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Table 2 Mental health system governance challenges, facilitators & recommendations: overview

From: Health system governance to support integrated mental health care in South Africa: challenges and opportunities

Principle

System level

Sub-theme

Challenges

Enabling factors

Recommendations

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