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Putting a number on mental health costs

- Charlotte Matthews

Mental health costs should be counted in people, not rands and cents.

Woman and Child © unsplash

“The thought of suicide is a great consolation: by means of it one gets through many a dark night,” said Friedrich Nietzsche, one of history’s known depressives.

From depression (termed by Winston Churchill, another sufferer, as the “black dog”) to bipolar mood disorder, anorexia, epilepsy and schizophrenia, the prevalence of mental illness in South Africa is probably widespread and possibly even increasing, but no-one knows exactly what the numbers are.

What is known is that more than 90% of those who need public healthcare for mental illness are not getting it. As South Africa is caught in the grips of the Covid-19 pandemic and government takes the first steps towards implementing a broader health system, National Health Insurance (NHI), it is essential to ensure that the economics of good-quality treatment for mental disorders are properly understood and an affordable, appropriate service is delivered across the country.

Quantifying the problem

The last time the prevalence of mental health and neurological disorders,  such as epilepsy, in South Africa was quantified in detail was in the 2002-04 South African Stress and Health Study. This showed SA’s level of anxiety, depression and substance-use disorders was higher than in most other low- to middle-income countries, except for Nigeria and Ukraine, where there was likely to be underreporting. The reasons could have ranged from post-apartheid trauma to what was then the rapid spread of untreated HIV/Aids.

However, the study did not cover more severely disabling illnesses, such as bipolar disorder and schizophrenia. 

Dr Lesley Robertson, a Lecturer in the Psychiatry Department at Wits, says there are other sources of data on prevalence of depressive symptoms in South Africa, such as the National Income Dynamics Survey and the South African National Health and Nutrition Examination Survey, but there is no data on psychiatric illness.

Obviously, this poses a challenge for the government in trying to set a budget to treat severe mental illness.

The 2016/17 national survey, Mental Health System Costs, Resources and Constraints in SA, commissioned by the Department of Health, showed that the department was spending about five percent of its total public health budget on mental healthcare, which is in line with similar economies. However, there were big disparities between provinces.

The study showed that just over eight percent of those requiring public in- or out-patient care were receiving it. While 86% of spending was on in-patient care, about a quarter of those patients were re-admitted to hospital within three months. This suggests hospital care has limited efficacy on its own. It needs to be supplemented with community-based care, says Robertson.

Community care

Community-based services are considered the most effective approach to dealing with mental illness, as shown in a  2019 paper, Strategies to strengthen the provision of mental healthcare at the primary care setting: An Evidence Map, led by Witness Mapanga from Wits’ Centre for Health Policy in the School of Public Health. Yet, in most health systems in the world, community-based services are underfunded.

Dr Paul Stiles, Associate Professor in the Department of Mental Health Law and Policy in the Louis de la Parte Florida Mental Health Institute at the University of South Florida, US, who visited  Wits University on the Fulbright Specialist Roster in March, said the US de-institutionalised mental healthcare in the 1960s and 1970s.

Caring for the mentally ill in their homes and communities is widely regarded as the most successful treatment option, but it is not cheaper than institutionalisation, says Stiles.

The cost of not caring

In South Africa’s most notorious reported case of the de-institutionalisation of mental care, largely aimed at saving costs, over 1 500 people with severe mental illness were transferred from Life Esidimeni hospitals to community-based care in 2015. As a result, almost 150 died.

South Africa’s Mental Health Care Act of 2002 endorses community-based healthcare, but making the transition from institutional care has not been successful, owing to a lack of resources, inequity between provinces and lack of data.

The National Mental Health Policy Framework and Strategic Plan 2013-2020 sets out a plan for aligning SA’s healthcare with that of the World Health Organization’s recommendations.

Costs of mental healthcare

The costs of treating poor mental health are not only direct but also indirect, in the financial and emotional burden placed on family members as well as other issues, such as having to draw on police or ambulance services in a crisis, says Stiles.

Professor Jane Goudge, Director of the Centre for Health Policy at Wits, says the costs of caring for the sick at home, not only those with mental illness, can be a huge financial burden on households and the community in general, unless those carers are supported by specialists. 

Those who are most violent and aggressive, of whom the majority are men, are usually treated at specialist hospitals. Women with mental illness who are non-violent may end up cared for at home where they are do not receive a similar level of specialist attention.

“For community-based care to work, primary healthcare workers need support from specialists,” says Goudge. “This support needs to be provided at the district level, not from a remote hospital, in order to increase the willingness and capacity of those healthcare workers to treat people with a serious mental illness, including those who are unable to access care in a hospital.”

While the majority of South Africans use public health facilities, 16% use private mental care. However, even for those who are a member of a medical aid scheme, access to mental healthcare is problematic. 

According to the South African Depression and Anxiety Group, there are 11 mental health conditions covered by the Council for Medical Schemes’ prescribed minimum benefits that medical schemes must provide to their members. But there are only two conditions, bipolar mood disorder and schizophrenia, that are classified as chronic, and what medical aids will pay for these may vary.

Under resourced and under funded

Robertson says the NHI’s goal of delivering universal health coverage should include people with serious mental illness. ‘Serious mental illness’ covers any disorder in people over 18 that causes marked functional impairment, with a higher risk of mortality than in the general population.

“These sufferers will probably be unable to access health, education and employment opportunities, which perpetuates the cycle of poverty and ill-health,” she says. “They need community care, general hospital psychiatric units and psychiatric hospitals.”

But Robertson thinks the current system is under-resourced and underfunded. The public sector has an acute shortage of mental health professionals. The WHO notes 0.4 public sector psychiatrists per 100 000 people in SA but has no figures for other mental health specialists. There is also a dire shortage of specialist nurses.

The department of health has a ‘balanced care’ model for mental illness and a target of 10 beds per 100 000 for psychiatric institutions and 28 beds per 100 000 for general hospital wards. But there has been little progress in achieving these targets.

Goudge says studies have shown that the level of specialist care available varies significantly, both between provinces and areas of SA. In some areas of Gauteng there are primary healthcare nurses who can deal with severe mental illness with specialist support. It is important to document the benefits and costs of this model.

The National Mental Health Alliance Partnership has proposed that the NHI should provide for a District Health Management Office to co-ordinate not only general primary healthcare but also the provision of mental health services, including psychologists and occupational therapists. These professionals would support primary healthcare for those with more complex conditions. 

While the US in general does not experience the same shortage of specialists to assist home carers or district nurses that SA faces in rural areas and poor provinces, Stiles says there are some shortages in tribal lands. Some of the solutions used include having psychologists working in those areas licensed to prescribe certain medications and the increasing and successful use of technology – telemedicine – to enable those needing counselling to speak to a therapist by phone.

  • Charlotte Matthews is a freelance writer.
  • This article first appeared in Curiosity, a research magazine produced by Wits Communications and the Research Office.
  • Read more in the 10th issue, themed: #Mood how our mental health and wellbeing are impacted by the socio-economic, political, psychological, legal, ethical, cultural and technological interpretations of our world.