Background
Health system governance framework
Principle
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Domains
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Strategic vision
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Leaders have a broad and long-term perspective on health and human development, along with a sense of strategic directions for such development. There is also an understanding of the historical, cultural and social complexities in which that perspective is grounded | Long-term vision; comprehensive development strategy including health |
Participation & consensus orientation
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All men and women should have a voice in decision-making for health, either directly or through legitimate intermediate institutions that represent their interests. Such broad participation is built on freedom of association and speech, as well as capacities to participate constructively. Good governance of the health system mediates differing interests to reach a broad consensus on what is in the best interests of the group and, where possible, on health policies and procedures | Participation in decision-making process; stakeholder identification and voice |
Rule of law
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Legal frameworks pertaining to health should be fair and enforced impartially, particularly the laws on human rights related to health | Legislative process; interpretation of legislation to regulation and policy; enforcement of laws and regulations |
Transparency
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Transparency is built on the free flow of information for all health matters. Processes, institutions and information should be directly accessible to those concerned with them, and enough information is provided to understand and monitor health matters | Transparency in decision-making; transparency in allocation of resources |
Responsiveness
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Institutions and processes should try to serve all stakeholders to ensure that the policies and programs are responsive to the health and non-health needs of its users | Response to population health needs; response to regional local health needs |
Equity
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All men and women should have opportunities to improve or maintain their health and well-being | Equity in access to care; fair financing of health care; disparities in health |
Effectiveness & efficiency
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Processes and institutions should produce results that meet population needs and influence health outcomes while making the best use of resources | Quality of human resources; communication processes; |
capacity for implementation | |
Accountability
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Decision-makers in government, the private sector and civil society organizations involved in health are accountable to the public, as well as to institutional stakeholders. This accountability differs depending on the organization and whether the decision is internal or external to an organization | Accountability: internal; accountability: external |
Intelligence & information
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Intelligence and information are essential for a good understanding of health system, without which it is not possible to provide evidence for informed decisions that influences the behaviour of different interest groups that support, or at least do not conflict with, the strategic vision for health | Information: generation, collection, analysis, dissemination |
Ethics
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The commonly accepted principles of health care ethics include respect for autonomy, nonmaleficence, beneficence and justice. Health care ethics, which includes ethics in health research, is important to safeguard the interest and the rights of the patients | Principles of bioethics; health care and research ethics |
Methods
Design
Recruitment and participants
Data collection
Data analysis
Ethics
Results
Rule of Law
Strategic Direction
“often these things that we do at the top, at national government, they’re always good on paper, and they sometimes arrive at the sites where they’re supposed to be implemented, and land up in cupboards. They gather dust…there’s a problem in resourcing this process” (NR2).
“we are of the opinion that the strategic planners are better placed to make sure that mental health is included in their annual provincial plans and also, they develop the relevant indicators to make sure that the programme is monitored and evaluated” (NR3).
Responsiveness & Integration
Responsiveness to mental health as a public health priority
“If you are HIV positive or you are AIDS sufferer, the mental health issue comes into play and it needs to be taken care of. If you suffer from diabetes or cancer, there are mental health issues. That’s how we need to understand it across the board, and my view is that we currently don’t understand it that way. Because we keep on saying it cuts across and I don’t think people understand when we say it cuts across” (PR4).
“I don’t think it’s because they don’t think that mental health is important, but they do think that other things are more important… I also think that when people are dying in large numbers, health representatives feel that they need to respond to that, and who am I to say that they’re wrong? I think they’re probably right actually. So, you know, we face crises after crises” (NR1).
Responsiveness at a facility level
“We are losing many patients or users into the cracks because you find that the user is seen at a facility, maybe admitted. Once the user leaves the facility, we don’t keep track whether the user ultimately follows up, adherence to treatment, all those aspects” (NR3).
Responsiveness at a community level
“our approach that we inherited from the previous … apartheid government of institutionalising people with disabilities, has in a way created some dependency and some expectations especially among the family members. And now when you really get and move the services to the community where a large number of people with mental disability can actually then be able to receive the services, we might actually meet with some resistance especially from the community and from families, because communities know that they’ve got this perception and understanding that if you have a mental disability then you should be closed up in an institution” (NR4).
Effectiveness & Efficiency
Human resources
“If only the staff structure can be addressed whereby these posts are available at sub district level, then it will be easy for sub districts to have appointments. But if it’s not on the staff establishments, then it’s really a challenge to get these people appointed” (DR4).
“some of the provinces are now starting to look at where they can move resources to where they might be more effectively utilised. And, you know, if you start with psychologists, well maybe you can go onto OTs and to social workers and to other resources as well – maybe the nurses” (NR1).
“Attitudes are really a difficult thing to change, and you are not always there at the facility. You’ll find when you’re doing monitoring and evaluation, they will manage the client correctly but as soon as you turn your back…but we must also look at the factors why, why are people (not identifying mental disorders), (it is) their attitudes, at times it’s severe workloads, it’s other pressures that we are not considering” (DR4).
Financing
“going to be detrimental to implementing (the policy), it really will. I mean but I think our provincial head office knows that the way they are budgeting doesn’t make sense in today’s world any more, they know they should be getting a health economist in and really do an overhaul but, that hasn’t happened” (DR8).
Infrastructure
Medicines & technologies
“There is a tender process. There is a supplier that is contracted in and there are sometimes challenges that we will experience with suppliers not being able to supply on time or the adequate amounts and it impacts directly (at the) operational level. Clients will come to the facility and supplies wouldn’t be there, which again contributes to them defaulting” (DR1).
Participation & Collaboration
“There are areas that are already involved with Social Development in terms of providing community-based residential and day care services, including services for children with intellectual disabilities…but in other provinces and districts, Social Development doesn’t really play the role that is prescribed in that plan” (NR3).
“this kind of collaboration to take place at all levels, whereby even the executive managers, like heads of department, are to meet and talk about particular issues, they need to do that so that they can agree to say, for our Department this will be the way forward. So that when the implementers come in, it’s not about them having to pave the way forward for how they are going to work, it should have been cleared at a high level” (PR4).
“I was talking to a Prof from the University…and he said, but yeah but first of all you have to train people how to do local engagement! I said why? He said no, people don’t automatically know how to do this, you know, we assume, it’s just talking but it’s not just talking” (DR8).
Equity & Inclusiveness
Ethics & Oversight
Intelligence & Information
“we would request more indicators and data to be added. But we are competing with other programmes. And the health information system unit indicated to us that they are planning at reducing the number of indicators for all the programmes….it’s not convincing for them that we do use the indicators at all the levels” (NR3).
Accountability & Transparency
Principle
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System level
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Sub-theme
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Challenges
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Enabling factors
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Recommendations
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Rule of Law
| Governance | Legislation | Mental health care act lacks guidance on people with disabilities | Synergy between mental health care act & mental health policy | Clarify roles & responsibilities with respect to the act, particularly across sectors |
Enforcement | Insufficient training affects compliance & implementation | Provide sufficient training on mental health legislation & policies | |||
Strategic Direction
| Governance | Development of policies & plans | Lack of communication about the policy at district level | Including strategic planners in development of plans | Build capacity to translate policies into plans at provincial and district levels |
Insufficient capacity to translate policies into plans due to shortage of staff and skills | Champions who can advocate for mental health Support from national office | Include strategic planners in development of mental health plans | |||
District mental health teams used as a unit for planning | Use district mental health teams as a unit for planning at local level, provided they are sufficiently capacitated and supported | ||||
Implementation of policies & plans | Poor coordination in terms of planning & service provision between national, provincial & district levels | Clear understanding of roles & responsibilities with respect to implementation | Capacity building of managers in change management to facilitate the implementation of integrated collaborative chronic care, including mental health | ||
Disparity between provincial mental health units in terms of capacity | Coordination between different stakeholders | Clarify roles & responsibilities of different stakeholders & improve coordination | |||
Lack of qualified managerial staff to push implementation at ground level | Address resource and capacity disparities between provinces | ||||
Insufficient budget & inadequate infrastructure | |||||
Responsiveness & Integration
| Governance | Prioritisation of mental health | Mental health still not a priority in the face of many other health needs | Drive by national to develop policy seen as a step towards prioritisation of mental health by national government | Providing training and support in PC101 can facilitate integration of mental health into primary health care |
Mental health seen as separate from other health needs | Education & awareness raising about the benefits of integration among service providers & service users could facilitate buy-in | ||||
Service Delivery | Integration at facility level | Uncoordinated planning & lack of intersectoral collaboration hinders integration Negative or misinformed perceptions about mental health and integration Insufficient involvement of service providers in planning, leading to lack of buy in Lack of training on mental health among health professionals & lack of patient-centred orientation Inadequate follow-up between primary care facilities and tertiary institutions Resistance from mental health care users | PC101 can facilitate integration Recognition of benefits of integration in terms of patient outcomes & addressing comorbid conditions | Establish collaborative arrangements between the Department of Health, Social Development, Housing and other sectors at national, provincial and district levels, that establish clear roles and responsibilities with respect to community-based psychosocial rehabilitation (service provision & funding) Redistribute resources from tertiary-level institutions to community-based services | |
Integration at community level | Services still concentrated at institutional level Lack of coordination and role clarification between sectors Shortage of community-based centres & poor accessibility Shortage of human resources to deliver community-based services Resistance from families & communities | Redistributing resources from hospitals to communities Utilising DSD social workers, community health workers and NGOs in delivery of services, but need to be sufficiently capacitated Committed leadership driving this | |||
Effectiveness & Efficiency
| Human resources | Human resources capacity | Shortage of health professionals & specialists to implement policy High workload and high staff turnover Inflexibility of existing staff structures to accommodate creation of new posts for district mental health teams Budget not sufficient to appoint more staff Negative attitudes and resistance among staff to treating mental health | Building staff confidence & competence to treat mental health Creation of district mental health teams facilitated by using existing systems Flexibility & using existing resources more efficiently could facilitate establishment of district teams Adapting training to be more primary health care focused Entering into agreements with local universities to train graduates | Given shortage of mental health specialists, particularly in rural areas, need flexibility in creation of district mental health teams (e.g. pooling resources across districts) Collaborate with Department of Education to adapt training and train more graduates An orientation to comprehensive care and change management is needed |
Task sharing | Insufficient specialist capacity to provide training and support in PC101 | In-service, on-site & continuous training for health professionals | Task sharing can relieve pressure on health professionals | ||
High workloads mean poor uptake of PC101 Lack of clarity regarding responsibility for supervising & monitoring implementation of PC101 | District mental health teams could provide supervision & support Community health workers, home-based care workers and ward-based outreach teams to provide screening & follow up Role clarification for counsellors to include mental health | PHC personnel trained in PC101 need mentoring and support in implementation of mental health aspects Use lay counsellors as they will relieve pressure on health care professionals, but provide adequate role clarification, training and supervision Use community health workers, home-based care workers and ward-based outreach teams for screening, referral and follow up | |||
Financing | Financing | Funding for mental health is inadequate Disparity between provinces in terms of resource allocation for mental health Historical budget allocation is problematic | Using existing resources more efficiently – phased approach and piggy backing onto other programmes | Use existing resources more efficiently through, for e.g. a phased approach and piggy-backing onto other programmes Revise way of budgeting from historical to activity-related allocation of funds | |
Infrastructure | Infrastructure | Quantity and quality of existing infrastructure not sufficient Lack of coordinated planning between relevant sectors Lack of adequate counselling space in primary care facilities Breakdown in communication between hospitals, clinics and pharmacies results in inconsistent provision of medication Inadequate availability of PC101 guidelines | Creative ways of making more counselling space available – e.g. gazebos and park homes Extra steps taken to ensure patients get medication (e.g. delivering to patients homes) Master file of guidelines available at facilities | Include planning for counselling space within PHC facilities Improve communication between clinics, hospitals and pharmacies with respect to drug prescriptions and delivery systems Ensure availability of master file of protocols and guidelines in each facility | |
Participation & Collaboration
| Governance | Inter-sectoral | Lack of coordination & collaboration between sectors due to different roles and mandates Coordination does not filter down from planning to implementation level Reluctance of some departments to get involved in implementation of mental health policies & legislation | Clarify roles & responsibilities of different departments with respect to mental health Build capacity & commitment at leadership level to create stronger partnership between DSD & DoH; formalise structures to improve collaboration Train managers in stakeholder engagement | |
DoH – DSD | Lack of coordination in terms of planning & provision of psychosocial rehabilitation services Lack of clarity of roles and mandates | Capacity building & commitment at leadership level could help to build stronger partnership NGOs are the implementing arm of DSD – DoH could work through them | Build capacity among health professionals and managers to advocate for mental health | ||
Governance | With service users & service providers | Inadequate consultation with service providers Some resistance to policy directives among service providers | Service users consulted through clinic committees and advocacy groups and through holding imbizos to get community input | Improve consultation with service users through service user groups and communication with caregivers | |
Uncertainty about how to best consult with service users Need for greater involvement of families & service users in treatment decisions | Build capacity of service user groups to engage in advocacy, and allow for formal inclusion in collaborative structures | ||||
Equity & Inclusiveness
| Governance | Access | Size & remoteness of some provinces & districts make access to services difficult Disparity between districts in terms of number of facilities and community centres Lack of qualified staff to provide mental health services a barrier to access | Integrated care increases access Public education programmes a means to increase awareness; helplines a means to increase access | Integrating mental health into primary health care could increase access Raise awareness among service users regarding how and where to access services |
Stigma | Policy framework is not clear on how to address stigma Disparity between provinces in terms of how stigma is addressed Shortage of staff to drive these programmes Negative perceptions, driven by ignorance, lack of awareness and fear, a barrier to reducing stigma | Integrated care could reduce stigma Support from provincial and district managers could facilitate implementation of stigma programmes Using different forms of media to reach communities Support groups can empower users | Integrating mental health into primary health care could help to reduce stigma Implement anti-stigma campaigns in the community, with support from district and provincial managers Mass awareness campaigns using different forms of media, role models and support groups to reach and empower service users; clarify whose responsibility it is to do this | ||
Ethics & Oversight
| Governance | Ethical treatment | Disparity between provinces in terms of functionality & effectiveness of Mental Health Review Boards Staff shortages a hindrance to carrying out inspections & following up grievances Lack of indicators against which to evaluate performance | There are a number of mechanisms for ensuring quality/standards in health services in general, applied to mental health | Address disparity between provinces in terms of functionality and effectiveness of Mental Health Review Boards Introduce the WHO Quality Rights project and capacitate Mental Health Review Boards to use the toolkit to ensure that standards are being met |
Ethical research | Research units and ethics committees at provincial and national levels oversee health research National Health Act provides guidance on procedures for conducting research with health care users | ||||
Intelligence & Information
| Information | Lack of monitoring mechanisms/systems at all levels Indicators for mental health in the health information system are not sufficient in terms of quantity or quality Inadequate human resources to carry out M&E | Provincial and district officials need to play a role in monitoring quality of mental health services Build M&E capacity at all levels and improve the use of indicators to inform policy and service planning | ||
Include indicators for mental health in the health in the health information system that provide sufficient information to inform intervention decisions and assess quality improvements |