Background
WHO defines ‘intersectoral action for health’ as a relationship between the health sector and other sectors which is necessary to improve health outcomes more effectively, efficiently or sustainably than would be achieved by the sole action of the health sector [
1]. The need for intersectoral collaboration in the provision of comprehensive community-based mental health services is well recognised internationally and in South Africa [
2‐
7]. The WHO Mental Health Action Plan 2013–2020 also cites a main objective of improving provision of integrated mental health and social care services in communities [
8].
Intersectoral collaboration is crucial, particularly for provision of psychosocial rehabilitation (PSR) for those with severe mental illness (a mental disorder meeting DSM5 and/or ICD10 diagnostic criteria and causing serious functional impairment). These individuals are recognized as having a range of medical and psychosocial needs [
9] whether they are hospitalised or living in the community. The potential benefits of an intersectoral approach are well accepted and in high income countries (HIC) intersectoral work is mandated for a range of health and social services [
10]. For example, models of Assertive Community Treatment and more recently Intensive Case Management involve multidisciplinary specialist community-based teams (comprising psychiatrists, nurses, social workers, psychologists, occupational therapists and others) [
11,
12] and rely on partnerships with service users, families and local community services, including social welfare and housing sectors [
13]. The human resource crisis for mental health in many low and middle income countries (LMIC) currently precludes the feasibility of a community-based specialist team for PSR. Provision of adequate long-term care in the community in LMIC, within the real-world resource-constrained context, will however of necessity require collaboration between the relevant government and non-government sectors.
In the African context although some countries have policies on development of community-based services, actual implementation of these policies has proved challenging [
14]. One reason for this in South Africa [
15], as internationally [
16], is rapid progress in down-sizing of specialist psychiatric hospitals that has not been accompanied by the recommended ring-fencing of money saved for direction to community-based services [
2,
4]. As in some HICs in the past, the process of deinstitutionalisation in South Africa in particular has been viewed as an opportunity to cut mental health budgets [
7] and the overall low level of resources for psychosocial community-based services persists [
2,
17‐
19]. This challenge may be compounded by lack of skills on the part of managers and those implementing policy to advocate for resource allocation for community-based services in the milieu of competing health and mental health priorities [
9], a challenge that may not be limited to South Africa or other LMIC settings.
Similar to the situation in other LMIC, there are therefore important gaps in the provision of PSR services in South Africa, particularly in rural areas [
2]. The Government Health and Social Development sectors are clearly mandated in national policy for provision of PSR. Current levels of service provision however vary widely across provinces, with the National Department of Health (DOH) remaining focused on a biomedical treatment model and the National Department of Social Development (DOSD) activities being limited to provision of disability grants and funding of non-governmental organisations (NGOs). As in other LMIC, current service provision for PSR in South Africa thus continues to be mainly through NGOs [
7] (e.g. South African Federation for Mental Health). These NGOs are partially funded by DOSD to provide this service, under the DOSD Policy on Disability [
20]. Since DOH is not routinely funding NGOs in a similar way for provision of PSR services, the question remains as to what extent savings resulting from deinstitutionalisation are following patients into the community [
7,
21]. Experience of PSR in LMIC indicates NGOs are typically limited in their ability to provide sustainable services. NGOs in middle income countries particularly may find it challenging to secure sustainable donor funding. The failure to fully integrate NGO services with those provided by government Health and Welfare sectors to ensure continuity of care and provision of the full range of services required also challenges sustainability and limits the quality of care provided [
22].
Addressing the PSR service gap is a key challenge in South Africa [
23] and other LMIC. Notably in South Africa this service is urgently needed to reduce the revolving door phenomenon (repeated discharge into the community followed by rehospitalisation) and high numbers of individuals with severe mental illness being homeless or living in prisons [
15]. Within the health sector in South Africa, there is limited care for those with severe mental illness in primary care except for symptom management through the provision of ongoing antipsychotic medication. Lack of capacity at this level for medication management, poor links with other levels of the health system and supply chain issues are however known to lead to inconsistency in the availability of medications and reduced adherence [
24,
25]. Time constraints on clinic staff lead to nurses providing a service of dispensing medication with little psychosocial intervention [
11]. Furthermore a lack of orientation and skills of service providers towards holistic and chronic care is also an issue, although DOH is making inroads into addressing this [
26]. DOH has in fact made important progress towards the provision of comprehensive mental health services, particularly through the development of the National Mental Health Policy Framework and Strategic Plan 2013–2020 [
15]. While this includes provision for community residential care and day care services as well as task-shared community-based rehabilitation programmes (PSR) in all provinces, implementation remains a challenge. There is however growing evidence from LMIC on task-shared interventions for PSR (e.g. [
27]) and a recent study showed potential for task-shared PSR in low-resource South African settings [
28]. The National Mental Health Policy highlights the role of intersectoral collaboration between Departments of Education, Social Development, Labour, Criminal Justice, Human Settlements and NGOs. Some progress is noted to have been made on intersectoral collaboration at the national level but at the provincial and district levels such collaboration is rare [
15]. A key provision of this policy is the establishment of specialist mental health teams at district level which will have responsibility for operationalisation of the framework and have important potential to move forward progress on intersectoral collaboration at the district level.
This study aims to document perspectives of a range of key informants regarding current challenges and the way forward for intersectoral provision of PSR. This was done with a view to providing recommendations for strengthening intersectoral collaboration. These insights may be of use to other middle income countries contending with the complexity of intersectoral working, as well as to low income countries, particularly in Africa, which may have different policy and service delivery contexts, but which could benefit from a strengthened intersectoral approach as mental health services develop.
Discussion
This study was undertaken against a backdrop of low levels of service provision for community-based PSR in South Africa, particularly in rural areas [
2], and limited intersectoral collaboration [
3,
37]. Although local contexts and policy and resourcing environments differ, similar challenges are likely being faced in other African countries and wider LMIC contexts. South Africa is however poised to benefit from positive recent developments such as the introduction of new National Mental Health Policy and plans for roll out of specialist district mental health teams [
15]. The study aimed to investigate challenges to intersectoral working between governmental and non-governmental actors for the provision of community-based PSR services and to gain perspectives from key informants on strategies for addressing challenges. Strategies identified are particularly relevant for other middle income countries with similar resourcing environments and service delivery platforms, but also for lower income countries seeking to make progress on provision of comprehensive mental health services.
The majority of participants in this study agreed that current levels of intersectoral collaboration for PSR were low, suggesting lack of progress since previous South African research describing intersectoral working at national level but not at district levels [
3]. Participants identified isolated cases of intersectoral working, which were not supported by organisational structures. This type of working strategy has been identified internationally by WHO reports on intersectoral action for health which recognize that ‘small scale, local action’ gives motivated individuals opportunities to form strong, productive relationships. However dependence on individual action is not sustainable for long-term provision of country-wide services [
1]. WHO case studies on intersectoral action for health suggest the need for involvement of a variety of intersectoral partners, each with support from their own organisation for involvement in the intersectoral action [
38]. For example the Sonagachi HIV/AIDS International Project (SHIP) in India was based on a partnership between WHO, All India Institute of Hygiene and Public Health (AIIHPH), the British Council, and a number of Ministries and local NGOs. This project was aimed at sex workers in Kolkata, initially aiming to provide treatment and prevention of sexually transmitted infections in sex workers in the area. The involvement of partners whose work focused on outcomes beyond direct health outcomes led to broader economic empowerment of sex workers as a result of literacy and microcredit programmes and the institution of a member organisation [
38]
Key challenges to intersectoral work that emerged from the data were (i) inadequate communication and structure in working relationships; (ii) the ongoing challenge of delineating roles and responsibilities; and (iii) a perceived lack of support between sectors. Although there is strong recognition in the public health sphere internationally of the need for intersectoral collaboration, even for HIC there is little peer reviewed evidence on the real-world application of this strategy [
39]. Challenges identified in this study however do mirror those identified in a HIC context in which a lack of culture of ‘working together’, lack of knowledge of one sector on the work of other sectors, and lack of structures and guidelines for joint work have also been identified as particular challenges [
10].
Key informants provided several feasible strategies for addressing these challenges, outlined below. These strategies correspond well with research from HIC indicating success factors for intersectoral working to be effective communication and planning at both the organisational and service-delivery levels; improving relevant professionals’ knowledge and skills; and appropriate resource allocation [
10,
38,
39]. This suggests the relevance of the recommendations from this study both to South African policy makers and health programmers, but also to those in other African countries and beyond.
Strategies identified by participants for improving intersectoral collaboration for PSR
Participants in this study identified the need to clarify, in a practical sense, the roles of intersectoral partners in PSR programming, to ensure understanding between sectors of other sectors’ roles, and to build capacity where needed to fulfil these roles. To some extent different participants had different solutions to problems identified (e.g. increasing funding to NGOs vs direct employment by DOH or DOSD of more social workers). While this underscores the need for sector role clarification, it also suggests potential for actors to move beyond their previously defined roles through sharing resources and responsibilities in the intersectoral partnership.
Proposed DOH role
Given the recognized role (supported by most participants in this study) of DOH in leading the process of provision of PSR services, recommendations for DOH action at the service delivery level and at the organizational/planning level were made.
At the service delivery level the role of tertiary staff in diagnosis and of primary health workers in ongoing medication management was well supported by participants in this study. Recommendations for PHC nurses include improving their capacity to ‘create an informed, motivated, and adherent patient’ [
26] in line with the development of the South African Health System which is embracing an integrated chronic disease management model (ICDM) [
26]. PHC nurse provision of psychoeducation for those with severe mental disorders and their caregivers is the most obvious activity indicated. There is evidence that even hospital-based staff in South Africa see themselves as ill equipped to provide PSR, given the lack of focus of previous mental health policies and training on this area [
34] so significant inputs for capacity building would be required. The acknowledgement of participants in this study of the need for DOH service providers to provide a lead role in provision of PSR also points to the role of the PHC nurse in ‘case management’, the need for which was emphasized. In this context the case management role would of necessity be scaled back in comparison to the HIC Intensive Case Management model [
40] but would entail maintaining contact with patients, tracking adherence and hospital/specialist referrals, and making referrals to other services (e.g. social services) as required, and is in line with the ICDM call for an increased role in holistic care for PHC nurses [
26]. Other developments in line with the ICDM would be additional ‘case management’ functions (e.g. working with families, health promotion, initiation of support groups) to be provided by ward-based outreach teams [
26], and promotion of medication adherence and tracing of treatment defaulters for all chronic conditions by current HIV counsellors [
26]. The role of primary health care workers at clinic level in providing the case management function and managing referrals at service points may be applicable to a variety of LMIC. In very low resource contexts this function may feasibly be provided by another cadre (e.g. community health workers).
At the planning/management level, the South African National Mental Health Policy framework and strategic plan has the objective of roll-out of at least one specialist mental health team per district by the end of 2015 [
15] which provides a clear opportunity for progress on intersectoral working. The Terms of Reference for these specialist teams cover their role in improving referral pathways from primary care to specialist services, but do not emphasise referral to other services in other sectors [
15]. This could be a key opportunity for improvement of intersectoral working at the district level. These teams would also need to include specifics for intersectoral collaboration in the development of district mental health care plans as a core objective under their terms of reference [
15]. The role of referral of people with severe mental illness to primary health services, and to the social/community services that are available, is one that could be strengthened in the work of, for example, community health workers, who, as indicated, may be present even in very low resource settings in LMIC contexts.
Proposed DOSD role
Similar to the role of DOH in provision for biomedical aspects of treatment, the role of DOSD in provision of social grants and funding NGOs was well supported by participants in this study. Some participants in this study recommended that DOSD should take a broader approach. Since PSR is grounded in a community-based rehabilitation framework, services should not focus only on psychosocial support but also on social inclusion and equalisation of opportunities for people with psychosocial disability [
41,
42]. This aligns with growing acknowledgement across LMIC of the need to dovetail approaches for mental health and social development [
42], although there has been limited integration of mental health into social development in some countries’ development models to date [
43]. DOSD can have a key role in incorporating service users with mental illness into their overall community development approach, specifically to address calls to alleviate the impact of poverty on those with severe mental illness [
44,
45]. Increasing evidence is mounting (largely from NGOs such as BasicNeeds) on the feasibility, cost effectiveness and benefit of inclusion of those with mental disorders in community development models [
46]. This approach would also support South African progress on alignment with UN proposed sustainable development goals which include a target to promote mental health and wellbeing [
47]. Practically, integration across the mental health and social development sectors would be beneficial across LMICs and will be encouraged by development of cross cutting indicators for monitoring progress (e.g. mental health outcomes of social development programmes) [
43].
The unavailability, described by participants in this study, of social workers to meet the needs of mental health service users underscores previous calls for national training centres for psychiatric social workers in South Africa [
48]. General social workers are overburdened and focused on the needs of orphans and vulnerable children and families living in poverty—similar challenges are likely being faced particularly in African countries and those with high rates of HIV prevalence similar to South Africa. More social workers focused on psychosocial disability are greatly needed, but there are unlikely to be sufficient numbers in the near future, underscoring the need for para professionals and working in a task-sharing model. The suggestion was also made in this study to assign DOSD social workers to primary health clinics to work closely with the district mental health team. However this approach could be hampered since levels of stigma against people with severe mental illnesses, particularly schizophrenia, are high in South Africa [
49]. Social workers without previous experience of working with mental health care users may need training and support to reduce stigmatising behaviour.
DOSD participants in this study had somewhat limited knowledge of the South African Mental Health Care Act and the National Mental Health Policy, and of psychosocial disability in general, which may have contributed to the perspective that addressing this is a ‘health’ issue. This is likely a challenge in other relevant sectors (e.g. housing) [
3]. Mutual training between sectors may be beneficial for intersectoral working [
39] in South Africa and other LMIC contexts particularly to work towards reduction of stigma against mental health care users.
Improving communication, structured working relationships and leadership
Communication challenges were identified between the majority of participants in the study, both at the level of individuals mental health providers (e.g. between health workers and social workers) and between different levels (provincial, district) of the health and social service systems. Clarifying and supporting pathways for communication and referral between levels of the health system is a recognised priority for the planned district mental health teams in South Africa [
15] but work on pathways with DOSD and other community services needs to be similarly emphasized. Several participants also identified the existing social development clusters as the key avenue for potential communication on issues relating to PSR services. A vital part of the district mental health team planning/management role as identified earlier could be in the representation of issues relating to PSR in this forum as well as a promoting the institution of cluster meetings if these do not exist. Supporting this in the South African context is the documented need across the sectors for increasing capacity at provincial level for managers to conduct operational planning in an integrated way [
37]. Other LMICs may have similar fora in place and it is possible that similar challenges hinder their functionality. Where possible these fora should be harnessed and strengthened for the promotion of PSR. In settings where they do not exist, their set up would represent a key step towards promoting intersectoral working for PSR and other health and social development issues. A directive from national and provincial levels of the social development cluster (or its equivalent in other LMIC) for requirements for well-functioning clusters with regular meetings and monitored actions would increase accountability for intersectoral work.
This study highlighted that at the provincial and district level, service level agreements between intersectoral partners are not present, but would be beneficial. A key challenge for many countries is the focus on limited mandates for government departments and the fact that each department has its own specific ‘language and culture’—which leads to people working in ‘silos’ and competing for resources [
1], which was mentioned by several participants in this study. A written agreement with roles and responsibilities for service providers to assemble a comprehensive PSR service at district level, with negotiated and agreed input from all sectors, is a feasible approach to address this challenge in South Africa and elsewhere. Key performance indicators on intersectoral action for service providers and managers in the sectors may also be relevant.
In terms of leadership, the main area of need seems to be clear directives from DOH for different sectors concerning implementation of PSR services from the national to provincial level [
50] and beyond this to district level. Leadership for intersectoral collaboration by Health sectors across LMIC at national and provincial levels will require building trust and enabling other sectors to focus on the broader benefits to society of intersectoral action (e.g. social justice and equity) [
1] as well as showing clearly why intersectoral action is appropriate for provision of this service [
38]. These in turn should help to make mental health relevant to other sectors and enable pooled resources to flow in the required direction. Governments as a whole also need to foster a more positive orientation to intersectoral action as part of their ‘fundamental stewardship responsibility in health’ [
1] [
51]. This means a recognition from high levels of leadership that this way of working needs to be built into structures and working practices, and therefore requires a dedicated budget (e.g. for monitoring frameworks for intersectoral action) [
1].
Direction of available resources to community-based PSR services
Budget constraints for mental health services are an ongoing challenge, particularly considering the burden of other chronic and communicable diseases in South Africa [
6]. This is borne out by the lack of a specific budget for mental health at district level and at the subdistrict level where services are provided. There is consequently a lack of a budget line specifically for PSR, as highlighted by several participants in this study. With respect to budgets for mental health, the constraints experienced in South Africa (and other LMIC) are unlikely to change in the near future as identified by a DOH national representative in this study. Participants in this study did however highlight the contrast between the lack of provision of PSR services with the substantially more developed substance abuse rehabilitation programme, which has a dedicated funding stream from DOSD, and in which a functional partnership between DOH and DOSD has been instituted. Experience from a variety of countries shows that the wider resource constraints in the public sector, as well as administrative structures, act as an impediment to intersectoral collaboration [
51] and that long-term sustainable intersectoral action can be costly and time intensive [
1]. The most discussed need for resource allocation by participants in the study was for the provision of infrastructure and management of community residential facilities which is addressed in the National Mental Health Policy. There were however contrasting perspectives on the availability of resources for PSR services between district and national level participants. District level NGO and DOH representatives felt the effects of scarce resources on the ground and a sense of competition within DOH for different disease priorities affecting the country. This is the manifestation of the public sector resource-constrained environment which fosters competition instead of collaboration between sectors [
9] in many LMIC. By contrast, national representatives generally felt resources for PSR were available. This reflects knowledge that resources at tertiary level are available, but there remains limited redirection of these resources to community level. There is a crucial need for accountability and assessment of the adequate transfer of resources in this direction [
52] but reallocation of resources to community services is a complex undertaking for South Africa and other LMIC. There are key learnings from recent progress in Brazil involving negotiation with municipalities for resource reallocation from hospital beds to community mental health services (through Centers of Psychosocial Care—CAPS), residential services, cash transfers and psychosocial support for community integration as well as programmes for employment/income generation for people with mental disorders [
53]. Sixty-six percent of the Brazilian population was estimated to be covered adequately through CAPS services as of 2010. These positive developments have been grounded on ‘political will, adequate financial resources and attention to technical aspects of the implementation’ [
54]. South Africa and other LMIC will need to bolster each of these to see progress on intersectoral provision of community mental health services. Working with municipalities as a key intersectoral partner was not identified as theme in this study, although one district level DOH participant did highlight the role municipalities could have in provision of community residential facilities. The National Mental Health Policy does state the role of local government in providing for transport, housing and recreational needs of people with mental disabilities [
15] but the practical involvement of municipalities as a key partner for intersectoral provision of PSR in South Africa will be an important area for future investigation.
Authors’ contributions
CBS conceptualised the study, contributed to design of interview schedules, conducted some interviews, conducted qualitative analysis, drafted and revised manuscript. CL advised on analysis, reviewed and edited manuscript. IP aided in conceptualisation of the study, contributed to design of interview schedules, contributed to analysis, reviewed and edited manuscript. All authors read and approved the final manuscript.