Mental health service policy , implementation and research in South Africa — are we making progress ?

The World Health Report of 2001 and other studies 5 report that mental illnesses form a considerable proportion of the diseases causing disability and that many of these illnesses are underdiagnosed and inadequately treated. It is clear from the World Health Report 2001 Atlas of Resources that resources to treat these disorders are limited and extremely unevenly distributed. What is also highlighted in the report is the existence of effective psychopharmacological and psychosocial treatments for these disorders. In an ideal world, people with mental disorders can be effectively treated and integrated into their communities, but is this realisable anywhere in the world, even in the best-resourced countries? It is certainly a far and distant dream for many.

certainly a far and distant dream for many.
South Africa has recently emerged from a dark period characterised by racism, discrimination and inequity.Together with the almost universal prejudice against, and marginalisation of, people with mental illness, this resulted in very poor treatment for the majority of people with severe psychiatric disorders.Screening for and identification of people with treatable mental disorders in public sector primary care facilities was and continues to be inadequate. 7(A survey of mental health services was conducted in Gauteng in 2001. Information from the primary health care (PHC) minimum dataset in Gauteng showed that the detection rate of new mental illnesses in PHC services was less than 1% of the total headcount in these services.)The policy to de-institutionalise mental health care and to develop integrated comprehensive community-based mental health care services is in line with international trends.Our new legislation echoes these trends and entrenches the rights of people with mental illness to receive adequate treatment in the least restrictive environment possible.The challenge is also to create equity across the country in terms of resources for mental health services.But how one gets from the current situation to the policy ideals 8 is fraught with difficulty.

Progress/constraints since 1994
With the establishment of a democracy in South Africa, new health departments were established in the nine provinces.
Mental health and substance abuse were seen as priorities and mental health and substance abuse programmes were established in the national and provincial departments of • Improvements in inpatient services and care through the development of norms and standards for services for people with severe psychiatric disability, 9 as well as the establishment of acute psychiatric units in general hospitals.
• Development of treatment services for people with substance use disorders and victims of violence and trauma.
• Development of services for children and adolescents with mental disorders/disabilities.
The need for a broad approach to mental health issues means that intersectoral collaboration in mental health care is critical, and this has been a significant focus for these programmes.
A major focus area has been the development of new legislation on mental health care, resulting in the Mental Health Care Act (Act 17 of 2002).This legislation aims to entrench the rights of people with mental illnesses to access to services, dignity and retention of their human rights as far as possible and treatment in the least restrictive environment possible, as well as protection of the public in the case of individuals who may be a danger as a result of their mental illness.The successful implementation of this legislation will require considerable effort and dedication on the part of mental health service managers and providers, and it remains to be seen how practicable the legislation is.It does, however, provide a useful tool in lobbying for improvements in existing services.
Other focus areas at national and provincial level have been the development of mental health information systems as well as standard treatment guidelines and an appropriate essential drugs list for psychiatry, an attempt to review expenditure on mental health services and the development of policy guidelines for child and adolescent mental health, substance abuse, psychosocial rehabilitation and HIV/AIDS and mental health.Some of these projects are still in progress or have not been fully implemented.
The major constraining factor in the development of adequate mental health services is lack of resources.There will always be a gap between need and existing resources.Even in developed countries, mental health services do not always receive sufficient financial resources relative to the existing need. 6South Africa is an emerging economy, with high levels of unemployment, crime and violence, which impact on the ability of communities to cope with the transition from institutional to community-based mental health care.In addition, in South Africa, expenditure on health was previously inequitably distributed across the population groups and provinces, and since 1994 there has been an effort to spread available resources more evenly across the country. 10 compound this difficulty the impact of HIV/AIDS has begun to be felt at all levels within the health care sector, including mental health services, both in general and psychiatric hospitals.
Other constraining factors include the transformation processes within health departments, managerial inexperience at many levels and loss of experienced mental health professionals at both management and clinical level.This has also impacted on intersectoral collaboration, where these same issues have affected other departments and sectors.
At a national level, the Department of Health has developed an integrated health planning framework to try to counter over-expenditure in certain areas of health care. 10The need for equity on a restricted budget has resulted in a squeeze on the health budgets of the more developed provinces.One of the proposed solutions to over-expenditure is to shift resources from tertiary to primary care.However, it needs to be borne in mind that expenditure on mental health services countrywide is inadequate (estimated to be between 1% and 5% of the total health budget). 6Also, introducing mental health into general health services is often seen as an additional burden by general health service managers and providers.A major challenge in terms of the integration of mental health into general health care and the development of primary mental health care has been overcoming negative attitudes and prejudice towards mental health service users, work overload and burnout among primary care staff.
Currently the National Tertiary Services Grant funds provinces for tertiary services.The only mental health service that is currently part of this grant is the maximum-security forensic psychiatry facility in the Eastern Cape.There is a national process to develop a more rational basis for the allo-

Role of research in mental health service policy development and implementation
Bowling 11 provides a useful definition of different types of health research in her book.This is summarised as follows: Research into mental health systems and services has taken South Africa was a partner country in this initiative.The project aimed to identify gaps in research, which could assist in the implementation of mental health policy in sub-Saharan Africa.[14] Also, in 1997, the Centre for Health Policy (CHP), Department of Community Health, University of the Witwatersrand, initiated a project to collect and review a database of literature on mental health in southern Africa, with particular emphasis on mental health services.A database of 542 references was collected up to May 1999, and a selection of articles was reviewed.A report was published in 2000. 15 2000, the Health Systems Trust (HST) commissioned a project which attempted to build on these previous initiatives.
The HST had funded a number of mental health projects, with particular emphasis on health systems and health services research.The HST commissioned this project because there was concern about a lack of direction in the field, duplication of research efforts and that findings of research were not having an impact on policy and implementation.
A significant finding of the CHP review was that less than half of the database consisted of original research articles.This • To make recommendations for future research.
The methodology of the project included a review of relevant literature and research articles, as well as extensive networking with key stakeholders, using individual questionnaires and interviews.Two focus group discussions were held in two provinces.A dissemination workshop was held in June 2001 in order to inform a selected audience of the findings of the project, and plan a way forward for mental health services research in South Africa.
The work done in this project illustrates that a significant amount of research has already been done, and is currently underway to assist in the implementation of mental health policy in South Africa.The bulk of the research that was reviewed is descriptive or analytic in nature (i.e. it describes the extent of mental disability and the need for services and it highlights the obstacles to implementation of policy).These studies have given us good information.However, there is a limited amount of work that goes further than this to test interventions and assess their impact (Fig. 2). 16me of the gaps in terms of research include: (i) accurate If one accepts the above model and takes 'the long view', there is still a need to consider how researchers and policymakers can interact over a period of time in order to facilitate the exchange of knowledge and information.There is evidence that collaborative efforts between researchers and policy-makers and commissioned research both enhance and facilitate the process of policy implementation and review.
However, this relationship needs to be seen within the context of other constraints, such as political, ideological, economic and other factors.There are differing opinions in the literature as to what role researchers should play.Most of the literature reviewed suggests that researchers should take on a greater advocacy role, arguing and promoting the evidence from their research in order to add impetus to the policy-making process.
An area that is currently being researched is chronic mental health care and de-institutionalisation.This field illustrates very clearly the issues described above.This is an area where there is significant collaboration between policy-makers and researchers.3][24] At the same time, there are competing policies and pressures to decrease the number of institutional beds for people with chronic mental illness.These pressures are partly political and economic, and it appears likely that they will play a significant role in how the de-institutionalisa- In terms of dissemination of research findings, the need for targeted user-friendly information was highlighted, including concise articles in peer-reviewed journals, brief reports in existing publications that are disseminated to health service managers (such as those produced by the HST), and use of electronic methods of dissemination and linking of key stakeholders.As a start, the database of references developed by this project is accessible on the HST website, and the reports of the project 25,26 have been sent to the over 200 people who contributed to the CHP, CAP and HST projects.Ways could also be found of linking contributors to these projects with other networks, such as the African Association of Psychiatrists and Allied Professions.

Conclusion
health.These programmes have attempted to develop policy and services around all aspects of mental health care, including: Volume 10 No. 2 July 2004 -SAJP Mental health service policy, implementation and research in South Africaare we making progress?Dr Thom has been involved in public health research in mental health through the Centre for Health Policy, School of Public Health, University of the Witwatersrand, and the Health Systems Trust.This article relates to work done through the CHP and HST.Rita Thom articles • Integration of mental health into general health services (including primary care).• De-institutionalisation of people with chronic mental illnesses and the development of community-based mental health services (both by the public sector and non-governmental organisations).
cation of these funds, called the modernisation of tertiary services process.The challenge remains how to develop adequate primary, secondary and tertiary mental health services Volume 10 No. 2 July 2004 -SAJP articles in all provinces, without destroying existing services in the more developed provinces.
place in southern Africa since the 1960s.Previous attempts to co-ordinate a research agenda began in the early 1990s, spearheaded by the South African Medical Research Council, the Department of National Health and Population Development and provincial departments of health, the Centre for Health Policy at the University of the Witwatersrand and various progressive mental health organisations.Since 1994 a process of Essential National Health Research has been established and mental health and sub-stance abuse are both in the top 10 priorities for Essential National Health Research in South Africa.In addition, a European Commission-funded Concerted Action Project entitled 'Methods for interventions on mental health in sub-Saharan Africa' operated from 1997 to 2000.
epidemiological studies; (ii) the development of sustainable models of services and interventions; (iii) piloting these models/interventions; (iv) evaluation of models/interventions; (v) health economics in mental health; (vi) integration of mental health into general health services (including primary health care); and (vii) deinstitutionalisation and the development of community-based mental health care.In particular, there is a need to research certain critical crosscutting areas: (i) child and adolescent mental health services; (ii) HIV/AIDS and mental health issues; (iii) substance abuse and mental health; (iv) violence and trauma; and (v) human rights issues in mental health services.A significant component of the project was the exploration of the relationships between policy-makers, managers, service providers, service users and researchers, and the obstacles to research findings being incorporated into policy and implementation strategies.Much of the literature 17-21 on the relationship between policy formation, implementation and research highlights that policy formation is a process, not a discrete event.It occurs over time, is influenced by the context in which it develops, and by a number of different actors who play a role in policy development and implementation.It is suggested that policy development and implementation do not follow a linear rational knowledge-driven model, but rather an interactive, infiltrative, enlightenment model, where thinking and research around a particular policy issue changes slowly over a period of time as evidence accumulates on the issue.
Mental health services in South Africa are under-resourced and face considerable constraints.Despite this, there have been significant strides in policy development and implementation of programmes at national and provincial level.Mental health systems and services research can play an important role in this development.The research review undertaken shows that although a significant amount of the research taking place can inform mental health policy and implementation, it needs to be better co-ordinated.The National Department of Health, academic institutions and organisations like the HST can work together to co-ordinate this type of research and build links between researchers, policy-makers and managers, service providers and service users and their families.This would encourage greater collaboration in research projects by all the above role-players.The outcome of this could be better research practice and wider dissemination of research findings.
tion process develops.It is unclear at this stage whether ate research tools and methodology was highlighted, as well as the need for earmarked funding for mental health services research.