Suntosh R Pillay is a clinical psychologist in public service in Durban, and PhD candidate at the University of KwaZulu-Natal, researching public mental health in South Africa.
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On the surface of the disaster caused by the Gauteng Department of Health, it seems bizarre that vulnerable people were treated with no respect for their human rights, in a country whose Constitution fiercely protects them, supported by explicit legislation on the rights of the mentally ill (the Mental Health Care Act, No. 17 of 2002). Additionally, government has an explicit national policy on mental health (the Mental Health Policy Framework and Strategic Plan), referencing the World Health Organisation’s Comprehensive Mental Health Action Plan, both ironically right in the middle of their lifespan (2013 – 2020).
Why, then, does our Health Ombudsman report read like a horror story? Why did Health MEC Qedani Mahlangu allow almost 1400 mental health care users to be sent to 27 unlicensed organizations masquerading as community care centres? How did this single incident become post-apartheid South Africa’s most disastrous case study of how not to do deinstitutionalization? Is it true, as others have lamented, that our watchdogs lack voice and teeth?
I interviewed local experts who were clear on three points: Firstly, these deaths were entirely preventable; secondly, de-institutionalising requires serious planning; and thirdly, mental health must become prioritized.
Professor Anthony Pillay was adamant that “mental health care must be moved to AAA rating and out of the junk status that it currently seems to be accorded.” He is principal clinical psychologist at Fort Napier Hospital and professor at Nelson R Mandela School of Medicine at the University of KwaZulu-Natal.
He lamented the fact that this tragedy was entirely preventable.
By acting without consideration for expert opinions who warned against this, the authorities revealed their arrogance and heavy-handed approach, suggesting that they were experts in the area and knew everything there is to know about chronic mental health care, deinstitutionalization and community-based care. Evidently they did not – and close to 100 patients and their families have paid the price.
Pillay, who is also editor of the South African Journal of Psychology, urged the national and provincial Departments of Health to prioritize mental health care: “While it is acknowledged that there are several health conditions needing attention in our country, pushing mental health care lower down in the hierarchy of needs does not help because mental health cuts across every aspect of human life and well-being.”
According to Pillay, the main lesson here is that deinstitutionalization and community mental health care are not cheap alternatives to institutional care.
“Deinstitutionalization requires that a comprehensive set of structures and resources are available to house, treat and support patients with chronic mental illness, and support for families and reintegration into family life. People with mental health problems and those with chronic mental illness are highly vulnerable individuals who need specialized care, and there is no getting away from that.
“However, this is not first time that we have heard senior health officials push the idea of deinstitutionalization being a cost-saving approach. It should not be decided on based on poorly reasoned assumptions of cost and health economics. Much education is needed – and again one of the reasons for ignorance in this area is because mental health care is not regarded as a priority. Evidence of this can be seen in the great amount of knowledge that health officials have in other prioritised areas of health care – but not in mental health care.”
Anne Kramers-Olen, a clinical psychologist with expertise in psychosocial rehabilitation, reiterated that “there are no short cuts in the care, treatment and rehabilitation of persons with chronic mental illness.”
While de-institutionalisation has found traction both locally and internationally, the reality is that the training, human resources, infrastructure and finances invested in institutional forms of care need to be transferred to community forms of care in order to potentiate re-integration through holistic community based care and skills training.
“The rights and healthcare needs of persons with chronic mental illness are as legitimate as those of people with physical illnesses, and this fact needs to find expression in health policies, budget, training, human resources, access to mental health care services, etc. This unnecessary loss of life could have been prevented simply if the concerns regarding the transfer of patients had been heeded!”
Daniel den Hollander, Chairperson of the Psychology in Public Service (PiPS) Division of PsySSA, hopes that this leads to “a refocus on prioritising mental health care services, in order to address the service provision challenges that affect mental health care services nationally, such as availability of appropriate infrastructure, equipment and human resources. I hope that through this experience, the voices will be heard of those who are left vulnerable.”
PsySSA had written to Mahlangu in January 2016 offering their expertise and advising her to exercise caution. She did not reply.
Cassey Chambers, Operations Director of the South African Depression and Anxiety Group (SADAG), also believes this tragedy was preventable “if proper plans, processes, assessments and engagement had taken place”.
Patients were moved so quickly to haphazard NGOs that were not equipped, ready or trained to take on these patients with such severe conditions needing specialized treatment, care and support. If the proper engagement and planning processes were implemented in the beginning when we first heard the announcement, patients would not have suffered and died.
Chambers said the Gauteng Department of Health has itself to blame.
“It wasn’t that they didn’t have the stakeholder engagement and support, it is because they chose to blatantly ignore our recommendations, suggestions and offers to assist in the process, and they ignored our concerns. There is already a good mental health policy framework that could have been implemented, but was ignored and not followed.
“However, the only way forward is through working together to implement the policy on the ground in the best interest of the patient. Better monitoring and evaluations have to be in place on an ongoing basis. Mental health deserves more attention.”
These experts’ views support the Ombudsman’s conclusion that this project “was unwise and flawed, with inadequate planning and a ‘chaotic’ and ‘rushed or hurried’ implementation process”.