Macro fiscal and Health-system context
Since 2012 public-health expenditure has only increased by an estimated 1.8% per year [
11,
21], with expenditure on health currently at 13.5% of total government expenditure and unlikely to reach the Abuja target of 15% [
11,
21] This is coupled with marginal economic growth of 1.3% in 2017 [
22] and low growth projections forecasted until at least 2020. These figures are concerning in the face of a growing population of uninsured South Africans who rely on the public health system, rising by an estimated 1.52% per year [
11]. According to Statistics South Africa (STATS SA), 86% of the total spend on healthcare is spent by provincial governments, tasked to manage the nation’s public healthcare system, comprising of 422 hospitals and 3841 clinics and health centres [
23]. The main expenditure items were hospital services (62%), public health family planning and disease detection (33%), and ambulance services (4%) [
23]. The in-depth interviews raised a number of concerns with respect to how the government has contained costs in the health sector following the economic recession, using strategies such as: limiting personnel numbers, centralised tendering for medicines and delays in major capital projects.
Further adding to this pressure is the implementation of
National Health Insurance for South Africa (NHI) [
5,
24] which represents an upward trajectory for health expenditure in the face of fiscal constraint [
11]. There is concern over the way in which the NHI pilots have been run and many stakeholders believe that it has been a wasted opportunity. Of note is the exclusion of key constituencies participating in NHI implementation including community health worker and nurses at the expense of powerful private sector bodies leading the process. As explained by a public financing expert:
“I’m very disappointed at how the NHI pilots have been run… they’ve been focusing on interventions related to maternal and child health. Why is there not a psychiatrist in the clinical specialist teams …because [mental health] doesn’t have as direct an impact on mortality and I think it’s been an absolutely wasted opportunity….to deliver comprehensive services that actually address the whole range of issues”.
Despite the adoption of the South African MHPF (2013), health budgets and broader health sector transformations have not followed to actualize the contents of the policy [
4,
25]. Most critically, there remains a lack of consistency between the content of, and priorities outlined in the MHPF and those expressed in the NHI Policy [
13,
26,
27]. The Guidelines have included mental health in the comprehensive package of services being re-engineered in the primary health system, and have specified the work of the Community Health Workers (CHWs) to include psychosocial support, adherence support for chronic conditions and referral support to social and health services. However, the training programs and manuals that have been developed and rolled-out for both for the CHWs and their team leaders have not included training on mental health [
27‐
29] and up until 2015, households profiled by the outreach teams reported no assessments or referrals for mental health. [
28].
Similarly, the implementation of the Integrated School Health Policy (ISHP) introduced in 2012 has neglected mental health service provision [
30]. Notably, across all of the ten pilot sites, the ISHP did not identify a single learner with mental illness or substance use disorder, despite the inclusion of the identification of cognitive and related developmental impairment in the range of services provided by the ISHP, among numerous other mental health services [
28,
30].
There are a multitude of factors that have weakened the provision of mental health services in South Africa, most critically the lack of human and financial resources to address treatment gaps [
10,
31,
32], limited routine information systems to understand the true burden of mental disorders and utilisation patterns and high levels of stigma [
33] As a result of poor access to good quality primary mental health care, the entry level for accessing mental health services at present is mostly at an inappropriate level of care (tertiary and specialist psychiatric services) [
10,
27]. This has significantly contributed to the high costs of health care and the inefficiency of the health system [
27]. This has also meant that care-seeking typically occurs when patients experience very severe symptoms, largely as a result of untreated mental illness, and often require long-term institutionalized care. Approximately two thirds of discharged patients (from psychiatric facilities) are readmitted, and largely remain institutionalized without much potential of returning to their communities [
34,
35]. This is largely due to limited availability of well-resourced community-based residential and day care service to manage mental health care users after discharge, coupled with the impact of poverty on households, with many families unable or unwilling to care for family members after discharge [
36].
While in-depth interviews acknowledged the significance of the policy effort, the key blockage has been a lack of budget allocations at the provincial level to allow for the implementation of the MHPF. As one interviewee explained:
“…without explicit earmarking of funds there is no way of guaranteeing the actualization of the MHPF, particularly when considering South Africa’s decentralized fiscal system and the current environment of strained fiscal capacity”.
Most stakeholders also acknowledged the biggest hurdle has been at provincial implementation, and the very institutionalized model of mental health care continues to persist with services and resources concentrated in hospitals. As clarified by one respondent from the NGO sector:
“…we find that…implementation in terms of the provinces…we can’t get any go-ahead, even if there’s policies at National or buy-in from National…provincial implementation is where the blockages are…so it doesn’t really help to have a policy”.
Similarly, a public financing expert reaffirmed this view clarifying that:
“…the vast majority of money for health services comes through provinces. And your battleground is every single province… who are currently struggling to actively fund existing services”.
Both the MHPF and the Mental Health Care Act (MHCA) (2002) explicitly mandate the role of the district hospital as the first point of contact for mental health care users (MHCUs), and assigns the responsibility of ensuring that MHCUs are assessed and provided with ongoing referrals to more specialist treatment within a 72-h period [
4,
37,
38]. Presently however, the majority of district hospitals in the country are not equipped with the infrastructure required to safely admit MHCUs for a 72-h observation, nor are they equipped with adequate room space for group therapy and self-help groups or workshop space for occupational therapy, as mandated by the MHCA [
4,
39]. Further, the White Paper on the NHI (2015), has specifically excluded Psychiatry and/or Mental Health services from the four cited disciplines on work to be provided at the District hospital [
27,
39]. This is in contradiction to efforts to integrate mental health services at lower level services to ensure wider access to care with district hospitals meant to serve as the first point of care for mental health care users.
Stakeholders mentioned that there has been little capacity for District Management structures to engage with mental health issues. The current tiered structure of the healthcare system, and the commitment to greater autonomy at the district level, in the context of ambitious reforms such as the NHI—“has created a situation wherein the success or failure of healthcare reforms will largely revolve around the strengths and weaknesses of district management” [
40]. As one stakeholder noted:
“…[they] don’t have the knowledge of what they are required to deliver…there are no measurable deliverables” associated with the MHPF for the district level, making it a very low priority for overburdened district health management teams”
Challenges to increased public and mental health financing
There is a lack of data available for mental health financing in South Africa, with Government being the main source of funding through tax-based health budgets [
41]. Provincial and national budgets for mental health services are not reported or routinely available. Based on modelled estimates (for expenditure on psychiatric hospital level services only), South Africa spent an estimated $59 million (US$ 5.94 per capita [
41]) on mental health services in 2005 [
42]. The National Government of South Africa uses two types of transfers, conditional grants and unconditional provincial equitable share funds, to send money to provinces in South Africa. Presently, South Africa does not have a ring-fenced budget for mental health and funding falls under general health allocations of the equitable share. This means that provinces receive a set amount of funds from the national revenue, based on a provincial equitable share formula, and resource allocations to health and to specific health programmes are therefore determined by the Province’s own priorities.
While this approach to financing is consistent with global trends of decentralizing expenditure responsibilities, stakeholders felt that it has contributed to a situation in which increases in resourcing to Provinces do not guarantee use of these resources for their intended purpose, and these provincial decisions often redirect additional resources for health to other needs. Provinces are not required to report on expenditure for specific health programmes paid for through the equitable share transfer, making it difficult to assess whether Provincial budget priorities are aligned to National priorities for health. Stakeholders from all sectors believed that motivating for mental health to be included in provincial equitable share is therefore unlikely to yield any measurable increases in revenues for mental health, or any measurable improvements in the mental health system.
Further, the absence of ring-fenced allocations for the development and maintenance of the specialized psychiatric service at the tertiary level has created a number of substantial challenges: the psychiatric hospitals are outdated and in disrepair; there is an acute shortage of mental health professionals available to deliver this service; these facilities are unable to invest in the advancement of their scope of service (for example, child and adolescent psychiatry, neuropsychiatry and old age psychiatry) [
34].
The NGO sector also reported severe challenges with respect to financing and it was estimated that 50% of the mental health NGOs in South Africa are struggling with sustainability at present. To secure funding from the Department of Social Development and/or Health, most mental health NGOs in South Africa have needed to commit to the delivery of statuary interventions, not mental health services. The NGO stakeholders believe that due to these models of funding, their mental health services become diluted and unspecialized—focusing on family planning, or foster care, or services to the aged.
Options for change for a scaled up mental health service in South Africa
Budget planning and allocations for mental health
The process of health budgeting has changed in the past 10 years, motivated by increased pressure after the 2008 recession and increased complaints around fiscal federalism and the lack of control over the use of funds by the Minister of Health. The respondent from the NT explained:
“…increasingly, rather than just giving an unlinked equitable share increase and allowing provinces to decide where to allocate these increases, the role of NT and the National Process has become more prominent…increases in budgets for major changes are hinged on the capacity and technical expertise that program managers possess in order to put together an effective budget bid…one shouldn’t be too pessimistic about funding possibilities….we have funded many things…[but] we’ve had very few mental health budget bids…a lot of programs don’t have economic capacity… they know what they want to do, but they don’t quite know how to convert it into a plan and cost it…”.
Recently, the NT funded an HIV and TB investment case, representing the first time any HIV and TB investment case was funded. A finance-level state stakeholder suggested that there is reason to be optimistic and that despite prevailing opinions being that there is simply not enough money, there are funds that could be made available if mental health tabled a series of big budget bids as was done for TB and HIV. Should a budget bid for mental health be successful, it would ensure an escalating resource envelope for mental health. As one respondent explained:
“…we’d have to tell provinces, “this money is for doing the following” …and the more specific…detailed and measurable it can be…in terms of the way you’ve costed it, the easier it is for us to know whether the provinces are using the money for that.”
The likelihood of seeing a successful budget bid for mental health was challenged somewhat by the health-sector stakeholder, who believed that demonstrating cost-saving and returns on investment for mental health does not necessarily guarantee it will be funded:
“…even if we can demonstrate that [investing in] mental health makes sense…in this climate …unless something very dramatic happens economically in our country, and that doesn’t look very likely at this point in time…there isn’t going to be a lot more resources to give around…what one really needs to be looking at more is “how does one make better use of resources” rather than “how do we get more resources”.
Nonetheless, the respondent from the NT did also mention that a key criterion for evaluating these bids is the ability to demonstrate efficiency gains and value for money, meaning that efficiency is a priority for both health and the finance-sectors. Some opportunities for improving efficiency that emerged from the interviews included: improved matching of human resource posts and budget with workload; a review of hospital platforms with activities that support shorter length of stays and greater outpatient care, and; reducing budgets for new facilities, with a focus on dedicating budgets to ensure existing facilities that are only partially operationalized become fully operational.
A further difficulty to the budget planning process was identified as the very medical model used by the DOH, and the difficulty in conceptualizing developmental models—which leads to very little resourcing for psychosocial rehabilitation, outside of the licensing of these facilities with most resources going directly into hospitals. Yet this service is a critical component of treatment for the service users. Respondents noted the need for increased advocacy among policy makers to ensure that both developmental and medical models of mental health care are recognised, with adequate recognition and resources dedicated to community psychosocial support.
At present, stakeholders reported that there is no way of monitoring mental health financing in the public sector outside of specialized hospital care for mental health. The NHI model is intended to include improved expenditure tracking and mechanisms by which the NHI Fund will be able to associate services at all levels of the health care system with the resources made available, however these mechanisms are still not fully developed and little information has been provided to these stakeholders regarding how and when this improved monitoring system will be implemented. It is hoped that this will ensure the health system can be more responsive and accountable.
Strengthening mental health systems
Stakeholders who were interviewed highlighted a series of mental health system reforms that should be prioritized. These included: the explicit inclusion of mental health services in NHI implementation efforts through the expansion of the mandate of District (first referral) hospitals to include mental health services in their priority services; secondly, investing in infrastructure upgrades required to safely treat patients who are admitted for 72-h observation, as per the MHCA (2002); ensuring the availability of mental health specialist staff in District and community health services whilst allowing for psychiatrist input into district management teams and ensuring that clinical specialist teams include at least one psychiatrist; and investing in targeted mental health training for all generalist staff particularly in mental health screening and diagnosis including anti-stigma training. Due to the critical shortage of psychiatrists working in the public sector, this strategy would necessitate contracting of private providers and the provision of an explicit reorientation program to ensure they commit to the delivery of therapies based on a public health approach, and; acknowledgment that particularly in rural settings, a Medical Officer with a Diploma or an interest in psychiatry may be the only available option in the short-term.
The potential for the private sector to address the chronic human resource shortage for mental health services in the public sector was also emphasized by a number of stakeholders. Considering the discussions around the NHI, accessing private sector resources, including human resources, would be facilitated through contracting the private providers through the NHI central fund.
“…when you look at how much is being spent in the private sector and how many people are in the private sector dealing with mental health, it’s pretty substantial… if we could unlock all of those people… …if they moved away from, sort of doing long-term therapies to doing more community-oriented work and to looking more at preventive interventions and so on, there’s huge resource”.
There was consensus that there is interest from private sector psychiatrists and psychologists to contribute their services and time to the public sector, however challenges have already emerged with respect to the provider payment contracting through the NHI implementation efforts, with provinces not having the resources to pay the private providers for their time. Details of the strategic purchasing arrangements through the NHI Fund are still unclear, however would impact on the success of drawing on the private sector. As one respondent explained:
“…[only] on their terms…where and how their services are provided and also at what price…and that’s not affordable”.
The interviews also emphasized the need for an integrated multi-sectoral response to community-based service delivery for mental health:
“…we have education, we have health, we have social development, we have public works, we have transport and all these must come into one package for mental health services, because only then we have adequate resources”.
According to the respondents, strengthening community-based service delivery must to be complimented with an empowerment of mental health care users through education, particularly for those with intellectual disabilities and severe mental health problems. In addition, all stakeholders believed there is a need to engage with communities to establish their own needs, and to understand the range of NGOs operating within their districts to ensure a more efficient and targeted model of service. There was a strong importance placed on capitalizing on the capacities of all stakeholders involved in mental health service delivery into a unified, efficient service.
Financing mechanisms
Innovative financing mechanisms do not serve as a significant revenue generation source for the health sector, and although these mechanisms are exciting and innovative, their contributions are marginal in the broader sense, according to the respondent from the NT:
“…so called “innovative financing” is a bit fringe in a way…that sits on the margin… it doesn’t really matter whether funding is raised through VAT or personal income tax or company tax, or alcohol tax or tobacco tax … in general the source of revenue is not so relevant for the health sector…what’s important is that there is sufficient revenue for the service”.
On the other hand, while conditional grants from the NDOH make up only 20% of provincial health department budgets, they play a very important role in provincial health care delivery because are used by the National government to protect special health programmes or start up new programmes. This commitment over the next several years could ensure that Provincial departments submit detailed business plans for the allocation of funds to various mental health systems activities, aligned with performance targets detailed in the MHPF. The NDOH would then be responsible for approving these business plans and transferring funds to provincial or local departments for their implementation. This mechanism will require that Provinces and local governments report on their expenditure against specific mental health targets. In the short term, the priority areas for activities funded through a conditional grant should include the development of community based mental health services in South Africa.
In the long term, the transition to the NHI model was highlighted as the main mechanism to generate additional funding for health and could potentially play a key role in reversing the trend of low public health expenditure growth. NHI should increase public funding from around 4% of GDP to around 6% of GDP; the NHI is considered the best chance for increased funding for the health sector and further provides an opportunity for the provinces to purchase services from the private sector.