Mental health leadership and patient access to care: a public–private initiative in South Africa

The stigmatization and prejudice experienced by people living with psychiatric disorders remains one of the most pressing challenges in the care of the mentally ill worldwide. Despite the growing awareness of the importance of mental health as a public health and development issue in low and middle income countries, people with psychosocial disabilities continue to be marginalized-socially, occupationally and as beneficiaries of government attention and development aid. Cognizant of the aforementioned issues, the 2014 Declaration on Mental Health in Africa [1] specifically stated that “There is an urgent need for political vision, commitment, and leadership at the highest level to encourage national dialogue on mental health.” Such a pronouncement resonates with the notion of developing leadership capacity at a mental health professional level with the intention of promoting enhanced patient care through effective advocacy. In South Africa neuropsychiatric disorders are ranked third in the national burden of disease [2]. It is estimated that one in six South Africans are suffering from a common mental disorder [3] yet mental health is given little attention as a national health priority [4]. The South African National Department of Health (NDoH) itself has acknowledged that “for the majority of people with mental health problems there is just no care” [5]. Similar treatment gaps have been noted in many other countries both within and beyond Africa due to low prioritization, poor funding and inadequate human resources for mental health globally [6]. Mental illness contributes to high levels of absenteeism, poor work quality and impaired productivity. However, mental health care continues to be underfunded and under supported. The NDoH currently spends only 4% of its budget (about ZAR 9.3-billion, equivalent to approximately USD 660 million) on mental illnesses. A ministerial level Government official has described mental health as the “Cinderella of the health system” [7]. In the Foreword to South Africa’s National Mental Health Policy Framework and Strategic Plan 2013–2020 it is emphasized that good mental health will contribute substantially to economic and social development [8].

Mental health care professionals (MHCPs) are uniquely placed to advocate for their patients. Engaging with hospital administrators, government departments and funders has become an integral part of patient care. Yet in spite of this expectation, MHCPs are ill-prepared to take on an advocacy role. The focus of conventional medical training is generally on individual patient and family interactions. There is little formal training directed at leadership and managerial skills to promote service development, policy planning or building partnerships for action.

Recognizing the potential for mental health care professionals to provide leadership in transforming the health care environment and ensuring better access to care for their patients, the Department of Psychiatry at the University of the Witwatersrand (Johannesburg, South Africa) embarked on an innovative mental health leadership training program conducted in the public mental health sector in collaboration with Sanofi South Africa [9]. A similar leadership and advocacy program has been undertaken in West Africa, i.e. the “Mental Health Leadership and Advocacy Program (mhLAP)” [6]. Although the ultimate goals for the two programs were similar, developing and empowering relevant role players, there were significant differences in approach. Whilst the mhLAP aimed to effect change by promoting the development of advocacy efforts, in the current program an advocacy agenda was embedded in a practical real life project which was pursued within a structured, facilitated process.

Stigma in mental health traditionally focuses on that experienced by patients given the putative impact of stigma on access to care. The focus of the current programme did not have a patient/community orientated approach but rather one of engaging and empowering mental health professionals in the field. The role of stigma in influencing resource allocation would appear to require a broader role for psychiatrists within the context of patient advocacy. Public attitudes towards resource allocation have demonstrated a greater willingness to endorse cuts for spending on psychiatric rather than medical conditions [10]. In addition, mental health care professionals themselves are disempowered by fellow colleagues from outside of psychiatry through denigration [11]. Whilst a recent review of public attitudes appears to show more favourable attitudes towards both psychiatry and psychology [12] disempowerment from within the system needs to be addressed if mental health is to receive the necessary attention and commitment of resources. The specific intention of the current program’s approach was to enhance health care professional leadership skills and enable them to more effectively address the need for mental health to be accorded appropriate priority [13].

This is a descriptive report of a process rather than a study per se. The programme did, however generate both quantitative and qualitative data at various longitudinal points which are reported. These relate to evaluation of content and subjective self-assessment.

This program was designed to equip mental HCPs with the leadership and managerial skills to better enable them to advocate for their patients. It offered a novel, collective and supportive environment outside of the isolation of the workplace in which the execution of concrete plans with defined objectives could be discussed and analysed. Based on individual comments and project outcomes it appears that the programme objectives were achieved. Skills have been acquired, confidence built and leadership roles undertaken.

Participants are now extensively networked both internally and externally. They have established relationships with a number of health professional colleagues in numerous locations. They have learnt to engage more successfully with administrators and decision makers within their institutions and referring health care facilities. As permanent employees in the state health sector, they will continue to utilize these skills in effecting change to the broader benefit of the health services and their patients.

The program has done far more than equipping individuals. The six projects themselves have achieved considerable success. Systems have been improved and additional resources drawn in. Stakeholders have been engaged and partnerships forged. Changes have been embedded and have grown endogenously in each participating health district. The momentum is now independent of the individuals who initiated the changes.

From a financial perspective, the projects have been self- sustaining with no need for the commitment of additional budgetary resources. By targeting MHCPs already inserted into the health services, and tackling participant-identified real-life situations as practical training projects, there have been minimal ongoing costs, and no need for additional staffing support. As a training initiative the concept is transferable. Participants have identified local needs and structural constraints, ensuring that the content is locally relevant.

The program has been impactful and widely acknowledged, both locally and internationally following presentations in various forums, most recently at the World Psychiatric Association International Conference 2016 in Cape Town, South Africa and the 2016 World Association for Social Psychiatry Congress in New Delhi, India. The need for a public mental health agenda within South African psychiatry has repeatedly been raised [23, 24]. The inclusion of public mental health leadership training in the specialist training curriculum of the College of Psychiatrists, a direct outcome of the Mental Health Leadership Training Programme, goes some way to addressing this with a clear intention to broaden the pool of health care professionals who are better equipped to engage in patient advocacy.

As this was an educational and empowerment programme rather than a study, it is difficult to exclude the possibility that at least some of the activities and personal development that we have documented would not have occurred independently, or as a result of some other intervention. We can say with confidence, however, that the programme was a catalyst to the projects themselves, as entry was based on the generation of a project idea. We have to assume that the successful execution thereof was at least in part a consequence of the mentor supervision, and intermittent workshops designed to analyse successes and overcome difficulties. The very enthusiastic ratings and qualitative responses expressed by individual team project members (see “Results” section) indicates that they themselves attributed their enhanced skills and leadership development to the initiative itself. The value that the participants attributed to the programme is reflected in the remarkable achievement of 100% attendance at each of the five 6-monthly workshops extending over a period of 2 years.

To the extent that the selection process—via academic teaching institutions and their satellite services—targeted motivated, committed individuals, the outcomes may not be generalizable to clinicians in the discipline generally. However, it is anticipated that the introduction of public mental health into specialist training will enhance the awareness, capacity and inclination of the broader mental health care community to pursue similar initiatives.

The aim of the programme was to build leadership capacity amongst MHCPs in a resource limited setting. It was a clinician-driven, patient-focused, mentor-supported training program, driven by a public–private partnership. The process took a number of years from conception and development (2011, 2012) to implementation (2013, 2014), culminating in the integration of public mental health into the specialist training curriculum and a national Public Mental Health Forum in 2015. A further Forum is scheduled for 2017 with the intention of this being a 2 yearly event. The programme has been successful both at the individual and organizational level. Mental health care professionals have been empowered, increased resources have been secured and greater efficiencies introduced into the health system. We now have 15 mental health clinician advocates in multiple locations who are potential drivers of change in the health sector.

The outcomes went well beyond personal development, improved services and better resources, ultimately influencing national public mental health education and training through curriculum development of specialist training. The Mental Health Leadership Programme has been the catalyst for training of emerging psychiatry specialists in public sector advocacy. These graduates will now be better equipped to drive change in the public mental health sector. The net result should, in time, see enhanced services and better resource allocation for the vast numbers of patients with mental illness in South Africa.