Community mental health services (CMHS) are a central objective of the National Mental Health Policy Framework and Strategic Plan. Three core components are described: residential facilities, day care and outpatient services. Primary mental health care with specialist support is required according to an intervention pyramid. Staffing norms provide for a minimum mental health service coverage of 2.7% of the population for adults and 1.5% for children and adolescents.
The aim of this study was to describe the existing CMHS in Southern Gauteng in terms of the National Mental Health Policy.
The CMHS of the City of Johannesburg, Ekurhuleni, Sedibeng and West Rand districts were studied. Information regarding service organisation and staffing was obtained via the Gauteng Directorate of Mental Health. Routinely collected District Health Information Systems data for the 2014/2015 year were analysed.
The organisation of services was not consistent with that recommended by the Mental Health Policy, and specialist CMHS were inappropriately situated within primary care. Only 2.23% of clinic visits were for mental health, and 80% of these were at specialist CMHS. Overall mental health coverage was approximately 0.3% of the population for adults and 0.02% for children and adolescents. Staffing, residential facilities and day care were far below the cited norms for minimal cover.
Our audit revealed that the CMHS in Southern Gauteng did not meet any of the norms cited by the Mental Health Policy. Barriers to implementation of this aspect of the Mental Health Policy need to be explored.
In South Africa, community-based mental health care is a requirement of the Mental Health Care Act of 2002
In contrast to the MH Policy, the National Health Strategic Plan 2014 and 2015 – 2018 and 2019
A description of the Southern Gauteng CMHS, together with a list of most of the clinics and an audit of the staffing and patient numbers served was previously conducted in 2005.
Our aim was to describe the CMHS in Southern Gauteng in terms of the structure and norms proposed by the MH Policy. The primary objective was to gain better understanding of the current situation to advance the implementation of policy.
A retrospective secondary analysis of the DHIS data collected for the 2014 and 2015 financial year was performed. Additional information regarding the organisational structure and staffing of the CMHS and hospital psychiatric units was obtained from the Gauteng Directorates of Mental Health and of Specialised Services, district mental health managers and district psychiatrists.
The DHIS collected data in the form of clinic visits. The data were captured by the DHIS from tick-box forms completed on site by clinic staff. We studied the cleaned data for the Gauteng region served by the University of the Witwatersrand, that is, the two metropolitan areas of City of Johannesburg (COJ) and Ekurhuleni, and the two districts of Sedibeng and West Rand. Over 9 million people are served by the CMHS in these districts (
District population indicators, according to the National Census, 2011.
National Census 2011 Population Indicator | Southern Gauteng | City of Johannesburg | Ekurhuleni | Sedibeng | West Rand |
---|---|---|---|---|---|
General population, 2011 | 9 350 776 | 4 434 827 | 3 178 470 | 916 484 | 820 995 |
General population, 2001 | 7 246 532 | 3 226 055 | 2 481 762 | 794 088 | 744 627 |
% Population growth per annum, 2001–2011 | 2.68 | 3.18 | 2.47 | 1.43 | 0.98 |
% Increase in population, 2001–2011 | 29.0 | 37.5 | 28.0 | 15.4 | 10.3 |
Unemployment rate (%) | 26.3 |
25.0 | 28.8 | 31.9 | 26.3 |
Youth (15–34 years) unemployment rate (%) | 34.0 |
31.5 | 36.9 | 41.7 | 35.2 |
Matriculate rate of adults ≥20 years (%) | 34.7 |
35.0 | 35.9 | 32.7 | 30.7 |
Housing: % population with formal dwellings | 79.6 | 81.4 | 77.4 | 84.8 | 72.7 |
Figures for the whole of Gauteng, including Tshwane.
Data from a total of 301 district clinics were available for the period 01 April 2014 – 31 March 2015. The sample selected for the study was of the data collected for the following indicators:
At PHC level clinics:
Total PHC visits. First visit for mental illness. Follow up visit for mental illness.
At secondary care level mental health clinics (CMHS):
Mental health visit by people aged 18 years or more. Mental health visit by people under the age of 18 years. Referral in, from:
Self (includes MHCUs brought in by relatives or friends). PHC. Hospital (includes from medical or psychiatric units). Other sector (includes any health or non-health sectors, e.g. schools). Referral out, to:
PHC. Hospital (includes any hospital).
The other health indicators were excluded as they did not contribute any additional information. The data were analysed on Excel® using descriptive statistics.
The following modelled norms and standards referenced by the MH Policy were used for comparison:
Regarding child and adolescent mental health services, minimal coverage aims to serve between 15.0% and 30.0% of those with mental illness and equates to 1.5% of the general population.
Permission to use the DHIS data in a peer-reviewed publication was granted by the Gauteng Directorate of Policy, Planning, Research and Monitoring and Evaluation. The study was approved by the Health Research Ethics Committee of the University of the Witwatersrand
The CMHS were administered by the District Health Services within the PHC budget. They consisted of an outpatient service operating from the PHC clinics and of residential and day care facilities. Psychopharmacological care was provided by psychiatric registrars and medical officers under the supervision of consultant psychiatrists. Most MHCUs collected repeat prescriptions from the CMHS nursing staff; more stable users would collect from PHC nurses and return to the CMHS for medical review. Psychotherapeutic services were provided by psychologists attached to the CMHS. With PHC re-engineering, there were no occupational therapists or social workers attached to the CMHS; MHCUs requiring these services were referred to the generalist PHC occupational therapists and social workers, who were not required to have any specialist mental health expertise.
Specialist level medications were available in each district according to the National Essential Medicines List. Nursing staff were responsible for issuing of repeat medication, monthly review of the mental state and well-being of the MHCUs, co-ordination of hospital and inter-sectoral referrals, psychoeducation of the patients and their families, and conducting local mental health awareness campaigns. However, there was no consistent system of assertive psychiatric nursing with active tracing of non-adherent MHCUs or home visits.
The CMHS functioned independently of the general hospital acute psychiatric units, which fall under Hospital Services administratively. There were no designated case managers for the co-ordination of patient care between hospital and district. PHC re-engineering towards an integrated model of chronic disease management had begun in all districts. Training of PHC practitioners in primary mental health care was provided by the CMHS psychiatrists and nursing staff. However, although ward based PHC outreach teams and community health workers had been introduced in all areas, mental health was not included in the training manuals.
A total of 18 751 326 clinic visits were recorded during the 2014 and 2015 financial year, of which 2.23% (428 844 visits) were for mental health. However, primary mental health care accounted for only 0.5% of all clinic visits, as 80% of the mental health visits were attended by the specialist staffed CMHS and only 20% by PHC. Regarding the referral of MHCUs to the CMHS, about 25% of MHCUs were referred to the CMHS from each referral source, although the proportions differed with each district (
Referral source for the Community Mental Health Services of each district.
As, in general, the MHCUs attending the CMHS are chronic care users who visit the clinic on a monthly basis, the monthly average should correspond roughly to the number of MHCUs served. Therefore, it may be estimated that just under 27 000 adults and almost 2000 children and adolescents were attended to by the CMHS over the 12-month period (
Estimated number of mental health care users attending the Community Mental Health Services with respect to population.
Variable | City of Johannesburg | Ekurhuleni | Sedibeng | West Rand | Total |
---|---|---|---|---|---|
General population |
4 434 827 | 3 178 470 | 916 484 | 820 995 | 9 350 776 |
Target MHCUs ≥ 18 years (2.7% of population) |
119 740 | 85 819 | 24 745 | 22 167 | 252 471 |
Target MHCUs < 18 years (1.5% of population) |
48 391 | 47 677 | 13 747 | 12 315 | 140 262 |
Estimated MHCUs ≥ 18 years | 13 270 | 7200 | 3766 | 2547 | 26 784 |
Estimated % population covered for MHCUs ≥ 18 years (%) | 0.4 | 0.3 | 0.5 | 0.4 | 0.3 |
Estimated MHCUs < 18 years | 638 | 570 | 624 | 152 | 1983 |
Estimated % population covered for MHCUs < 18 years (%) | 0.01 | 0.02 | 0.07 | 0.02 | 0.02 |
MHCUs, mental health care users.
The human resources as of March 2015 are summarised in
Human resources serving adult and child and adolescent Community Mental Health Services.
Variable | Norms for adult CMHS only |
City of Johannesburg |
Ekurhuleni |
Sedibeng |
West Rand |
||||
---|---|---|---|---|---|---|---|---|---|
/100 000 | /100 000 | /100 000 | /100 000 | ||||||
General nurses | 9.4 | - | - | - | - | - | - | - | - |
Psychiatric nurses | 3.9 | 26 | 0.6 | 6 | 0.2 | 17 | 1.9 | 8 | 1.0 |
Occupational therapists | 3.5 | 14 |
0.3 |
13 |
0.4 |
5 |
0.5 |
3 |
0.4 |
OTAs | 7.4 | - | - | - | - | - | - | - | - |
Social workers | 6.0 | 25 |
0.6 |
17 |
0.5 |
11 |
1.2 |
13 |
1.6 |
Psychologists | 2.5 | 16 | 0.4 | 13 | 0.4 | 2 | 0.2 | 3 | 0.4 |
Psychiatrists | 0.4 | 1 | 0.02 | 1 | 0.03 | 2 | 0.2 | 1 | 0.1 |
Registrars/medical officers | 1.8 | 8 | 0.2 | 5 | 0.2 | 5 | 0.5 | 3 | 0.4 |
Managers | 0.5 | 1 | 0.02 | 1 | 0.03 | 1 | 0.1 | 1 | 0.1 |
CMHS, Community Mental Health Services; OTA, Occupational Therapy Assistant; PHC, primary health care.
Serve the whole of PHC as well as CMHS, residential and day care facilities.
A total of 71 government subsidised community residential homes and day care centres were provided by non-governmental organisations in Southern Gauteng. Forty-six of these were for children and adolescents with intellectual disability. There were no facilities for children and adolescents with mental illness as the primary criterion for admission. There were 25 facilities for adults with mental illness, six of which were day care centres. These were inequitably distributed across Southern Gauteng (
Residential beds and day care places/100 000 population for adult mental health care users in comparison to norms of the Mental Health Policy.
There was a wide variation in the distribution of general hospital-based psychiatrists (
Distribution of general hospital-based psychiatrists.
City of Johannesburg |
Ekurhuleni |
Sedibeng |
West Rand |
||||
---|---|---|---|---|---|---|---|
Hospital | Psychiatrists ( |
Hospital | Psychiatrists ( |
Hospital | Psychiatrists ( |
Hospital | Psychiatrists ( |
CMJAH | 7 | Tembisa | 1 | Sebokeng | 1 | Leratong | 1 |
CHBH | 7 | Natalspruit | 1 | - | - | - | - |
HJH | 2 | - | - | - | - | - | - |
CMJAH, Charlotte Maxeke Johannesburg Academic Hospital; CHBH, Chris Hani Baragwanath Hospital; HJH, Helen Joseph Hospital.
Overall, the data and information revealed a specialist service which was inappropriately positioned within PHC, a lack of integrated primary mental health care and a very low mental health care coverage of the population. Human resources, residential facilities and day care were far below the numbers recommended by the MH Policy. In addition, there was a marked discrepancy between districts regarding staffing of the CMHS and the balance with general hospital acute psychiatric units.
The positioning of the CMHS as a PHC programme has important potential ramifications. Firstly, the separate administration from the acute hospital units may present a barrier to continuity of care following hospital discharge of MHCUs. Secondly, it might render specialist care too accessible to the community. This may be seen in the high rate of self-referrals and referrals directly from other health and non-health sectors. However, the reasons for people to bypass PHC need further exploration. As no information regarding diagnosis, treatment or disease severity were collected by the DHIS, it cannot be deduced whether these MHCUs had severe illness which warranted specialist care or if they could have been managed at the PHC service level. Thirdly, utilising specialists at PHC level may theoretically contribute to the low rate of integrated primary mental health care, as it could reinforce the misguided impression that all mental illness is to be seen by specialists.
It is probable that incomplete data contributed to the low estimated population coverage because of the routine on-site nature of its collection. However, it is highly unlikely that the coverage was under-estimated by almost 250 000 adults and 140 000 children and adolescents, the target numbers of MHCUs which would be attended to if minimal mental health care coverage was provided (
Two plausible reasons for the low population coverage are the low numbers of mental health visits at PHC and the low allocation of human resources to the CMHS. A large proportion of the population coverage should be for people with mild to moderate illness at PHC.
Not only were there insufficient human resources compared to the numbers recommended in the MH Policy, there were also important changes in the numbers of MHCUs served and the staffing of the CMHS since the 2005 audit.
Although estimated norms for residential and day care facilities are recommended by the MH policy,
The ratio of one community-based to nine hospital-based psychiatrists is consistent with historical structures of psychiatric care
Although using data collected centrally for planning purposes allows for an overview of the entire service, it is also a substantial limitation of the study. Firstly, the data set was not designed for research purposes. This resulted in the use of broad estimates and limited the interpretation of the data, as certain measures, such as diagnostic categories, were not included. Secondly, inaccuracy and incompleteness of data are possible because of the onsite, routine nature of data collection.
Notwithstanding its limitations, this study is important as it revealed that the existing CMHS in Southern Gauteng did not meet any of the modelled norms referenced in the MH Policy. It highlights the need for further research for the development of CMHS. In addition, it draws attention to the necessity of a comprehensive information system, itself a requirement of the MH Policy.
The authors thank Ms Sennelo of the Gauteng Directorate of Mental Health, Ms Sukhlal of the Directorate of Specialised Services, the district mental health managers, Ms Jalal, Mr Mbele, Mr Maredi and the district psychiatrists, and Prof. Moosa and Dr Rama for providing information regarding the staffing and organisation of the CMHS.
The authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article.
L.J.R. was the principle researcher and C.P.S. provided guidance in interpreting results and editorial support.