Health Care Services for Mentally Ill: Mpumalanga & Northern Cape Departments of Health

Meeting report

The Chairperson welcomed everyone and said the two provinces presenting today are the last amongst provinces invited by the Committee to present on the state of mental health. Cognisant of what had transpired in Gauteng; mental health issues are now thrust into national prominence. The Committee will therefore not be content with presentations alone and will visit the province to see things for itself. Provinces should be open with the Committee so it can be determined where help was needed. Mental health was a complex illness and it was important to put systems in place for people to seek help and empower communities in understanding that mental health is just like any other illness.  The Chairperson said that she happened to have a family member with bipolar disorder who completely refuses to be treated.

State of mental health: Mpumalanga

Mr Gillion Mashego, MEC for Health, Mpumalanga, thanked the Committee for the opportunity to present on the state of mental health in the province especially since June was an important month dedicated to a very important segment of South African society: youth. This month salute young heroes who profoundly changed and shaped the socio-economic landscape of the country.  Events that triggered the uprising can be traced to the policies of the Apartheid government that resulted in the Bantu Education Act in 1953. After taking over from the Apartheid government, the focus was to rebuild what was lost and to empower young people towards developing South Africa for the better. Today many young people are drug addicts which leads them being admitted to mental health institutions. The abuse of drugs such as dagga, nyaope and many others increase violent crime experienced today in the society.  Many young people continue to lose their lives due to violent acts committed by them. Today, South Africa was infested with the killings of women by their boyfriends which are a rising concern. It simply means that government must do something to stem the tide. Our country however must also thank those young persons who have risen above the bar to play a significant role in our society.

Mental health was an integral part of health and improved mental health was crucial for the realisation of government’s programme of a long and healthy life for all. To achieve this, there must be investment in mental health programmes as government. Mental health programmes cut across various segments and this will assist in reducing violent crime, drug abuse, violence against women and children and in reducing the rate of HIV infection because all of it had a substantial impact on mental health.  Progress was being made in improving mental health such as the establishment of the Mental Health Review Board (MHRB). This board was appointed by the MEC Office in line with the Mental Health Care Act promulgated in 2004 which directly reported to the Office of the MEC. The board reports any infringements of the human rights of mental health care users to the MEC’s office.  The workload of the MHRB (one at the moment) was too much and plans are in motion to increase the number of review board in the province.

Three years ago, the province had a long list of offenders awaiting observation which necessitated the employment of a forensic psychiatrist. This move has ensured that the province currently has no waiting list.  In spite of the achievements, a challenge such as the absence of a psychiatric hospital in Mpumalanga has negatively impacted on the work done. This has forced the Department to now train student nurses and medical doctors specialising in psychiatry in other provinces. This was an impediment to attracting specialists in mental health to the province. As an intervention, the Department was working with the Mpumalanga Economic Growth Agency (MEGA) to fast forward the construction of a psychiatric hospital in the province that will hopefully commence before the end of the current financial year.

Mr Mashego said another challenge was the use of general hospitals to deliver psychiatric services which has resulted in adverse events such as the mushrooming of unlicensed non-profit organisations (NPOs).  Most importantly, psychiatric patients are escaping from hospitals and committing suicide. There was a recent case of a mentally ill patient climbing to the rooftop of Themba hospital. It took more thirty six hours for the police to get the patient down from the roof. Mpumalanga province was working round the clock to ensure that a psychiatric hospital is constructed sooner so it can train student nurses and attract qualified medical specialists.  The Department acknowledges its shortcomings but was working very hard to deliver quality services to the people. What happened in Gauteng was a wakeup call to everyone in this sector.

Dr Savera Mohangi, Head, Mpumalanga Department of Health (DOH), said Mpumalanga province had a population of roughly 4.3 million in 2016. The province consisted of three districts which are Ehlanzeni, Gert Sibande and Nkangala. It bordered Swaziland and Mozambique. The province was mostly rural and that made it difficult to attract skilled professional mental health specialists. In its service delivery platform, the mental health care package is delivered t the following levels

-In the community via ward-based public health care outreach teams;

-In 287 primary health care facilities;

-In 25 hospitals that conduct 72-hour assessments

-In substance abuse cases, all 28 hospitals in the province provide detoxification to clients already booked for rehabilitation services by the Department of Social Development;

-The Department contracted Life Esidimeni for the provision of chronic mental health services at Siyathuthuka that had 250 adult beds and Baneng that had 20 beds exclusively for children;

-Forensic psychiatric services are conducted at two hospitals in Ermelo and Tintswalo for both single and panel observations; and

-Forensic psychiatric outreach services are provided to five prisons in Nelspruit, Barbeton, Ermelo, Witbank and Middleburg by a forensic psychiatrist once a month.

On the number of admissions for the past three years (2014/15- 2016/17), Dr Mohangi said there had been 315 for persons younger than 18 and 8 686 for persons over 18. Primary health care facilities refer mental health care users to 72-hour assessment facilities. Mental health care users from 72-hour assessment facilities are either discharged back to the community or transferred for further care and treatment to three designated psychiatric units which are Rob Ferreira, Witbank and Tintswalo hospitals. Conversely, mental health care users from designated units may either be discharged home or referred to chronic care facilities at Siyathuthuka in the case of adults and Baneng for children. Difficult mental health care users that needed further management from designated facilities are referred to Weskoppies and Sterkfontein hospitals in Gauteng due to lack of a specialised psychiatric hospital in Mpumalanga.

In terms of human resources, there are a lot unfilled vacancies in the province’s health department. Four vacant psychologist positions, 15 community psychiatric nurses, 11 social workers and occupational therapists respectively, 45 registered counsellors and 15 community psychiatric nurses amongst others. It has to be noted that most of the senior positions filled are in acting capacities. The province has also inaugurated one provincial Mental Review Board that comprises of a legal practitioner, a medical health practitioner and a community member.

There are 314 beds expected to be delivered from six hospitals in 2020/21, and once this was done, the province will then start building a specialised psychiatric hospital. This was earmarked to be a five year project expected to be completed in 2025/26.

Discussion

The Chairperson said there are no longer “prisons” in South Africa, but should be referred to as correctional centres. In terms of the referral system, it was mentioned that patients are discharged to communities and there seemed to be no programme in place to assist and empower communities to understand and accept mentally ill patients. Most communities in South Africa still believed that mentally ill patients are to be locked up. It was also good to unpack in written submissions to this Committee even for one district, the statistics of the kinds of illnesses such as bipolar, schizophrenia and the contributory factors because it made for better understanding why a certain district has more bipolar or schizophrenic patients. Does the Department also have inter-sectoral collaboration with the South African Police Service (SAPS), the Department of Basic Education (DBE) and youth formations?

Dr S Thembekwayo (EFF) said mention was made about the mushrooming of unlicensed service providers and this required urgent attention because there should not be a re-occurrence of Esidimeni in Gauteng. Part of that problem was also because of unlicensed service providers.  Another issue that should be addressed was the high number of vacant positions. Of the 18 community psychiatric nurses that are needed, only three are filled. If these positions are filled then these nurses can be deployed to work in the communities and this could make a huge difference. The same goes for occupational therapist vacancies. What is the time frame envisaged by the Department to fill all these vacancies?

Ms C Ndaba (ANC) wanted to know whether there was follow-up for clients/patients discharged from hospital to ensure that they take their treatments. What role do community health workers play in the mental health space?  There are NGOs that has community health workers in their employ and the services they render are vital in the communities. Are their services extended to mental health? What relationship does the Department have with traditional leaders and healers regarding mental health and substance abuse?

Mr S Jafta (AIC) asked if the Department embark on awareness campaigns targeted at the broader community to educate them on mental illness, because there was still the perception in some communities that mental illness was associated with witchcraft. What are you doing about mentally ill persons loitering in the streets? These people take no treatments, so who is caring for them?

Dr P Maesela (ANC) also commented on the unfilled vacancies in the health department of Mpumalanga and this situation is unacceptable. What is the reason why because these personnel are needed to deliver services to the community? Does the department only have three psychiatrists employed in the whole province? It looks like the province has a lot of mental health facilities, how do the three psychiatrists go round them because it might take the whole year for them to go round the facilities you have?

Mr A Mahlalela (ANC) asked what the remuneration of the MHRB members are and if the three board members are sufficient to cover the whole province, because we their mandate also entailed accepting appeals and preserving the human rights of mental health patients. What is the budget for mental health in the province? How is it budgeted through the medium term framework (MTF) processes? There was supposed to be a directorate in place and it was now over four years since the action plan was put in place and he asked when the Department was putting that into action. He wanted to know why the Deputy-Director that dealt with this issue on a daily basis not present. One of the questions raised by the Chairperson was about inter-sectoral collaboration that was not mentioned anywhere in the report. Is there any such collaboration taking place and with whom within and outside government? What are the main prevalent causes of mental illness in Mpumalanga? The issue of advocacy around mental health should not be overlooked by the Department and the board members are part-time and he asked how it affected advocacy knowing that it was a requirement of the Mental Health Act. There was no mention of monitoring and evaluation. It will help the Department to be able to intervene and know the challenges arising thereof.  To what extent are you able to monitor NGOs providing services to mentally ill patients in Mpumalanga in keeping with Section 43 of the Mental Health Act? How prevalent are mental health patients kept in correctional facilities? Are they kept in conditions that are in accordance with the law knowing your staff constraints? The presentation from Limpopo acknowledged that one of their challenges was congestion of patients referred to them by Mpumalanga since the province had no psychiatric hospital. In the presentation, you mentioned referrals only to Gauteng. The Health Minister spoke about state patients kept in various psychiatric hospitals in the country. Mpumalanga was said to have fifteen patients in various hospitals and he asked for this to be clarified.  

Mr T Nkonzo (ANC) wanted to know if Mpumalanga was receiving more patients coming from neighbouring countries Swaziland and Mozambique. How are the vacant positions of community psychiatric nurses (15) and other unfilled vacancies affecting the delivery of mental health services in the province?

Mr W Maphanga (ANC) asked if it was true that because the province was a deep rural area it made it difficult to attract professionals from urban areas. Is there therefore any strategy in place to recruit rural youth from Mpumalanga especially matriculants to fill vacant positions?   

The Chairperson also complained about the state of human resources in the province. It meant that untrained nurses in mental health working in general hospitals are made to look after mental health patients. She wanted to know the challenges in terms of keeping patients for 72 hours and what the situation was with patients in correctional centres. This was unacceptable, because if the Department did not have enough staff it could lead to the non-deliberate violation of the human rights of mental ill patients and overburden nurses working in the space.

Responses

Ms Sarah Sitcanede, Director, Mpumalanga DOH, said there were gaps in some of the services being provided to the community. In terms of the follow-up of patients released from hospital, she said there are gaps due to human resources constraints, but the Department had district ward-based outreach teams that go to the communities and were instrumental in discovering the operation of unlicensed NPOs operating in the communities. They also do follow-ups on discharged patients.  The Department understands that they are not well trained for this service because the psychiatric health space was a specialised field.

The Department had inter-sectoral collaborative forums that embraced SAPS, Correctional Services and the Department of Education. Children are referred to the Department for psycho-social support and she admitted that the Departments did not at this time have enough specialised psychiatric nurses.

The Department was not collaborating with NPOs, but was aware they are there working in the communities. They are keeping some of the patients and the Department has community coordinators to check on them. The Department has three dedicated trained occupational therapists covering the three designated mental health facilities in the province helping the patients on medium to long term stay. The Department also conducts mental health awareness campaigns in line with the health calendar. They have been conducted with specific themes such as substance abuse in collaboration with other departments.  The Department has few psychiatrists as a result of the province not having a fully fledged psychiatric hospital. The workload for them was very daunting added to the fact that the province has no High Court at the moment. A second MHRB was needed to lessen the pressures of the current board.

Ms Sipho Motau. Acting Deputy Director-General: Clinical Health, Mpumalanga DOH, said in profiling the common causes of mental illness in the province, most patients have been diagnosed with bipolar, schizophrenia , depression, anxiety disorder and substance induced psychosis, in that order. The Department will unpack comprehensive details in a written response. With regards to advocacy, the fact that the province has only one MHRB that covered the whole province made it difficult for the members to perform adequately. As a result they dedicate one day in a week to institutions in the province attending to mental health issues. The leadership was working on inaugurating a MHRB in all the districts in the province.

Monitoring and valuation was another weakness experienced. Monitoring in all layers of the department is not done at the moment. Mental health awareness was being taken to the communities and taxi ranks and even scheduling mental health discussion slots in community radios.   A meeting was held with the Limpopo DOH with the aim of signing an MOU with them. This was because Mpumalanga province has areas bordering Limpopo province. It was in that meeting that it discovered that many people from our province cross over to Limpopo to seek medical care. This informed the Department’s decision to have more interactions with the Limpopo DOH to relief them of the burdens of our province’s mentally ill patients that they are carrying. As Mpumalanga had no hospital to cater for them, Limpopo has agreed to continue to help but we have asked for a database of all patients coming from Mpumalanga province to them with the aim to locate their relatives so that treatments will continue with supervision when they are discharged..

Dr Mohangi acknowledged that there are major challenges in filling vacant posts but the main reason was budgetary constraints. Priority will however be given to current organogram positions that are vacant. The Department was presently giving bursaries to   clinical psychology students studying who will be employed in the Department when their studies are completed. In terms of the Department’s human resource development, there was an ongoing programme targeting high school students in grade nine to guide them on subjects to choose if they are in interested in the health sciences sector. There was presently a problem attracting psychiatrics to the province and even the private medical sector did not have enough psychiatrics to fill their vacancies. The Department has entered into an agreement with the University of KwaZulu-Natal (UKZN) to train its doctors. Currently there are two doctors undergoing registrar training in psychiatry who then will be absorbed into the Department when their studies are completed. The same was happening with psychiatric nurses training as well.  Other questions will be answered in writing.

The Chairperson cut in to reiterate why the powers of the MHRB was so important. If they cannot function to the expected capacity because of being overburdened with work, it then meant there are mentally ill patients whose rights are being trampled on and some of the appeals may not be properly looked into. The MEC should see to this issue.

The MEC replied that comments and suggestions are taken constructively. He also promised that more boards will be established in all districts to cover the entire province. The budget will be reprioritised to accommodate and fill some vacancies. He acknowledged that there are shortcomings which must be addressed.

The Chairperson said the Department must come back in three months to present a progress report.

State of mental health: Northern Cape

Mr Lebogang Motlhaping, MEC for Health, Northern Cape, said last year was not a good year for mental health in the country given what happened in Gauteng. Northern Cape was doubling its efforts to ensure that such an unfortunate incidence did not occur in the province. The reason why the chairperson of the MHRB accompanied the delegation was to demonstrate that there are no issues between the board and the Department.  Having listened to Mpumalanga province’s presentation, there are common challenges. The board has only five members and their workload was heavy such as was mentioned by Mpumalanga. Northern Cape was trying to rectify such weaknesses.

Ms Nomathemba Mazibuko, Acting HOD; Northern Cape Health Department, gave an overview of mental health in the province. Mental health was mainly provided by the government and there was one licensed private psychiatrist hospital and a large NGO providing limited disability services. Non-complicated mental illness was managed by primary health care and government has no community based accommodation for clients with mental illness or profound intellectual disability.

Oversight and hospital coordination was provided by a provincial mental health coordinator while district mental coordinators are responsible in the district level. A limited outreach service to the districts was provided in the West End Hospital (WEH) psychiatric hospital in Kimberley. This hospital also did specialist outreach for psychology and psychiatry.

WEH was the main source of support and referral for acute mental illness and was also the only referral resource for state patients, forensic patients and child and adolescent mental health services (CAMHS).

In terms of primary health care clinics, they do the following;

-Screening for mental health disorders;

-Treatment for mental health disorders; and

-Screening for substance abuse

Involuntary and voluntary 72-hour mental assessments in general hospitals aim to eliminate any underlying medical condition such as urinary tract infection, and should be provided across various districts, regional and tertiary hospitals. Many of the hospitals are not meeting the 72-hour deadline for assessment set by the National Department of Health (NDOH) policy. The province has made funds available for hospital refurbishment this financial year. Such refurbishments are planned in the following hospitals: Kimberly hospital (20 beds); Old Gordonoa and Upington (32 beds), Tshwaragano (10 beds) and four beds each in De Ar, Hartswater, Springbok, Calvinia and Postmansburg.

WEH did general adult psychiatry (voluntary and involuntary), acute and chronic for state patients, child and adolescent psychiatry, intellectual disability (outpatients only).

For the new Northern Cape mental health hospital, construction is expected to be completed in early 2018 and the value of the current contract was R680 305 062. Admin blocks A, B and C are 95% completed and will be inspected in July 2017. After completion, six months will be needed to for equipping and commissioning and was expected to initially have 199 beds.

The overarching role of the MHRB was the protection of the human rights of the mentally ill. The board was made up of five members: two mental health practitioners, one legal practitioner and two community members. Board members are appointed by the MEC and are remunerated at an hourly rate.

The challenge of mental health personnel capacity was being addressed through the registrar programme with the University of the Free Sate (UFS). The psychiatrist shortage was being addressed by rotating the medical officers from the district to WEH in-service training.

Discussion

Dr Thembekwayo thanked the delegation for the presentation but commented on the term ‘acting’. As the delegations were being introduced, most of the personnel positions are all in acting capacity. This was very problematic as it rubbed off on the efficient execution of government policies. Something has to be done to change acting positions to actually occupying the position.  Vacancies also have to be filled because there are no psychiatrists in all the district hospitals in the province. Human resources at district level have to improve and there must not be a repeat of what happened in Gauteng.

Mr Maphanga commended the idea of establishing a mental health advocacy groups. Their sustenance should be taken seriously and he wanted to know what efforts have been put in place to ensure that they continue to function in years to come. Are they making use of volunteers and how many are qualified? Looking at the challenges and solutions mentioned thereof, he asked how far ahead the Department was in implementing the proffered solutions.

Dr Maesela asked how only one licensed psychiatrist hospital in the province helped the public. She asked how many psychiatrics and psychologist are in the outreach team. How do they do function? Why are most of the hospitals not meeting the requirement of a 72-hour assessment policy set by NDOH? The province should state the challenges they have, because the Committee could make some suggestions. All board members are appointed by the MEC and are remunerated on hourly basis. She asked if they are beholden to the MEC who appointed them and if there are weaknesses in that set up. The Department mentioned they are in the process of solving the lack of psychiatric personnel in the districts and increasing their capacity by sending some registrars to UFS and she wanted to know if it meant that presently there are no registrars in the health sector in the whole province.

Mr Nkonzo asked why traditional healers and women are not part of the MHRB. The inclusion of traditional healers and women working hand in hand with medical personnel could add another dimension to their work.

Mr Mahlalela also spoke on the high number of personnel working in an acting capacity in the Department. Some of the acting positions have exceeded one year and counting. What is the difficulty for instance in appointing a permanent HOD? Such an appointment will bring stability to the sector and reduce some of the challenges faced by the Department. This matter should be prioritised.  According to the strategic framework agreed on by the health sector in 2013, a directorate and a director responsible for mental health should have been established by 2014/15. What is the state of that directive in the province presently? It was mentioned that additional funding was needed to fill your vacancies. H asked where the funding was going to come from, had National Treasury been approached or if the departmental budget was going to be adjusted to accommodate such appointments. Last year when the Department presented to this Committee, there was a huge challenge in its budget and he asked if it had been stabilised.  What is the budget for mental health in the province? If only WEH was doing advocacy promotion, he asked if it covered the whole province. Are there other promotion and prevention programmes taking place in the province? What are the main causes of mental illness in the province?  Does the Department have an inter-sectoral collaboration with other stakeholders? Who are your partners? What M&E mechanisms are being used to aid your work in the province? There was mention of a large NGO the Department is collaborating with and he wanted to know how big the NGO was. How much is allocated to them to do this work and what areas are they covering in the province? Does the MHRB have dedicated personnel to service them since they are not working full time? The Act did require that they have dedicated staff working with them. How independent is the board when they are appointed by the MEC of Health? With whom does their accountability lie?

The Chairperson asked how many hours a day and for how much does the review board work since they are remunerated hourly. Who are the advocacy groups the Department is working with outside of government structures? She asked if the Department budgeted for everything including equipment for the new mental health hospital to be completed soon. What is the budget breakdown for this project? Is the Department utilising the 12 psychologists from the private sector in government hospitals as indicated in the presentation? Why are you more dependent on private sector health specialists to do your work? The Northern Cape Health Department was not taking the sector seriously. The report presented to the Committee was also too general and lacked specifics. Either the Department was not taking their jobs seriously or was not being completely honest with the Committee.

Responses

In her response, Ms Mazibuko said the budgetary allocation has worsened with a 3.5% cut in the budget. So instead of even getting an inflation-linked increase which was the normal expectation, the Department received 3.5% less on the baseline of the previous financial year. This was significant because the Department was receiving 26% of the provincial allocation of about R12 billion. When compared to the national norm for provincial departments across the country, it was only Northern Cape and Mpumalanga that received 26% while the national norm was 31%. There are even provinces such as the Western Cape, KZN and Gauteng that are getting up to 34%.   When the 5% was sub-divided from the 26% it translated to R1.8 billion that the Department has been short changed with. The Department has had discussions with its national counterparts and it was difficult to envisage how many more nurses and doctors can be affordably be appointed.  Even 2% increase would make a difference. The province was not spending even 60% of the budget on compensation of employees whilst other provinces are spending more than 62%. This Department was presently unable to fund its human resources requirements. A qualified psychologist presently working in the private sector was willing to join the Department but the truth was that Department cannot afford him.

Just opposite the psychiatric hospital currently being built, was a private sector facility that opened officially last year. The Department was losing revenue from private patients because they prefer to go that facility. The private sector specialist reflected in the slide was because the Department intended to show how many specialists both private and public are working in the province. Those mentioned from the private sector did not form part of the Department’s employees.

Mr Richard Jones, Chief Director, Northern Cape DOH, said the lack of qualified mental health personnel was a challenge. The Department currently has three registrars who are funded and studying at UFS. It was a four year programme and they are expected to join the Department on completion. The other major challenge was the 72-hour assessment. This has not been a priority for the Department for the time being. Limited bed space in the current facilities was hampering compliance. The MHRB has female members and the chairperson was female. Presently there are no traditional leaders in the board and that was something the MEC will look into. On the mental health organisational structure, the programme sat with priority programmes and was managed by a Chief Director, followed by the Director for Non-communicable Diseases and the Deputy Director who was the programme manager.

Mr Albert Links, CEO, WEH, said there was no relationship between the private and government sector in the mental health sector in terms of functionality. The capacity constraint was affecting the district health’s ability to comply with the 72-hour assessment.  There was also no concrete relationship with the advocacy groups. They operated autonomously. Since he assumed the CEO position at WEH there had not been any contact with them. On the specialist and outreach programmes, he said there are five districts in the province and there was only one (Namaqualand) not being served.

Ms C Isaacs, Chairperson, MHRB, Northern Cape DOH, said the board was established in April 2016 and started functioning in July. The Act specified a minimum of three members and a maximum of five. There was a wide range of members covered in the board membership. Even though the board was appointed by the MEC, it did not rubberstamp the health management’s decisions. The board worked 40 hours a month, ten hours a week mainly on Mondays and Tuesdays. The Act also allowed members to do their private business.

The Chairperson told the Department to prepare a record of those admitted for mental illness to be presented in two months’ time.

The meeting was adjourned.