South Africa has taken steps towards strengthening mental health care in the last 20 years. These include reforming the Mental Health Care Act 2002 and developing a National Mental Health Policy Framework and Strategic Plan 2013–2020.

The strategic plan aims to integrate mental health into general health services to reduce the burden of untreated mental health conditions. It also aims to transform the system to provide quality mental health services that are accessible, equitable and comprehensive, particularly for community-based mental health care.

But significant information gaps have limited the country’s ability to initiate a sustained response to mental health care. For example, the most up to date population based prevalence estimates of the burden of mental disorders date as far back as 2003/4.

The failure to implement the public policy on mental health was brought to light by the Life Esidimeni tragedy in 2017. Nearly 150 patients died after being moved from the Life Esidimeni Hospital to unlicensed facilities.

New challenges are now arising with the planned introduction of the National Health Insurance (NHI) scheme, which is intended to move South Africa closer to universal health coverage. But early evidence from NHI pilot districts show an inconsistency with the strategic plan and limited integration of mental health. If the relevant priorities aren’t explicitly reflected in the policies and activities supporting the NHI, mental health is likely to remain on the back burner.

The system must be clear about the care that mental health patients are entitled to and how providers will be identified and paid. Mental health care has to be recognised as an integral part of the health care system.

South Africa needs a good grasp of the problem and the resources required to address it.

The gaps

Until recently the country knew very little about a range of important factors related to mental health care. These included: the current state of investment in mental health; whether these investments were being used optimally; where the inequities in resourcing and access lay; and what priorities and plans should be in place to address these inequities.

In response to some of the biggest information gaps, we worked with national and provincial health departments and the South African Medical Research Council. We evaluated the health system costs of mental health services and programmes in South Africa for the 2016/17 financial year. We also documented and evaluated the available resources and constraints to inform a rational approach to planning effectively to improve mental health service delivery.

Our findings offer – for the first time – a nationally representative reflection of the state of mental health spending. They draw attention to inefficiencies and constraints in existing mental health investments in the country.

The current situation

South Africa spends 5% of the total health budget on mental health services. This is in line with the lower end of international benchmarks of the recommended amount that countries should spend on mental health.

Yet, alarmingly, our study crudely estimated a treatment gap of 92%. This means that fewer than 1 in 10 people living with a mental health condition in South Africa receive the care they need. We also found huge disparities between provinces in the allocation of mental health resources. Provincial spending on mental health ranged widely across all levels of the health system. For example, in Mpumalanga, spending on mental health per uninsured South African was R58.50 while in the Western Cape it was R307.40.

Inpatient care took up 86% of the mental health care budget. Spending at specialised psychiatric hospitals made up 45% of the total. Services at the primary level of care made up only 7.9% of overall mental health spending.

This reflects a reactive mental health care system that is focused on treating the most severe conditions, rather than preventing or providing early interventions.

Mental health care users were admitted for longer periods than other patients – twice as long as other patients at district hospitals. At regional and tertiary hospitals, their admissions lasted around 6 to 8 times longer. At central hospitals, they spent almost 5 times longer. Mental health patients spent an average of 157 days in psychiatric hospitals per admission. Nearly 1 in 4 mental health patients were readmitted within three months of being discharged from any hospital. Readmissions alone consumed 18% of South Africa’s total mental health spend.

This indicates a highly inefficient system that fails to help patients transition to care in their communities. There is potential for cost savings in providing continuity of care and supporting people to live well in their communities after discharge from hospital.

Other findings included:

• Only three provinces had child psychiatrists in the public sector.

• There was an extreme shortage of psychiatrists and auxiliary workers critical for rehabilitation and supportive services.

• There wasn’t alignment between the national database of NGOs licensed by the department of health and those reported through primary data collection.

• A number of drugs critical for the management of chronically disabling conditions such as bipolar disorder and depression, were not routinely available.

• Most district hospitals weren’t compliant with the Mental Health Care Act, though they are expected to provide 72-hour assessments and subsequent referrals for further care, treatment and rehabilitation.

Way forward

For the first time, South Africa has a nationally representative reflection of the state of mental health spending and an appreciation of the inefficiencies and constraints emanating from existing mental health investments. This is one of the highest sample sizes of any costing study conducted for mental health in low- and middle-income countries.

Our study points to some obvious improvements that could be made. These include stronger service delivery at community and primary health care levels. And better referral pathways could reduce unnecessary readmissions. This would also shorten hospital stays.

The next phase must focus on accelerating the country’s progress towards meeting the goals set out in the strategic plan and taking forward the recommendations of the South African Human Rights Commission Report. With these study findings in hand, the government now has a baseline from which to begin a rational planning process.

The government has asked us to help develop a mental health investment case for the country, which comes at a crucial time for the country’s mental health response, in light of the recent passing of the NHI Bill. This work will involve intensive and ongoing dialogue with a range of players involved in the provision of mental health services and research across the country.