WHO has recently published guidelines for the development of Mental Health Information Systems that are linked to general health management information systems. (7) These guidelines could usefully be applied in a general review of mental health information systems in all provinces. This would be consistent with international trends and WHO recommendations for the integration of mental health into general health care. (1,8) This is endorsed by South African national policy which recommends the integration of mental health into general health care, and the need for general hospitals to move in this direction. (9)

Although we have cast the spotlight on the Western Cape through our audit, we also need to acknowledge the progress that has been made in this province. The Provincial Government of the Western Cape (PGWC) is currently in a process of reviewing the implications of the Mental Health Care Act for hospitals. For example, planning for seclusion facilities in district hospitals is currently being evaluated and is at an early stage. An active Mental Health Review Board has been established in the Western Cape, and we believe that a number of hospitals are fully compliant with the Act, and provide patients with access to trained staff. Some of us have been involved in initiatives with the PGWC to decentralise mental health care to district level and develop community-based care in the Western Cape, a process that is also consistent with the Act. The PGWC has also set out plans for the development of community-based mental health services through Healthcare 2010. (10)

A third challenge is to improve quality assurance measures for mental health care among both psychiatric and general hospitals in South Africa. Steps in this direction have already been taken by the national Department of Health, with the development of national Standards of Care for people with severe psychiatric disorders, adopted in 1998 after an extensive consultation process. (11) The national Standards of Care need to be used to assess the current quality of care in health facilities, for example through accreditation agencies or review boards. The national Department has also commissioned and adopted a set of standard treatment guidelines (STGs) for common mental health conditions. (12) It is important that these resources be used to monitor and improve the quality of care in health facilities. For example, STGs need to be readily available for clinicians in health facilities. Our Western Cape audit found that only 6 of the 19 hospitals were in possession of the STGs.

To conclude, as partners with the PGWC and the national Department of Health, we are aware of the difficulties posed by implementing the new Mental Health Care Act, particularly in the light of our historical legacy and underresourced services. Nevertheless, we believe it is essential that these difficulties be faced and that the challenges they pose be overcome in the interests of providing appropriate mental health care and protecting the human rights of people with mental disorders.

The authors would like to thank Professor T Zabow and Dr Hering for their contributions to this editorial.

Corresponding author: C Lund (

(1.) World Health Organization. World Health Report 2001, Mental Health: New Understanding, New Hope. Geneva: WHO, 2001.

(2.) Bradshaw D. Initial Burden of Disease Estimates for South Africa, 2000. Cape Town: Medical Research Council, 2003.

(3.) World Health Organization. WHO Resource Book on Mental Health, Human Rights and Legislation. Geneva: WHO, 2005.

(4.) Lund C, Flisher AJ. Staff/population ratios in South African public sector mental health services. S Afr Med J 2002; 92: 161-164.

(5.) Lund C, Flisher AJ, Lee T, Porteus KA. Bed/population ratios in South African public sector mental health services. Soc Psychiatry Psychiatr Epidemiol 2002; 37: 346-349.

(6.) Lund C, Flisher AJ. Community/hospital indicators in South African public sector mental health services. J Ment Health Policy Econ 2003; 6: 181-187.

(7.) World Health Organization. Mental Health Policy and Service Guidance Package: Mental Health Information Systems. Geneva: WHO, 2005.

(8.) World Health Organization. Mental health policy and service guidance package: organisation of services for mental health. Geneva: WHO, 2003.

(9.) Department of Health. White Paper for the Transformation of the Health System in South Africa. Pretoria: Government Gazette, 1997.

(10.) Health Western Cape. Healthcare 2010: Health Western Cape's Plan for Ensuring Equal Access to Quality Health Care. Cape Town: Department of Health, Western Cape, 2003.

(11.) Muller L, Flisher AJ. Standards for the mental health care of people with severe psychiatric disorders in South Africa: Part 2. Methodology and results. South African Psychiatry Review 2005; 8: 146-152.

(12.) Department of Health. Standard Treatment Guidelines for Common Mental Health Conditions. Pretoria: Department of Health, 2003.

C Lund

D J Stein

A J Flisher

Department of Psychiatry and Mental Health

University of Cape Town

S Mehtar

Unit for Infection Prevention and Control

Tygerberg Academic Hospital and

Stellenbosch University

Tygerberg, W Cape
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Article Details
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Title Annotation:Editorial
Author:Lund, C.; Stein, D.J.; Flisher, A.J.; Mehtar, S.
Publication:South African Medical Journal
Geographic Code:6SOUT
Date:May 1, 2007
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