Mental health system costs, resources and constraints in South Africa: a national survey.

Sumaiyah Docrat,Susan Cleary,Crick Lund,Emmanuelle Daviaud,Donela Besada

doi:10.1093/heapol/czz085

Abstract

The inclusion of mental health in the Sustainable Development Goals represents a global commitment to include mental health among the highest health and development priorities for investment. Low- and middle-income countries (LMICs), such as South Africa, contemplating mental health system scale-up embedded into wider universal health coverage-related health system transformations, require detailed and locally derived estimates on existing mental health system resources and constraints. The absence of these data has limited scale-up efforts to address the burden of mental disorders in most LMICs. We conducted a national survey to quantify public expenditure on mental health and evaluate the constraints of the South African mental health system. The study found that South Africa’s public mental health expenditure in the 2016/17 financial year was USD615.3 million, representing 5.0% of the total public health budget (provincial range: 2.1–7.7% of provincial health budgets) and USD13.3 per capita uninsured. Inpatient care represented 86% of mental healthcare expenditure, with nearly half of total mental health spending occurring at the psychiatric hospital-level. Almost one-quarter of mental health inpatients are readmitted to hospital within 3 months of a previous discharge, costing the public health system an estimated USD112 million. Crude estimates indicate that only 0.89% and 7.35% of the uninsured population requiring care received some form of public inpatient and outpatient mental healthcare, during the study period. Further, mental health human resource availability, infrastructure and medication supply are significant constraints to the realization of the country’s progressive mental health legislation. For the first time, this study offers a nationally representative reflection of the state of mental health spending and elucidates inefficiencies and constraints emanating from existing mental health investments in South Africa. With this information at hand, the government now has a baseline for which a rational process to planning for system reforms can be initiated.

Highlights

Over the past decade, calls to address the increasing burden of mental, neurological and substance use (MNS) disorders and to include mental healthcare as an essential component of universal health coverage (UHC) have attracted mounting interest from governments (Prince et al, 2007; Mnookin, 2016; Chisholm et al, 2019; Patel et al, 2018)
Since the World Health Organization (WHO) Mental Health Atlas (MHA) initiative commenced in 2001, our understanding of mental health systems and ability to monitor progress towards the ambitious global mental health goals outlined in the Sustainable Development Goals (SDGs) has improved significantly (Chisholm et al, 2006; WHO, 2013, 2016) Yet, significant gaps in the knowledge base remain among most Low- and middle-income countries (LMICs), including South Africa
This study found that the total health system costs of inpatient and outpatient mental health services across all provinces of South Africa amounted to an estimated USD573.6 million in the 2016/17 financial year (FY) (Table 2)

Summary

Introduction

Strategies include: the explicit recognition and inclusion of mental health in the UHC agenda; intensified investments in mental health systems; reducing inefficiencies in the use of resources through the redistribution of budgets from hospi-centric care to the community; taskshifting mental healthcare to non-specialist providers who receive ongoing specialist supervision; amplified training for all cadres of mental health professionals and specialists; the initiation of early interventions that are accessible to at-risk populations; integration of mental health in broader primary healthcare, and; the active engagement of those living with and effected by MNS disorders in the reform process (Chisholm et al, 2007; Patel et al, 2010; WHO, 2010; Lund et al, 2012; Hanlon et al, 2014; Thornicroft and Patel, 2014; Lund, 2016; Hanlon et al, 2018; Patel et al, 2018). The most common reason for missing data is that it does not exist, with a further limitation that most information provided by countries relates to the country as a whole, overlooking important variability across regions, concerning the degree of policy implementation, availability of services and the existence of promotion and prevention campaigns for mental health (WHO, 2018b)

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Conclusion