Why does a Rural Mental Health Campaign exist?*

The Rural Mental Health Campaign (RMHC) was started in 2014 by a group of organisations including RHAP who are advocates for rural health as well as mental health care services in South Africa. Today’s active members of the RMHC are RuRESA, the South African Mental Health Federation, RHAP, RuDASA, Cape Mental Health, PRIME and the Psychology Department of the University of Stellenbosch. The RMHC members are concerned about the lack of access to mental health services and the lack of progress made in the implementation of the National Mental Health Policy Framework and Strategic Plan (NMHPF) which was released in 2013. The RMHC is also advocating for policy to be “rural proofed” so that the context and specific needs of rural populations be considered in strategic and operational planning for mental health care service delivery. Many rural people with mental health issues in rural areas live in the direst circumstances without access to mental health care.

What have we done so far?

Our 2015 report included the testimonies of mental health care users from rural areas who shared the challenges they face in accessing care. The findings showed that rural mental health care services are still largely inadequate, due to the inaccessibility of existing services, budgetary constraints, psychiatric medication shortages, insufficient human resource capacity and a lack of integrated care, as well as stigma and discrimination. The RMHC may not have been successful, or even have reached the Ministerial advisory committee, if it didn’t appreciate the important role of mental health care users in their own self advocacy and that no interventions should be planned without their voices:

“I need to see the psychiatrist to discuss my case as I would like to know if I am better now. I am just drinking medication again and again forever. I would like to know the name of my illness and what caused it.”

“People see mentally ill people as being mad and should be locked away in an institution”

“Sometimes the medication is not available and I am referred to the hospital that is far and even there the medication is not available. Two months I did not receive Haloperidol as it was not available.”

“To access ARVs is not a challenge – it is easily accessible. Doctors are always available when I am booked for an appointment. All services are in place. The challenge that I have is that mental health hospitals are very far from where I live. I need to take one or two public transport to reach the place.”

The RMHC has made a submission to the South African Human Rights Commission for the upcoming Hearing in the second half of 2017. Follow this space for updates and to access the submission in due course.

Campaign goals
The overall objective of the RMHC is to see good mental health care being provided as part of PHC in every rural community. The testimonies of mental health care users demonstrate how existing PHC services fail to address the complex needs of someone with mental illness, with serious consequences for rural communities.

Recommendations

The core recommendation for overall strategic orientation is to translate the National Mental Health Policy Framework and Strategic Plan (2013–2020) into provincial strategic and operational plans. Systematic considerations must be made in the design of these provincial strategic and operational plans to ensure that rural actualities are adequately planned for. Provinces’ plans must include targets, indicators, budgets and timelines that support the realisation of quality mental health care services for rural populations. Furthermore, as outlined by national policy, provinces’ health departments must monitor and evaluate the implementation of the National Mental Health Policy Framework and ensure the provision of a sustainable budget for mental health services to develop the capacity of mental health departments and supporting structures. The Rural Mental Health Campaign also proposes the following recommendations in support of the commitments made by the NDoH to improve the mental health care system:

  1. The National Mental Health Policy Framework tasks provinces should accurately collect and use minimum datasets for mental health that are integrated into the general health information system at all levels. The Campaign recommends that the frequency of admissions to inpatient psychiatric facilities should be included as an indicator to monitor and evaluate the relapse rate of patients accessing inpatient psychiatric facilities. These indicators will help provide data to track improvements in the move towards community-based models of care.
  2. The findings on the shortage of health care workers delivering mental health care services in rural areas are of major concern. The Campaign calls on provinces to formalise human resources strategies that are favourable to rural mental health care settings and are in line with the commitments of the National Mental Health Policy Framework. Provinces’ plans must include targets, indicators, budgets and timelines that support the realisation of quality mental health care services for rural populations.
  3. Complementary to this human resources strategy, task-sharing and transdiagnostic community-based models should be explored in these settings in order to increase the reach of mental health care services and to ease the burden on specialist mental health care workers. Additionally, registered counsellors, counselling psychologists, mid-level rehabilitation workers, clinical associates and other already established registrations should be adequately trained in public mental health and seriously considered as a recruitment profile of the DoH. These profiles should be used to task-share services and essentially expand the coverage of mental health care services in rural settings. More focus needs to be placed on the absorption and recruitment of mental health care specialists in rural settings.
  4. There is a need for mental health care services to extend beyond the physical parameters of rural clinics due to sparse rural populations and the limited number of mental health care professionals working in these rural areas. Transport must be prioritised for outreach services to further increase the reach of health professionals and their ability to offer community-based services and support. Furthermore patient transport vehicles are essential in creating accessible services and play a vital role in the promotion of mental health and prevention of relapse in rural areas. The availability of transport from rural clinics to Community Health Centres and district hospitals will greatly increase access to mental healthcare services.
  5. Those working on the Campaign are greatly concerned by several testimonies of stock outs of psychiatric medications. More attention by all mental health stakeholders needs to be placed on ensuring that all psychiatric medicines, as provided on the standard treatment guidelines and essential drugs list, are available to people living in rural communities.
  6. Stigma and discrimination remain significant barriers that continue to prevent mental health care users from accessing mental health care services. The National Mental Health Policy Framework speaks of mental health care user participation in implementing the policy, but from the testimonies it is clear that this is not happening. For mental health care users to become effective participants in the implementation of the National Mental Health Policy Framework and to fully enjoy all their constitutional rights, active measures must be taken to empower mental health care users. Consultation and collaboration should extend to mental health societies and mental health care users on the most effective and efficient ways to reach communities in rural areas. Awareness must not only be targeted at the community at large, but also among all health care workers and must include training on the rights of persons with mental disability. Furthermore government must support advocacy initiatives of community-based organisations. It is integral that a national public education programme for mental health extends to rural settings and is integrated within district services.
  7. Mental health services must be integrated into HIV/AIDS programmes and services at PHC and district levels (WHO, 2008). Primary and district level staff who manage patients living with HIV must routinely assess and treat for mental, neurological and substance-use disorders. Furthermore, community health care workers should be adequately trained to screen for mental health-related disorders, provide basic counselling and referral.

Please see our 2015 report for more information and testimonies of mental health care users, with chapters in budgeting for mental health, HRH, stigma and discrimination, the role of rehabilitation services, access to medicines, and a pledge of support by the Treatment Action Campaign.

Contact the RMHC:
Shannnon Morgan, Rural Rehab South Africa (RuReSA), Campaign Chairperson, morgan.shanny@gmail.com
Mafoko Phomane, Rural Health Advocacy Project (RHAP), Campaign Secretary, mafoko@rhap.org.za

* Excerpts from the Rural Mental Health Care Campaign Report (2015) and RMHC submission to the SAHRC (2017)