“Make mental health for all a global priority” is the theme for this year’s World Mental Health Day, which is marked annually on the 10th of October to raise awareness about mental health and garner support for those experiencing mental health issues. Since 2013 -the year when the United Nations adopted the Day – one of the biggest challenges has been unequal access to mental health care, especially in low and middle-income countries where some population groups are more at risk and less likely to get help. About 75 – 95% of people with mental disorders in low and middle-income countries are unable to access mental health services, according to Deputy Minister of Health Dr Sibongiseni Dhlomo, who led a debate on the prevalence of mental illness in South Africa before the National Council of Provinces in February this year.

Demand for mental health services exceeds supply by far

In line with the United Nations’ efforts to raise global awareness about mental health, South Africa has marked October as Mental Health Awareness Month, with many organisations working in the field offering information and counselling to people directly or indirectly affected by mental health issues.

The spectrum of mental health conditions is wide, and includes mental disorders of different severity and symptoms, such as Depression, Anxiety Disorder, Bipolar Disorder, Post-Traumatic Stress Disorder (PTSD), Schizophrenia, Eating Disorders and Neurodevelopmental Disorders such as Attention Hyperactivity Disorder (ADHD) or Autism Spectrum Disorder (ASD), to name just a few.

The wide range of mental health conditions makes specialised treatment by professional staff such as psychologists, psychiatrists, specialised counsellors and health workers a basic requirement. However, there is a massive shortage of psychologists and psychiatrists in the country – especially in the public sector. There are only a total of 451 psychologists within the public sector, with vacancy rates between 80% and 83% in Mpumalanga, Limpopo and the Eastern Cape. The shortage of psychiatrists in the public sector is even more severe with a psychiatrist/patient ratio of 1 to 3338295 for the Eastern Cape and 1 to 1581194 in Mpumalanga.

While the important work of health workers and counsellors in promoting de-stigmatisation of mental health issues in communities by providing information and raising awareness must be commended, the acute shortage of psychologists and psychiatrists in the public sector raises the question: what does it help to raise awareness around mental health and campaign for individuals and relatives to come forward when there is not enough capacity to provide the required services and offer them the help that they need?

Unequal access to mental health services

South Africa, the country with the highest social inequality in the world, has a two-tiered and highly unequal healthcare system. According to a 2021 article by Russel Rensburg, Director at the Rural Health Advocacy Project (RHAP), the private sector – largely funded through individual contributions to medical aid schemes or health insurance – serves only around 27% of the South African population, while the majority – ca. 71% depend on the state-funded public sector.

Focusing on the availability and accessibility of mental health services in general and in the public sector in particular, the situation looks dire. In an answer to a parliamentary question from the Democratic Alliance, the Department of Health has recently revealed that more than 6.5 million people in South Africa need professional mental health intervention, of which almost 1.3 million “need care for severe psychiatric conditions”. The fact is that South Africa has only 19 752 beds in public and private mental healthcare facilities available.

The Government plans to address these huge disparities in healthcare services and to achieve universal access to quality healthcare for all South Africans in accordance with section 27 of the South African Constitution by adopting the National Health Insurance (NHI) Bill, which is currently before Parliament. However, the Bill – with its plan to create a single framework throughout the Republic for the public funding and public purchasing of health care services, medicines, health goods and health related products, and to eliminate the fragmentation of healthcare funding – has raised much concern and criticism from the medical fraternity and Human Rights organisations alike. Civil Society organisations, such as Section 27, the Helen Suzman Foundation, the FW de Klerk Foundation, the Institute for Race Relations, the Board of Healthcare Funders, the SA Medical Association and the SA Human Rights Council – to name just a few, criticise the Bill because of the Government’s proven inability to manage the present public health system, and because the NHI would be unaffordable with a price tag that could top R450-billion per annum. The Bill would also concentrate too much power in the hands of the Minister of Health, who would have full control over the accreditation of all public and private health establishments and would also have full discretion over all senior appointments, which poses the threat of appointments based on political affiliation and cadre deployment rather than on merit.

Mental health and wellbeing – a constitutional right

The Life Esidimeni Tragedy, still very much alive in our public conscience, that cost the lives of 141 mental healthcare users due to the decision by the MEC for Health in Gauteng to cancel a contract with a long-term psychiatric care hospital and move the patients to cheaper facilities, should serve as a reminder that oversight and control mechanisms are vital when it comes to decisions affecting the physical and mental wellbeing of vulnerable people. Too much power in one person’s hand always bears the risk of abuse and unethical behaviour. The list of badly run state entities is long, and does not help to convince critics of the merits of the NHI Bill. The Esidimeni tragedy further brings into question the viability of the proposed Bill that would require even more administrative capacity from the National Department of Health.

A report by the Health Ombudsman on the tragedy, published on 1st February 2017, states that constitutionally enshrined rights, such as the right to human dignity, the right to life, the right to freedom and security of person, the right to privacy, the right to an environment that is not harmful to their health or well-being and the right to access quality health care services, were violated and totally disregarded by certain government officials and NGOs.

The report points to the constitutional obligation of the South African government – as well as society as a whole – to respect the rights of people with mental health disorders and make quality health services accessible to all South Africans, irrespective of their social-economic status or in which part of the country they live.

As we mark World Mental Health Day, we should acknowledge the serious shortcomings in the provision of adequate healthcare services to South Africans suffering from mental disorders. Mental Health Month should be used by public officials, healthcare providers and organisations from the public and private sector working in that field to discuss how these problems can best be addressed. However, the first step of the solution may lie in fixing our badly broken public healthcare system and by making more rational use of the resources of the private health care sector – rather than by embarking on unaffordable and unworkable nostrums such as the proposed NHI system.

– Christina Teichman, FW de Klerk Foundation Board Member