Chapter 12: Mental Health and Substance Abuse
White Paper for the Transformation of the Health System in South Africa

1. Introduction/Background

Mental illness and substance abuse (including tobacco) is a major cause of morbidity and mortality in South Africa. The burden of mental ill health in South Africa is costly in terms of health care expenditure and loss of productive years of life. However, mental health promotion and the provision of mental health services have generally been neglected in the past. Further, existing mental health services are neither appropriate nor accessible to the majority of the population, especially those in the rural areas.

One of the goals of the RDP is to promote mental health and increase the quality, quantity and accessibility of mental health services. The White Paper also identifies this as one of the objectives of the Department of Health.

2. Objectives

The White Paper identifies the integration of mental health services into the primary health care system as a central objective. To meet this goal, there is a need to improve knowledge and treatment of mental disorders. Further, there is a need to increase access to prevention and treatment programmes in relation to substance abuse.

Some of the specific programmes which the Department will focus on are: programmes for children and women, victims of violence and substance abuse, as well as services for the mentally handicapped, and the aged.

3. Guiding Principles

The following principles will guide future efforts aimed at mental health and substance abuse:

• The development of a comprehensive and community-based mental health service (including substance abuse prevention and management). These services should be integrated with other health services.
• The inclusion of mental health and substance abuse research on the essential national health research agenda. This research must identify the magnitude of the problem.
• Capacity Building for mental health services. In this regard, personnel at various levels should be adequately trained to provide comprehensive and integrated mental health care based on primary health care principles.

3. Implementation Strategies

3.1 The development of a comprehensive and integrated community-based service

It is envisaged that comprehensive mental health services will be integrated at the national, provincial, district and community levels. In addition, the involvement of relevant stakeholders, including the communities themselves, will be promoted at all levels.

At the National Level: The Mental Health and Substance Abuse Directorate will be responsible for planning mental health and substance abuse services. The Directorate will facilitate the development of functions at the various levels of care. In order to provide comprehensive services, a multiprofessional approach will be adopted. Further, preventive services will be emphasised. The functions at the national level will include:

• Co-ordinating the restructuring and integration of mental health services into the primary health care system. This will include the development of norms and standards for services, as well as norms and standards for the education and training of staff.
• Exploring the nature and extent of collaboration with traditional healers;
• Monitoring and evaluation of the prevalence of mental health problems, national research, and mental health services nationally.
• Planning and promoting specific programmes and services to address substance abuse, child abuse, women abuse, and victims of violence. The National Department will also be responsible for providing and monitoring forensic psychiatric services, and planning and promoting services for the mentally handicapped and the aged.

At the Provincial Level: The planning, co-ordination, supervision, monitoring and evaluation of mental health services will be undertaken at the provincial level. The provincial health authorities should provide a sustainable budget for provincial and district mental health and substance abuse services. Provincial health authorities also need to ensure the integration of mental health and substance abuse services with other health services. Specific services for the mentally handicapped and the aged must also be included.

At District Level: Planning of mental health services should be undertaken with the active participation of various stakeholders, especially the communities. The following activities will be undertaken at the district level:

• Providing mental health and substance abuse prevention, promotion and rehabilitative services. Special attention will be given to planning, implementing and co-ordinating community-based rehabilitation. In addition, crisis intervention and counselling services should be provided.
• Establishing a 24-hour consultation service for mentally ill patients and victims of substance abuse.
• Providing training for health facility staff.
• Undertaking mental health education programmes in communities.
• Establishing and maintaining Mental Health Committees. In addition, collaboration with other sectors, private practitioners, traditional healers and NGOs should be maintained.
• Collecting data, and initiating and contracting out research in response to local needs.
• Developing appropriate indicators for monitoring and evaluation.

At the community level: Communities should be actively involved in the planning and implementation of community-based mental health care services. Communities should also be involved in substance abuse prevention, management and rehabilitation programmes. NGO and CBO involvement in services should be particularly promoted at this level.

In addition, the following will be promoted at the community level:

• Establishing community centres for crisis intervention.
• Setting up community mental health forums;
• Developing special programmes which will address violence within communities. There should be an emphasis on programmes for children and women, in particular.
• Developing special programmes aimed at educating and providing information and support to the mentally disabled and aged.
• Providing education and information on mental health and substance abuse, especially to the youth.

3.2 Including Mental Health Research in Essential National Health Research

Historically, mental health services and substance abuse services have been accorded inadequate attention by researchers. The Department notes that it is essential for future research to be directed at both prevention and rehabilitation issues. The following strategies to accomplish this have been identified:

• The allocation of additional funds for research on mental illness, substance abuse and violence.
• Encouraging young research interns to conduct research projects on mental health, substance abuse and violence.

3.3 Developing Human Resources

The Department has placed an emphasis on building capacity of personnel at all levels, to ensure the provision of comprehensive and integrated mental health care. To achieve this, the following strategies will be adopted:

• District health teams will be trained to improve their capacity for planning, implementation, supervision, monitoring and evaluation of mental health programmes at the district and community levels.
• Special training to deal with post-traumatic stress and the impact of violence will be provided to all mental health staff. In addition, communication and counselling skills of all mental health staff will be improved.
• Staff at lower referral levels, i.e. clinics and community health centres, will be trained to do basic screening and counselling. They will also be trained to identify and refer patients for further assessment and management.
• Drugs required for the management of psychiatric problems will be available at all levels of health care, as appropriate.

4. Indicators for success

The following will indicate success of the mental health programmes, by the year 2000:

Substance Abuse:

• Substance abuse among adolescents (especially tobacco, alcohol, marijuana and mandrax) reduced.
• Reduction in the prevalence of substance abuse (legal and illegal)
• Tobacco-free environments in public places are established.
• Alcohol-related motor vehicle mortality and morbidity reduced.

Mental Health:

• Improved counselling services for, and management of, victims of attempted suicide, violence and rape.
• Community-based mental health care services developed.
• Mental health services in prisons improved.
• Comprehensive mental health services for children developed in the provinces.

5. Some Issues Raised by the Chapter

• In order to effectively address substance abuse and mental ill-health in South Africa a well co-ordinated, multi-sectoral approach is needed. The White Paper identifies specific issues, such as child abuse and violence, which will require close collaboration with other government departments. It is unclear, however, how such collaboration will be achieved, and within which department(s) the co-ordinating functions will reside.

• The chapter proposes several strategies to deal with the clinical manifestations of mental illness and substance abuse. What plans are envisaged to raise awareness amongst both health care personnel and communities about the socio-economic factors that impact on people's mental health? Also, to what extent are mental health services intended to interact with development initiatives?

• Generally, the implementation strategies are not very specific, and timeframes are not provided for many of the plans. This will make it difficult for monitoring and evaluation.

• What categories of personnel are envisaged to provide mental health and substance abuse services? Specifically, in Chapter 4 of the White Paper the Department identifies the training of psychologists as a priority, but it is unclear how psychologists will fit into the restructured system. In addition, will mental health issues become part of the undergraduate training of all health care professionals? Further, will training of specific mental health professionals, such as psychologists, be made more appropriate? For example, will community mental health centres become accredited training sites for psychology interns?

• Many communities have been exposed to prolonged periods of continuous trauma. What interventions are envisaged to deal with this? The focus on PTSD may not be the most appropriate stategy to address the effects of continuous trauma.

• How will NGOs and community structures be supported in efforts to promote mental health and to reduce substance abuse?

For more information please contact Carnita Ernest at (021) 696-4954 or by fax at (021) 696-9308, or by e-mail at philaw@wn.apc.org . The PHILA programme is supported by a grant from the Henry J. Kaiser Family Foundation

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