South Africa faces a severe mental health burden compounded by a chronic shortage of mental health practitioners in the public sector. Over 30% of those living in South Africa have experienced a depressive, anxiety, or substance use disorder in their lifetime, according to a national survey. Yet studies show only 15% of those with mental health conditions receive treatment.
Part of this can be attributed to disparities in mental health personnel across provinces. According to a 2019 report, the availability of psychiatrists across the country ranges from 0.08 to 0.89 per 100 000 uninsured people. The average number of mental health workers globally is 9 per 100 000 people, according to the World Health Organization (WHO).
"There are simply not enough psychiatrists to go around," says Professor Crick Lund, Director of the Alan J. Flisher Centre for Public Mental Health at the University of Cape Town (UCT) and one of the report's authors.
Some of Lund's work examines the role of community health workers (CHWs) in filling that gap. The theory is that CHWs can provide a cost-effective, localised option for mental health support. Called task-sharing, it is a model endorsed by the National Mental Health Policy Framework and Strategic Plan 2013-2020.
"CHWs have a potentially valuable role to play in identifying and providing mental health interventions for mild-to-moderate disorders like depression, anxiety, and substance abuse, and with monitoring for relapse among people with severe conditions," Lund says.
A community-based approach to mental health services is also supported by the WHO. Guidance on the practice, published by the body in June 2021, calls it "a vision of mental health care with the highest standards of respect for human rights and gives hope for a better life to millions of people with mental health conditions and psychosocial disabilities, and their families, worldwide."
Pilots of this model in South Africa have been encouraging, revealing both willingness from CHWs to take on mental health services and potentially positive outcomes among their users. But experts say the model can only work with a mental health policy that includes earmarked budgeting and an overall strengthening of the public health landscape.
Mental health costs and strains
Mental health spending amounted to about R8.4 billion across all provinces in South Africa in 2016/17. At a national level, this represented 5% of the total health budget. However, spending itself was heavily skewed, with 86% used on hospital in-patient services and the remaining 14% attributed to outpatient care.
This spending is stark considering over 24% of inpatients are readmitted to hospital within three months of discharge, a cost that amounts to R1.5 billion against just R616 million of total primary healthcare spending on mental health.
The absence of competence and skill at community and primary care levels contributes to these costs and strains specialist services where skilled practitioners are located, says Goodman Sibeko, Director of the South Africa International Technology Transfer Centre (ITTC) and head of addiction psychiatry at the University of Cape Town.
For example, CHWs in the Western Cape, where Sibeko's pilot study was conducted, must be able to read and write but do not need additional education qualifications. They then receive training in providing basic medical support for conditions like hypertension, diabetes, HIV, and TB. However, they receive no standard mental health training.
"In many instances, the cases that reach the specialist level of care could have been managed adequately lower down in the treatment and referral pathway," he says. "There is strong evidence that CHWs can be successfully trained to detect and provide support for community-level mental health services."
Indeed, Lund says that CHWs could play a role in helping users manage mild cases of anxiety and depression, referring only those with advanced symptoms to specialist or hospital services. CHWs could also monitor those with known severe conditions, like psychosis or bipolar disorder, to help lower readmission rates.
"If we had CHWs in the community who know about those who have these disorders, it would be a simple matter of a monthly home visit to check on them to prevent crises and check on medication adherence," he says. However, he adds, the model would require adequate training and support for CHWs.
Developing a CHW model for mental health
How to develop that training was explored by Sibeko in a pilot study, which Lund co-authored. It introduced CHWs with some mental health background to cultural implications of mental health, features of common disorders, and the community health worker's role. At the end of an eight-day training period, case study vignettes were used to test how well the CHWs picked up the learnings.
"Our investigation found that CHWs successfully improved mental health knowledge when exposed to the structured interactive training in mental health, which was geared towards sensitising them to key concerns in the communities they serve," says Sibeko.
CHWs improved their ability to screen for and detect mental health concerns and could confront their own prejudices towards issues such as suicide and substance abuse. "This allowed them to engage with the reality that anyone can become a mental health care user," Sibeko says.
Some CHWs also uncovered personal challenges during the training that they had not felt comfortable seeking assistance for, such as anxiety and depression. "This highlights the importance of providing a safe and supportive environment for CHWs, particularly as we further capacitate them to provide more mental health detection and support services," says Sibeko.
Overburdening a stretched system
Raquel Maart, a 24-year-old CHW providing mental health services in Cape Town's Lavender Hill, was given training with one of Lund's CHW research programmes and her employer, the NPO Compassion Action Trust (CAT).
She says it has helped her deliver better care to all her users. "I see new moms, those with TB and HIV, and I apply these skills. The training has definitely improved how I work all around."
It also helped her navigate her own feelings of depression after the birth of her first child. "I know now that I wasn't being silly, I was depressed. Now I know exactly what a depressed person feels, and I can help someone through my experience."
While Maart is part of a supportive team, she says there are times when the workload is too heavy. "I sometimes feel I'm doing too much. I'm overwhelmed and tired," she says.
Overburdening CHWs who take on mental healthcare is a risk, says Lund. "CHWs are already very stretched. The worry is if they take on mental health roles, they need to be compensated for it and supported," he says.
Most CHWs are poorly paid and historically they have had little job security. While health departments have in recent years mostly standardised their pay to R3 500 per month, a study of districts in Gauteng and KwaZulu-Natal shows community-based care represents less than 5% of primary health spending.
Strengthening the public healthcare response
CHWs are only one part of a decentralised strategy that relies on a strong primary healthcare response, according to Donella Besada, a senior scientist at the South African Medical Research Council. "We can't have CHWs screening people and then referring them to a system that can't provide," she says.
"If we have CHWs do anything it must be in conjunction with significant investments in strengthening the public healthcare level, including training of generalist cadres who are right now uncomfortable with diagnosing and managing mental health."
Decentralisation of mental health services was central to the 2013-2020 mental health policy framework. However, the practice was instituted before the infrastructure was ready and contributed to [the] tragedy, says Leon de Beer, Deputy Director of the South African Federation for Mental Health.
In 2016, the Gauteng Department of Health moved over 2 000 mental healthcare users from Life Esidimeni Hospital inpatient care to ill-equipped and undocumented NGOs. The result was the death of 144 people, along with numerous human rights violations.
"As a country and as a sector, Life Esidimeni taught us the hard way how not to do decentralisation," De Beer says. "We can't take people out of hospitals without preparing the infrastructure for them and unless we've invested extensively in community-based mental health care."
Future of mental health services
South Africa's mental health policy framework, lauded as the first of its kind lapsed in 2020. De Beer says urgent action is now needed to address the future of mental health services in the country.
"We need a new policy framework that has a budget attached showing what it costs to run high-quality mental health services and what needs to be put in place. And those resources must be allocated on provincial levels with reporting done to government," he says.
At the request of National Treasury, Besada and colleagues, including Lund, are currently developing a mental health investment case that aligns with the needs of new policy development.
"Our work identifies at different levels of care what is the package of mental health services that can be provided and at what costs in order to plan a transition towards a more decentralised model," Besada says.
"It builds on the previous policy to say with this budget request, this is what we're buying, and we've advocated for earmarked funding over a period before NHI (National Health Insurance) is phased in."
Due for release in October, it will include recommendations for CHWs to be provided in the NHI in carrying out basic counselling for mild-to-moderate depression and anxiety, monitoring medications for psychosis, and providing counselling for pregnant women and new mothers.
Besada hopes that the investment case will guide a new policy framework. But she is wary about overemphasising the role of CHWs. "CHWs are a very important part of the picture, but they can't fill the gap for mental health needs in South Africa," she says.
Multiple attempts from Spotlight to obtain comment from the Department of Health on its plans for a new mental health policy framework, and where CHWs and the investment case would fit in, were not responded to.