/ 10 October 2022

Mental health for all is not a reality in South Africa

Morally bereft leadership raises questions of trust
(John McCann/M&G)

“Make mental health for all a global priority” is the theme for this year’s World Mental Health Day, which is marked annually on the 10 October to raise awareness about mental health and garner support for those experiencing mental health issues. 

Since 2013 – the year when the United Nations adopted the day – one of the biggest challenges has been unequal access to mental healthcare, especially in low- and middle-income countries, where some population groups are more at risk and less likely to get help. 

About 75% to 95% of people with mental disorders in these countries are unable to access services, according to South Africa’s deputy minister of health Dr Sibongiseni Dhlomo, who led a debate on the prevalence of mental illness in South Africa before the National Council of Provinces in February.

Demand for mental health services exceeds supply by far

In line with the United Nations’s efforts to raise global awareness about mental health, South Africa has marked October as Mental Health Awareness Month, with many organisations working in the field offering information and counselling to people directly or indirectly affected by mental health issues.

The spectrum of mental health conditions is wide and includes disorders of different severity and symptoms, such as depression, anxiety disorder, bipolar disorder, post-traumatic stress disorder, schizophrenia, eating disorders and neuro-developmental disorders, such as attention hyperactivity disorder and autism spectrum disorder, to name a few.

The wide range of mental health conditions makes specialised treatment by professional staff, such as psychologists, psychiatrists, counsellors and health workers, a basic requirement. 

However, there is a massive shortage of psychologists and psychiatrists in the country – especially in the public sector. There are only 451 psychologists in the public sector, with vacancy rates between 80% and 83% in Mpumalanga, Limpopo and the Eastern Cape. The shortage of psychiatrists in the public sector is even more severe, with a psychiatrist-patient ratio of 1 to 3 338 295 for the Eastern Cape and 1 to 1 581 194 in Mpumalanga.

While the important work of health workers and counsellors in promoting de-stigmatisation of mental health issues in communities by providing information and raising awareness must be commended, the acute shortage of psychologists and psychiatrists in the public sector raises the question: what does it help to raise awareness around mental health, and campaign for individuals and relatives to come forward, when there is not enough capacity to provide the required services and offer them the help they need?

Unequal access to mental health services

South Africa, the country with the highest social inequality in the world, has a two-tiered and highly unequal healthcare system. According to a 2021 article by Russell Rensburg, director at the Rural Health Advocacy Project, the private sector – largely funded through individual contributions to medical aid schemes or health insurance – serves only about 27% of the population, while the majority depend on the state-funded public sector.

Focusing on the availability and accessibility of mental health services in general, and in the public sector in particular, the situation looks dire. In an answer to a parliamentary question from the Democratic Alliance, the department of health recently revealed that more than 6.5-million people in South Africa need professional mental health intervention, of which almost 1.3-million “need care for severe psychiatric conditions”. The fact is that South Africa has only 19 752 beds available in public and private mental healthcare facilities.

The government plans to address these huge disparities in healthcare services, and to achieve universal access to quality health care for all South Africans in accordance with section 27 of the Constitution, by adopting the National Health Insurance (NHI) Bill, which is currently before Parliament. 

However, the bill – with its plan to create a single framework throughout the country for the public funding and purchasing of healthcare services, medicines and health-related products, and to eliminate the fragmentation of healthcare funding – has raised much concern and criticism from the medical fraternity and human rights organisations alike.

Civil society organisations, such as Section 27, the Helen Suzman Foundation, the FW de Klerk Foundation, the Institute for Race Relations, the Board of Healthcare Funders, the SA Medical Association and the SA Human Rights Council – to name just a few – criticise the bill because of the government’s proven inability to manage the present public health system, and because the NHI would be unaffordable, with a price tag that could top R450-billion a year. 

The bill would also concentrate too much power in the hands of the minister of health, who would have full control over the accreditation of all public and private health establishments, and would also have full discretion over all senior appointments, which poses the threat of appointments based on political affiliation and cadre deployment rather than on merit.

Mental health and well-being – a constitutional right

The Life Esidimeni tragedy, still very much alive in our public conscience, which cost the lives of 141 mental healthcare users due to the decision by the MEC for health in Gauteng to cancel a contract with a long-term psychiatric care hospital and move the patients to cheaper facilities, should serve as a reminder that oversight and control mechanisms are vital when it comes to decisions affecting the physical and mental well-being of vulnerable people. 

Putting too much power in one person’s hands always runs the risk of abuse and unethical behaviour. The list of badly run state entities is long and does not help to convince critics of the merits of the NHI bill. The Esidimeni tragedy further brings into question the viability of the proposed bill which would require even more administrative capacity from the national department of health.

A report by the health ombudsman on the tragedy, published on 1 February 2017, states the constitutionally enshrined rights – such as the right to human dignity; to life; to freedom and security of person; to privacy; to an environment that is not harmful to health or well-being and the right to access quality healthcare services – were violated and disregarded by certain government officials and NGOs.

The report points to the constitutional obligation of the government – as well as society as a whole – to respect the rights of people with mental health disorders and make quality health services accessible to all South Africans, irrespective of their socio-economic status or in which part of the country they live.

As we mark World Mental Health Day, we should acknowledge the serious shortcomings in the provision of adequate healthcare services to South Africans suffering from mental disorders. Mental Health Month should be used by public officials, healthcare providers and organisations from the public and private sector working in the field to discuss how these problems can best be addressed. 

However, the first step of the solution might be to fix our badly broken public healthcare sector – rather than embarking on unaffordable and unworkable nostrums such as the proposed NHI system.

Christina Teichmann is a political consultant and board member of the FW de Klerk Foundation.

The views expressed are those of the author and do not necessarily reflect the official policy or position of the Mail & Guardian.