System failures in mental health

7 February 2017 - Shehnaz Munshi and Janine Bezuidenhoudt

Patient deaths show South Africa’s care for the mentally ill is in disarray.

A report in South Africa detailing the death of 94 people with mental health disorders who were moved from the Life Esidemeni Hospital and placed in inadequate facilities has sparked outrage and led to Qedani Mahlangu stepping down as the local government Minister of Health in Gauteng province. Janine Bezuidenhout and Shehnaz Munshi unpack the report and what it reveals about mental health care in South Africa.

What did the report find and what does this say about the system failures in mental health care?

Generally people with mental health disorders have limited access to the appropriate health care services. They have a lower life-expectancy and the increased risk of co-morbid physical illnesses. It is critical for them to have a stable environment, with qualified medical professionals.

The health ombudsman¡¯s report was damning. It found that 94 patients ¨C and not 36 as previously reported ¨C died after they were moved from the hospital to facilities run by NGOs.

In total 1,039 patients were transferred to 27 NGOs. The reported deaths occurred in 16 of the 27. None had the appropriate license to take care of the patients.

The report¡¯s most damning findings are around the:

Transfer of patients: Patients were moved without their families being informed. Some incapacitated patients without wheelchairs were tied with bed sheets to support them. Others were transported in open trucks.

Patients ended up in organisations not originally selected for them or far away from the families. Some patients with co-morbid medical conditions, which requires specialised medical care, were transferred to facilities where no such care was available.

NGO conditions: The organisations were not sustainable. They did not have financial support for infrastructure, food, clothing and bedding for the winter months. As a result some had no bedding or blankets and others left patients hungry. Many patients were malnourished and suffered severe weight loss.

In addition, staff were not trained or prepared for the task of taking care of the patients. Overcrowding was common and some patients were left dirty, poorly groomed and without treatment. Some weren¡¯t given the correct medication which meant that they were at a higher risk of relapsing.

Fourteen of the 25 inspected NGOs were found not fit for purpose. The recommendation is that they should be closed.

Causes of death: A sample of 38 patients were selected to determine their cause of death. In 21 of the 38 patients, the immediate cause of death could be identified. For those, most died of pneumonia, uncontrolled epilepsy, stroke, sepsis or dehydration.

Families were not immediately notified of deaths. Some families only found out three weeks later.

What does the report tell us about the bigger picture of mental health care failings in South Africa?

The report shows that mental health care in South Africa is in a state of disarray.

South Africa has good policies for mental health care. But the implementation of these policies remain a challenge. Mental health services have not been integrated into the routine care of chronic diseases and within the primary health care system. As a result mental health has been marginalised and underfunded.

There are several areas that create barriers to effective mental health care services. These include:

• A lack of financial investment: without the financial resources invested in mental health, programmes will not be sustained. This is despite the fact that studies show that it costs more not to treat mental disorders than to treat it.

• Stock outs of medications: According to the stop stock-outs project, psychiatric medication made up 10% of the reported medication stock outs in the country between January and July 2015.

• The social stigma associated with mental disorders

Does mental health care play second fiddle to primary health care in the country?

Mental health care has always been the ¡°stepchild¡± of health care. In South Africa, it is estimated that 75% of people with a mental health disorder don¡¯t receive mental health care services. This is referred to as the ¡°mental health treatment gap¡±.

Integrating mental health care into the existing health system structures could reduce the stigma and result in greater effectiveness of health care interventions.

There are moves to incorporate mental health care better. Recent policies by the National Department of Health show a high level of commitment to integrate mental health care services into the primary health care chain.

The department¡¯s 2013-2020 mental health policy framework and strategic plan envisages scaling up and decentralising integrated primary mental health services. This includes community-based care, primary health care and district hospital level care. Implementing and sustaining these policies are key.

In the long term health plan under the National Health Insurance (NHI), mental health care appears to be sidelined. In the white paper on the NHI, mental health care is only broadly mentioned. Mental health services are included as part of the comprehensive package, but no detail is provided about programmes, or how the shortage of mental health professionals will be addressed.

What next? What steps should be taken to avoid this from happening again?

Five of the NGOs have already been closed down. The ombudsman recommended that remedial action should be implemented within 45 days of the release of the report.

The report needs to be studied in detail to establish which key actions should be taken to prevent this from happening again.

The report, combined with existing policies, should be used to put a plan in place for mental health care services. This was proposed by the social justice NGO Section27.

There also needs to be more transparency and accountability within the Department of Health. It was repeatedly warned that the transfer was placing patients in danger. The department was taken to court twice. It assured the court that the patients¡¯ health would not be compromised by the transfers. Its actions resulted in human rights violations as well as medical negligence.

Opposition parties have called for legal action. The Economic Freedom Fighters have laid charges of murder against the former local government minister and the Democratic Alliance of culpable homicide and contravening the Mental Health Care Act and the National Health Act. Several organisations involved in the tragedy are considering similar action. All believe that those responsible should be held legally accountable.

Janine Bezuidenhoudt co-authored this article. She works for the Foundation of Professional Development. Shehnaz Munshi, Lecturer in Allied Health Sciences, University of the Witwatersrand. This article was originally published on The Conversation. Read the original article.