Health system governance to support integrated mental health … · 2017. 8. 23. · RESEARCH Open Access Health system governance to support integrated mental health care in South

Marais and Petersen International Journal of Mental Health Systems (2015) 9:14 DOI 10.1186/s13033-015-0004-z

RESEARCH Open Access

Health system governance to support integratedmental health care in South Africa: challengesand opportunitiesDebra Leigh Marais1 and Inge Petersen2*

Abstract

Background: While South Africa has a new policy framework supporting the integration of mental health care intoprimary health care, this is not sufficient to ensure transformation of the health care system towards integratedprimary mental health care. Health systems strengthening is needed, incorporating, inter alia, capacity building andresource inputs, as well as good governance for ensuring that the relevant policy imperatives are implemented.

Objectives: To identify systemic factors within institutional and policy contexts that are likely to facilitate or impedethe implementation of integrated mental health care in South Africa.

Methods: Semi-structured qualitative interviews were conducted with 17 key stakeholders in the Department ofHealth and Department of Social Development at national level, at provincial level in the North West Province, andat district level in the Dr Kenneth Kaunda district. Participants were purposively identified based on their positionsand job responsibilities. Interview questions were guided by a hybrid of Siddiqi et al.’s governance frameworkprinciples and Mikkelsen-Lopez et al.’s health system governance approach. Data were analysed using frameworkanalysis in NVivo.

Results: Facilitative factors included the recent mental health care policy framework and national action plan thatembraces integrated care using a task sharing model and provides policy imperatives for the establishment ofdistrict mental health teams to facilitate the development and implementation of district mental health care plans;the roll out of the integrated chronic disease service delivery platform that can be leveraged to increase access andresources as well as decrease stigma; and the presence of NGOs that can assist with service delivery. Challengesincluded the low prioritisation and stigmatisation of mental illness; weak managerial and planning capacity todevelop and implement mental health care plans at provincial and district level; poor pre-service training of generalistsin mental health care; weak orientation to integrated care; high staff turnover; weak intersectoral coordination;infrastructural constraints; and no dedicated mental health budget.

Conclusion: This study identifies strategies to support and improve integrated mental health care in primaryhealth care services.

Keywords: Mental health system, Integrated care, Governance, Barriers & facilitative factors, South Africa

* Correspondence: [email protected] project, School of Applied Human Sciences, University ofKwaZulu-Natal, Durban, South AfricaFull list of author information is available at the end of the article

© 2015 Marais and Petersen; licensee BioMed Central. This is an Open Access article distributed under the terms of theCreative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use,distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons PublicDomain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in thisarticle, unless otherwise stated.

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Marais and Petersen International Journal of Mental Health Systems (2015) 9:14 Page 2 of 21

BackgroundLifestyle changes and better control of infectious dis-eases have resulted in an epidemiological transition fromcommunicable to noncommunicable diseases (NCDs).By 2030, NCDs, including neuropsychiatric disorders,will constitute seven of the top ten causes of disease bur-den globally, with depression predicted to be the leadingcause of disease burden [1]. Coupled with the transitionof communicable diseases such as HIV/AIDS to chronicconditions, there is a need for health care systems to in-creasingly provide chronic care. Chronic diseases, in-cluding mental disorders, frequently co-exist with oneanother [2-4] and the relationship between physical andmental disorders is bi-directional. Not only does mentalillness affect the prognosis (course and outcome) ofother chronic conditions in terms of help-seeking, diag-nosis, quality of care provided, treatment, and adherence[4]; many health conditions increase the risk for mentaldisorder [2,4,5] resulting in greater burden on the healthcare system and poorer patient outcomes. Integratingmental health into chronic care services, particularly atthe primary health care level, is likely to lead to im-proved medication adherence and lower healthcare costsin low- and middle-income countries (LAMICs) [6],with integrated collaborative care for clusters of coexist-ing illnesses, especially physical and mental disorders,increasingly shown to be more cost-effective than usualcare in high income countries [7]. There is growing evi-dence that integrating mental health into primary care isa viable way of treating common mental disorders, in-cluding depression and alcohol abuse [8-10]. However,while integration underpins the World Health Organiza-tion’s Mental Health Action Plan (2013–2020) [11],actions to integrate mental health is slow. Mental healthis still a low priority in many LAMICs [12], with overtwo thirds of those affected by mental illness worldwidenot in receipt of the care they need [13].Like many other countries, South Africa is currently

experiencing a rising burden of chronic conditions. Thecountry suffers from a quadruple burden of disease:HIV/AIDS contributes the largest burden, followed byNCDs, other communicable and maternal/perinatal andnutritional conditions, and injuries [14]. The health sys-tem's response to the NCD burden has taken a back seat[14], partly due to the demands placed on the system bythe overwhelming HIV/AIDS pandemic [15]. Competingwith multiple pressing health concerns, resource alloca-tion for mental illness in South Africa follows the glo-bal trend of being insufficient, inequitably distributedand inefficiently utilised in relation to need [16-19].Nonetheless, compared to many other African coun-tries, South Africa appears to be relatively wellresourced in terms of mental health facilities, humanresources, and provision of psychotropic medications

[17]. It also appears to have made progress towardsdecentralised care, particularly with respect to second-ary care, with designated hospitals providing a 72-houremergency management and observation service. How-ever, integration into the primary health care systemstill remains a challenge [18] and three out of fourpeople with a common mental disorder are not in re-ceipt of any care [20].South Africa’s progressive Mental Health Care Act was

adopted in 2002. The Mental Health Care Act was seenas an important step towards addressing mental healthas a public health issue [21], as well as advancing thehuman rights of those requiring mental health care, in-cluding the right to access to care [22]. However, it hasnot been without its challenges, particularly with respectto implementation and enforcement in an already over-burdened health system [16,21]. In 2013, South Africaadopted a new Mental Health Policy Framework(MHPF) and Strategic Plan 2013–2020 [23] aligned tothe WHO Mental Health Action plan that embraces tasksharing and the integration of mental health into pri-mary health care services. The MHPF is widely regardedas South Africa's first official mental health policy and isan important tool for the implementation of the MentalHealth Care Act of 2002 [17,24]. It integrates scientificevidence and best practice with an emphasis on humanrights and vulnerable populations [22]. The StrategicPlan 2013–2020 outlines eight key objectives: i) districtbased mental health services and integration of mentalhealth into primary health care; ii) institutional capacitybuilding for mental health care; iii) surveillance, researchand innovation to strengthen the quality of services; iv)strengthening infrastructure and capacity of facilities toprovide mental health care; v) improving mental healthtechnology, equipment and medicines; vi) deepeninginter-sectoral collaboration; vii) capacitating human re-sources for mental health; viii) advocacy, mental healthpromotion and prevention of mental illness.In response to the growing burden of chronic condi-

tions, the South African National Department of Healthhas also introduced a multi-disease integrated chronicdisease management model at the primary health carefacility, community and population levels [25]. Thismodel uses a health system building blocks approach in-volving: 1) health service re-organisation at facility level,2) clinical management support at facility level, 3)assisted self-management support at community level,and 4) strengthening of support systems and structureswithin the health system [25]. This integrated chronicdisease system has the potential to provide an enablingplatform for the integration of mental health into pri-mary health care. Its stepped care approach accounts forthe fact that, while primary care for mental health is acritical component of general primary health care, it is


not sufficient to address the full spectrum of mentalhealth needs of the population [10]. However, optimalfunctioning of these inter-related elements is dependenton overarching strong stewardship and ownership at alllevels of the health system.Governance inputs and processes underscore health

system performance, from providing strategic directionthrough policy frameworks to managing policy imple-mentation through system design. Some argue that, des-pite its growing visibility in global health debates, theconcept of governance – and how it differs from man-agement – is still poorly understood [26]. Perhaps as aresult of this, there are few frameworks or approaches tosystematically assess governance in health systems [27].Health governance concerns “the actions and meansadopted by a society to organize itself in the promotionand protection of the health of its population” [28]. Itthus goes beyond the formal mechanisms of governmentto include the “totality of ways in which a society orga-nises and collectively manages its affairs” [26]. For thispaper, we have used the WHO [29] definition of govern-ance as “ensuring strategic policy frameworks exist andare combined with effective oversight, coalition-building, the provision of appropriate regulations andincentives, attention to system- design, and account-ability” (p. vi). Management is also part of governancein so far as it is concerned with implementing policiesand decisions [27].

Health system governance frameworkRecognising that governance is the least well under-stood aspect of the health system, Siddiqi and col-leagues [30] developed a framework for the assessmentof health system governance at national and sub-national levels. The framework permits “diagnoses ofthe ills” in health system governance at the policy andoperational levels, and points to interventions for itsimprovement [30]. Drawing on a number of existinggood governance and stewardship principles, theframework identifies ten principles for assessing gov-ernance and defines domains against which these prin-ciples can be measured across different levels of thesystem. These principles are: rule of law; strategicvision; participation & consensus orientation; transpar-ency; responsiveness; equity; effectiveness & efficiency;accountability; intelligence & information; and ethics.Definitions for these principles, and their associateddomains, are provided in Table 1.While the goal of addressing governance challenges is

to improve health system performance, Mikkelsen-Lopezet al. [27] recognise that improvements in governancemay not necessarily result in improvements in overallhealth system performance due to various non-governance factors. It is therefore important to recognise

the inter-relationships between governance and healthsystem processes. Identifying and addressing barriers tohealth system performance is likely to improve govern-ance, and vice versa. In Figure 1, we combine Siddiqiet al.’s [30] governance principles, adapted for the SouthAfrican context, with Mikkelsen-Lopez et al.’s [27]health system governance approach to demonstrate theinterplay between health system performance and gov-ernance of the system. While governance has been iden-tified as one element of the health system [29], it canalso be viewed as overarching, with governance inputsrequired for all levels of the system. This is consistentwith Siddiqi et al.’s [30] assessment of governance acrossall levels of the health system.South Africa’s new policy framework supporting the

integration of mental health care into primary healthcare is not sufficient to ensure integrated primary mentalhealth care as the service delivery platform into whichmental health is being integrated needs to be functioningadequately as a first step. Assessing health system gov-ernance using the above approach allows for constraintson health system functioning to be identified and strat-egies developed to strengthen governance and function-ing of the system as a whole. The aim of this study wasthus to identify systemic factors within institutional andpolicy contexts that are likely to facilitate or impede theimplementation of integrated mental health care inSouth Africa. This was done with the view to recom-mending strategies for strengthening the health systemto support current legislature and policy imperativesfor integrated care. This study forms part of thebroader EMERALD programme (Emerging mentalhealth systems in low- and middle-income countries)that is a research consortium of six low- and middle-income countries (Ethiopia, India, Nepal, Nigeria,South Africa, and Uganda) that aims to strengthen inte-grated mental health services in LAMICs through gen-erating evidence of how best to strengthen healthsystem performance to support integrated mentalhealth care [31].

MethodsDesignA descriptive qualitative approach was adopted given theexploratory nature of the study. In particular, the studywas guided by a framework analysis approach [32] giventhe descriptive nature of the study. Framework analysisis also used in policy-related research to make recom-mendations for systems and service improvements. Theapproach has been used for over 25 years and has re-cently become a popular method for primary qualitativehealth research, particularly in multi-disciplinary re-search teams [33]. Framework analysis is best applied toresearch that has specific questions, a limited time

Table 1 Siddiqi et al.’s [30] governance framework principles

Principle Domains

Strategic vision

Leaders have a broad and long-term perspective on health and human development,along with a sense of strategic directions for such development. There is also anunderstanding of the historical, cultural and social complexities in which thatperspective is grounded

Long-term vision; comprehensive development strategyincluding health

Participation & consensus orientation

All men and women should have a voice in decision-making for health, eitherdirectly or through legitimate intermediate institutions that represent their interests.Such broad participation is built on freedom of association and speech, as well ascapacities to participate constructively. Good governance of the health system mediatesdiffering interests to reach a broad consensus on what is in the best interests of thegroup and, where possible, on health policies and procedures

Participation in decision-making process; stakeholder identificationand voice

Rule of law

Legal frameworks pertaining to health should be fair and enforced impartially,particularly the laws on human rights related to health

Legislative process; interpretation of legislation to regulationand policy; enforcement of laws and regulations

Transparency

Transparency is built on the free flow of information for all health matters. Processes,institutions and information should be directly accessible to those concerned withthem, and enough information is provided to understand and monitor healthmatters

Transparency in decision-making; transparency in allocation ofresources

Responsiveness

Institutions and processes should try to serve all stakeholders to ensure that thepolicies and programs are responsive to the health and non-health needs of its users

Response to population health needs; response to regionallocal health needs

Equity

All men and women should have opportunities to improve or maintain their healthand well-being

Equity in access to care; fair financing of health care;disparities in health

Effectiveness & efficiency

Processes and institutions should produce results that meet population needs andinfluence health outcomes while making the best use of resources

Quality of human resources; communication processes;

capacity for implementation

Accountability

Decision-makers in government, the private sector and civil society organizationsinvolved in health are accountable to the public, as well as to institutionalstakeholders. This accountability differs depending on the organization and whetherthe decision is internal or external to an organization

Accountability: internal; accountability: external

Intelligence & information

Intelligence and information are essential for a good understanding of health system,without which it is not possible to provide evidence for informed decisions thatinfluences the behaviour of different interest groups that support, or at least do notconflict with, the strategic vision for health

Information: generation, collection, analysis, dissemination

Ethics

The commonly accepted principles of health care ethics include respect forautonomy, nonmaleficence, beneficence and justice. Health care ethics, whichincludes ethics in health research, is important to safeguard the interest and therights of the patients

Principles of bioethics; health care and research ethics

(Adapted from Siddiqi et al. [30])


frame, a predetermined sample and a priori issues,where the primary task is to describe and interpret whatis happening in a particular setting [34]. Because theframework analysis method is not aligned with a specificepistemological, philosophical or theoretical approach, itis a flexible tool that can be used in qualitative researchthat aims to generate themes [33].

Recruitment and participantsPurposive sampling was used to recruit managers andpolicy makers at national, provincial and district levelson the basis that they could act as key informants re-garding integration of mental health care into primaryhealth care services. The target population was policymakers at the national level in the Department of

Figure 1 A systemic approach to health system governance.


Health, provincial (North West Province) coordinatorsand planners in primary health care and in mentalhealth, and district-level (Dr Kenneth Kaunda district)managers of primary health care and mental health careservices. The Dr Kenneth Kaunda district was chosen inthe North West Province as it is the site of EMERALDactivities and is a pilot site for the implementation of theintegrated chronic disease management (ICDM) model.Between January and April 2014, twenty four people

were contacted to request their participation in thisstudy. Seventeen of those 24 people were interviewed,yielding a response rate of 71%. Seventeen interviewswere conducted with key informants at national (n = 4),provincial (n = 5) and district level (n = 8), within thegovernment Department of Health (n = 14) and Depart-ment of Social Development (n = 2), as well as non-governmental organisations partnering with either ofthese two Departments (n = 1). The majority of partici-pants were female (n = 12). Of note, the majority of thenon-responders were at provincial level.

Data collectionData collection involved semi-structured qualitative in-terviews. The interview questions were guided by Siddiqiet al.’s governance framework [30], adapted for relevanceto the current mental health context in South Africa aswe move towards implementing the new mental healthpolicy framework for integrated mental health care. Inaddition, the emphasis on health system functioning re-quired by the implementation of this policy frameworknecessitated taking a systemic approach in interviewquestions, which was informed by Mikkelsen-Lopez

et al.’s [27] health system governance approach. The in-terviews were audiotaped and transcribed verbatim.

Data analysisThe interviews were analysed with a framework ap-proach using the NVivo software programme. Frame-work analysis is a form of thematic analysis used tostructure and summarise data in matrix form to identifycommonalities and differences in the data to aid in thesearch for explanation and interpretation [33]. It is mostsuitable for analysis of interview data, where it is desir-able to generate themes by making comparisons withinand between cases [33]. It has also been adapted as a“best-fit” framework-based synthesis method where, asin the case of this study, a conceptual model suitable forthe research question is used as the basis of the initialcoding framework [35,36]. A combination of inductiveand deductive coding was used in this study. An initialcoding framework was developed, guided by a hybrid ofSiddiqi et al.’s [30] governance framework principles andMikkelsen-Lopez et al.’s [27] health system governanceapproach. The framework focused on barriers and fa-cilitative factors to health system governance withrespect to integrated mental health care. As analysisprogressed, sub-themes emerging from the data werecoded inductively, and added to the coding framework,while keeping the categories from the governanceframework as parent themes.

EthicsPermission to conduct the interviews was obtained fromthe Department of Health at national and provincial


levels. Ethical approval for the study was granted by theBiomedical Research Ethics Committee (BREC) at theUniversity of KwaZulu-Natal (approval number BE407/13). Only participants who indicated that they under-stood the nature of the research and gave their volun-tary informed consent were recruited into the study.The data collection methodologies are considered torepresent minimal risk to the participants who agreedto participate in the studies. Structured, multi-levelprecautions were taken to safeguard the confidentialnature of the information gathered, and to ensure theanonymity of the respondents, from data collection todata storage, analysis and publication. Research staffwere trained to understand and implement ethical andresearch governance safeguards and protections. Allparticipants were allocated a unique identifier code andthe master identifier list kept in a password protectedrepository. Data and participant related files are subjectto password-protected access.

ResultsRule of LawThis principle pertains to mental health legislation, in-cluding the enforcement of such legislation and the syn-ergy of laws with mental health policies. Whileparticipants agreed that there were synergies betweenthe Mental Health Care Act of 2002 and the new mentalhealth policy framework of 2013 in terms of an emphasison integration of mental health into primary health care,a key challenge was implementation at an operationallevel. Representatives from the Department of SocialDevelopment, in particular, felt that there was insuffi-cient training on the Act, as well as a lack of clarity onresponsibilities of the different sectors. Guidance on ser-vicing people with intellectual disabilities also emergedas a pressing need: “There was no guidance and nodocument that would guide and actually talk to theresponsibilities of Departments, on the provision of ser-vices to people with intellectual disabilities” (NR4). Sug-gested strategies for addressing these challengesincluded greater clarification in relation to roles andresponsibilities with respect to the Act, particularlyacross sectors, as well as additional training on the Actto facilitate implementation and enforcement.

Strategic DirectionOriginally strategic vision, we amended this principle tostrategic direction to encompass both the vision and thestrategic policies and plans developed at national, pro-vincial and district levels to integrate mental health intoprimary health care. In particular, we explored the devel-opment and implementation of policies and plans.With regard to challenges, communication about the

policy framework had purportedly not filtered down

sufficiently to district level. One district level representa-tive explained: “there wasn’t such in depth discussion onthe document which I think is still lacking and we stillhave to do that so that everyone is on board” (DR1).There also seems to be poor coordination in terms ofplanning between national, provincial and district levels.Insufficient capacity as a result of staff shortages and

skills deficits to translate policies into plans alsoemerged as a key reason for the variation and poor qual-ity of plans at provincial and district level. As suggestedby a national representative,

“often these things that we do at the top, at nationalgovernment, they’re always good on paper, and theysometimes arrive at the sites where they’re supposedto be implemented, and land up in cupboards. Theygather dust…there’s a problem in resourcing thisprocess” (NR2).

Lacking qualified managerial staff who could push im-plementation at ground level was a particular challengein this respect. Problems with implementation were alsoattributed to inadequate resources and facilities at oper-ational level.Strategies to strengthen provincial and district imple-

mentation included support and constant communica-tion from the national office, to ensure that the relevantmanagers understand the policy conceptually. Includingstrategic planners, who are responsible for the develop-ment of overall health plans, in developing mental healthplans was seen as crucial. As noted by one participant,

“we are of the opinion that the strategic planners arebetter placed to make sure that mental health isincluded in their annual provincial plans and also,they develop the relevant indicators to make sure thatthe programme is monitored and evaluated” (NR3).

It was also suggested that greater clarity on the rolesand responsibilities of different stakeholders acrossnational, provincial and district levels with respect toimplementation, would aid implementation, as wouldaddressing resource and capacity disparities betweenprovinces. Champions who can communicate well and“win people to their side” (NR2) were reportedly neededto advocate for mental health at provincial and districtlevels and to push policy implementation. In addition,building capacity in change management, particularlywith facility managers, was identified as important to fa-cilitate the implementation of collaborative chronic careat facility level. The use of district mental health teamsin a public health role to coordinate the integration ofmental health into district health plans was also en-dorsed, provided they are sufficiently capacitated.


Responsiveness & IntegrationIn South Africa, this principle was amended to empha-sise integration given the need for an enabling servicedelivery platform for integration. First, we explored re-sponsiveness in terms of the public health priority ofmental illness. Second, responsiveness to integrationwas explored at both facility and community levels. Atfacility level, this included consideration of barriers tointegration, chronic care and rolling out Primary Care101 (PC101), as well as the factors which facilitatedthese processes, such as the benefits of chronic care interms of addressing comorbid conditions. Third, re-sponsiveness to integration at community level wasalso explored.

Responsiveness to mental health as a public health priorityWhile one participant indicated that mental health wasa priority at a political level and that there was politicalwill and ministerial support at a national level asreflected in the new Mental Health Policy Frameworkand Strategic Plan, there was a general view that men-tal health was still not a priority in the face of manyother health needs in South Africa, and was exacer-bated by mental health being viewed separately fromoverall health:

“If you are HIV positive or you are AIDS sufferer, themental health issue comes into play and it needs to betaken care of. If you suffer from diabetes or cancer,there are mental health issues. That’s how we need tounderstand it across the board, and my view is thatwe currently don’t understand it that way. Because wekeep on saying it cuts across and I don’t think peopleunderstand when we say it cuts across” (PR4).

Some felt that other programmes – particularly com-municable diseases like HIV and AIDS – have receivedall the attention at the expense of mental health asreflected in the following quotations from district andnational representatives: “(Mental health) is still thestepchild of medicine to a great extent” (DR5).

“I don’t think it’s because they don’t think that mentalhealth is important, but they do think that otherthings are more important… I also think that whenpeople are dying in large numbers, healthrepresentatives feel that they need to respond to that,and who am I to say that they’re wrong? I thinkthey’re probably right actually. So, you know, we facecrises after crises” (NR1).

Responsiveness at a facility levelSouth Africa is piloting an integrated chronic diseasemanagement (ICDM) model in three districts, one being

the Dr Kenneth Kaunda district in the North WestProvince. In this model, services for patients withchronic conditions, including mental health conditions,are integrated, and identification and treatment of theseconditions are conducted at primary health care facil-ities, with nurses being trained to detect a number ofmental illnesses using Primary Care 101 (PC101).PC101 is an integrated set of chronic care guidelinesadopted by the national Department of Health that in-clude mental health to assist primary health care staffin the management of multiple and often co-existingchronic diseases. A number of benefits to providingholistic services for integrating mental health care wereidentified, in addition to a number of challenges.With respect to the benefits, including mental health

as part of the ICDM at primary care level was seen as away of providing holistic care, increasing access and de-creasing stigma. According to a national representative,ICDM would assist in reducing stigma, because mentalillness will be seen “as a chronic disease, just like anyother disease” (DR2). It was also felt that ICDM wouldreduce the workload of health professionals. Because theneeds of people with any chronic illness are “prettymuch the same,…you can use one methodology of longterm care across different disease patterns” (NR1). Thebenefits of the patient-centred care focus of the ICDMmodel was also emphasised by a district representative:“the client … also giv(ing) their inputs. What are … theirneeds, what do they want, not what we perceive as whattheir needs are” (DR4). There was recognition of thebenefits of integration in terms of patient outcomes andaddressing comorbid conditions. PC101 was viewed asproviding the vehicle for integration: “PC101 will reallyassist us to see that everyone is on board, that they aretrained and …well conversant on how to manage a men-tal health client” (DR4).With respect to challenges, negative attitudes and lack

of experience or training in mental health by primaryhealth care nurses in particular was identified as a majorbarrier to responsiveness to integrated mental healthcare, with the integrated model not “be(ing) fullyembraced by all health workers” (NR1), and a prevailingbelief that psychiatric patients need psychiatric hospi-tals. Participants identified part of the problem asinsufficient involvement of service providers in plan-ning of service provision, leading to lack of buy in: “SoI have noticed with some of our clinics that they haveactually regressed because it was a talk-down and staffwasn’t really involved in the development of it” (DR5).This may have filtered down from the uncoordinatedplanning and lack of intersectoral collaboration at na-tional and provincial levels.Representatives from national, provincial and district

levels all suggested that a major challenge relating to


integrated chronic disease management was resistancefrom patients: “There (are) still (mental health) patientswho would prefer to be seen separately from other pa-tients because they believe maybe they, or they thinkthey were receiving better quality when they were seenseparately” (DR2). “The problem is with the mentalhealth users. They are resistant to integrate at theclinics. They want to have their own rooms…and theironly person for consultation” (PR3). “As soon as theICDM started, patients didn’t want to be integratedwith the rest of the facility patients and so they disap-peared” (DR3).A lack of continuity in care also emerged as a chal-

lenge. With the integrated model, patients are not guar-anteed that they will see the same nurse at eachconsultation, and some mental health care patientsstruggle with this. Poor communication between criticaldepartments also emerged as bedevilling continuity ofcare. An example provided was the poor follow up ortracking of patients for adherence in those admitted toan institution, and then down referred to clinics forfollow-up medication, with the result that patients re-lapse more often. A national representative noted that,

“We are losing many patients or users into the cracksbecause you find that the user is seen at a facility,maybe admitted. Once the user leaves the facility, wedon’t keep track whether the user ultimately followsup, adherence to treatment, all those aspects” (NR3).

Strategies to address these challenges included theneed to provide mentoring support and supervision forPC101 in addition to the training in PC101 for primaryhealth care staff. Change management could re-orientate and raise awareness of staff at facilities aboutthe benefits of integration for overall health, whileawareness raising in the community could educate ser-vice users about the benefits of integration and facili-tate buy in.

Responsiveness at a community levelWith regard to community-based services, the import-ance of empowering communities to play a greater rolein caring for patients at a community level was empha-sised. A national representative suggested that, whilegovernment could do a lot more, opportunities exist toenlist the support of user organisations to work withfamilies and go “beyond what government can do”(NR2). Communities should be encouraged, he said, toinformally address their needs. In addition, communityhealth workers, NGOs and Department of Social Devel-opment social workers could also be capacitated to de-liver community-based psychosocial services.

With regard to challenges, the move to deinstitutional-isation and introduction of community-based serviceshas been slow, and services are largely still concentratedat institutional level. Because of gaps in the provision ofcommunity-based residential care, as well as psycho-social rehabilitation programmes to facilitate recoveryand reintegration into the community, many patients re-lapse and have to be re-admitted to hospital. In othercases, where residential facilities exist, a lack of struc-tured psychosocial programmes at these facilities wasidentified as a problem. One participant also mentionedpossible resistance from families and communities asreflected in the following quotation:

“our approach that we inherited from the previous …apartheid government of institutionalising people withdisabilities, has in a way created some dependencyand some expectations especially among the familymembers. And now when you really get and move theservices to the community where a large number ofpeople with mental disability can actually then be ableto receive the services, we might actually meet withsome resistance especially from the community andfrom families, because communities know that they’vegot this perception and understanding that if you havea mental disability then you should be closed up in aninstitution” (NR4).

A shortage of human resources is another significantchallenge. In the Department of Health (DoH), there islack of human resources to provide community-basedservices, so “even if there can be resources in terms offinancial resources…there are no warm bodies to actu-ally render service” (NR4). Community health workersare not capacitated to intervene in mental health, andthere are no DoH-employed social workers at primarycare level. There also seems to be some confusionregarding who is responsible for providing community-based services and a lack of coordination and role clari-fication between sectors. The result is a gap in servicesat this level. According to one participant: “they’reconcerned about who’s going to run it. Because …theysay it’s not a (Department of ) Health competency. Be-cause they think Social Development or somethingshould run it” (DR8).It is thus not surprising that the need to establish col-

laborative arrangements between the Department ofHealth, Social Development, Housing and other sectorsat national, provincial and district levels, with respectto community-based psychosocial rehabilitation (ser-vice provision and funding) was identified as a strategyto address this gap in services by a number of partici-pants, as was the redistribution of resources fromtertiary-level institutions to community-based services.


Effectiveness & EfficiencyWith the focus on effective use of resources to meethealth needs, the sub themes that were developed in thisgovernance principle included human resources cap-acity, financing, and infrastructure.

Human resourcesCapacity barriers focused on the shortage of human re-sources to implement the mental health policy. TheMental Health Policy Framework and Strategic Planstipulates that mental health teams need to be estab-lished in each district. However, respondents anticipateda number of challenges with establishing these teams.Apart from the existing staff shortages, participants indi-cated that finding or attracting suitably qualified staff tojoin the district teams would be difficult, particularly inmore remote or rural areas. Some participants were con-cerned that, even if they could find the specialists tocreate these teams, the posts had not been created to ap-point them within the existing staff structures. Even ifthe staff structures could be created, participants wereconcerned that there are no resources to sustain fundingthese posts, because the money would also have to comefrom the equitable share budget pool. As suggested byone district level participant:

“If only the staff structure can be addressed wherebythese posts are available at sub district level, then itwill be easy for sub districts to have appointments.But if it’s not on the staff establishments, then it’sreally a challenge to get these people appointed”(DR4).

Suggested strategies to overcome these barriersincluded diversifying the roles of professionals who arealready appointed in the system and using existingresources more effectively. As one national level partici-pant explained,

“some of the provinces are now starting to look atwhere they can move resources to where they mightbe more effectively utilised. And, you know, if youstart with psychologists, well maybe you can go ontoOTs and to social workers and to other resources aswell – maybe the nurses” (NR1).

Further, a district level participant explained that, des-pite expansion of services, additional posts were notbeing created, which placed greater burden on existingstaff: “You continue to expand your services, expand ex-pand expand, with the same staff structure…And that isone of the reasons people are leaving, definitely, burnoutand work overload” (DR8). This problem applies to bothgeneralised and specialist personnel, with the few

specialists who do work in primary health care, particu-larly psychologists and psychiatrists, having a very highwork load. The need to capacitate general health profes-sionals to identify and treat mental disorders within atask sharing approach was emphasised by a number ofparticipants. As suggested by one participant, the key, isto “capacitate health care providers in terms of identify-ing mental disorders or mental illnesses, managing them,and also follow up care” (NR3). There was a lot of sup-port among participants for having all primary healthprofessionals trained in PC101. Factors compromisingoptimal implementation of PC101 included: i) insuffi-cient capacity to provide training and support forPC101, as well as the general lack of clarity regardingresponsibility for supervising and monitoring implemen-tation of PC101; and ii) the attitude that mental healthwas not the responsibility of primary health careproviders, coupled with high workloads, leading to pooruptake of PC101. As suggested by a district representative:

“Attitudes are really a difficult thing to change, andyou are not always there at the facility. You’ll findwhen you’re doing monitoring and evaluation, theywill manage the client correctly but as soon as youturn your back…but we must also look at the factorswhy, why are people (not identifying mentaldisorders), (it is) their attitudes, at times it’s severeworkloads, it’s other pressures that we are notconsidering” (DR4).

Providing staff with training and support was seen asone way to combat the resistance to the integrated caremodel as well as dealing with high staff turnover. Thistraining needs to be continuous and followed up regu-larly to ensure that people are following the PC101guidelines with respect to identifying mental healthissues. The potential role of district mental healthteams in providing supervision and support washighlighted. There is also a need for greater collabor-ation with the Department of Education to adapt train-ing towards comprehensive chronic care, and to trainmore graduates.The involvement of community health workers and

lay counsellors in mental health services was also dis-cussed. In general, participants seemed supportive ofthe use of community health workers in providingmental health screening and follow up services, andusing lay counsellors in the provision of counselling forcommon mental disorders. However, there were con-cerns that they do not have adequate training and simi-lar to PC101 do not have continuous support andsupervision from specialists. There was also a need forrole clarification with respect to the duties and respon-sibilities of these counsellors.


FinancingSome participants believed that funding for mentalhealth is inadequate. This is partly because mentalhealth shares a budget pool (“equitable share”) withother health programmes and “everyone is fighting forthe equitable share” (DR5). The existing shortage ofresources was identified as being a obstacle for the im-plementation of the mental health policy. As suggestedby a national participant: “A lot of provinces are alreadyoverspent. And anything more that you give them (askthem to do) does become a problem…if they (are) start-ing services from scratch, with the resources that they’vegot, what would they do?” (NR1). There seems to be adisparity between provinces in terms of resource alloca-tion for mental health.Others highlighted the budgeting process as problem-

atic, with funds being allocated to mental health basedon where the funds were allocated the previous year, butwith an inflation-related increase. Without tying fundsto specific activities, there will be difficulties in operatio-nalising many of the stipulations of the mental healthpolicy. As suggested by a district representative, this his-torical way that the budget is allocated is

“going to be detrimental to implementing (the policy),it really will. I mean but I think our provincial headoffice knows that the way they are budgeting doesn’tmake sense in today’s world any more, they know theyshould be getting a health economist in and really doan overhaul but, that hasn’t happened” (DR8).

Strategies to overcome these difficulties includedshifting resources from specialized hospitals to commu-nity care in the long term, but this was linked to theneed for activity-based budgeting. Leveraging resourcesfrom other health programmes such as HIV/AIDS,which were better funded, was also suggested as a po-tential strategy.

InfrastructureParticipants spoke about problems with quality andquantity of existing infrastructure to facilitate the shiftto community-based care in particular. This was partlyattributed to a lack of coordinated planning betweensectors: “capital planning was just building hospitalswithout consulting us” (PR3). The paucity of communityor residential centres to facilitate the integration of pa-tients who are discharged from hospitals back into thecommunities was highlighted. There was also generalagreement that there is “a huge challenge in terms ofprivacy and space” (DR4) for providing counselling ser-vices in primary health care clinics. According to onedistrict representative, “they (counsellors) are a bit at thebottom of the rung, so…they don’t really have dedicated

space” (DR5) in which to see patients. Possible ways ofaddressing this problem identified included lookingcreatively at how to make more counselling space avail-able. In particular, participants spoke about making useof park homes to add space to primary health carefacilities and provide dedicated space for counsellingservices. This was also felt to be a less expensive optionthan building new clinics or adding onto existinginfrastructure.

Medicines & technologiesProblems with the consistent supply of psychotropicmedication at district level also emerged as a major chal-lenge. As indicated by a participant at district level:

“There is a tender process. There is a supplier that iscontracted in and there are sometimes challenges thatwe will experience with suppliers not being able tosupply on time or the adequate amounts and itimpacts directly (at the) operational level. Clients willcome to the facility and supplies wouldn’t be there,which again contributes to them defaulting” (DR1).

Another challenge concerned communication prob-lems between different health care providers, particularlybetween hospitals, clinics and pharmacies. In someinstances, the correct medication was not provided be-cause of human error. In other instances, there was abreakdown in communication between the facility andthe hospitals which were down-referring patients, as wellas the facility and the pharmacy, where (in the lattercase) the “script isn’t written or sent on time, the medi-cation isn’t packed on time to be available for thepatient, and so the patient defaults” (DR4). A breakdownin communication was also identified as a problem thatneeded to be rectified with respect to drug prescriptionsand delivery systems. In addition, difficulties in ensuringadequate availability of the PC101 manuals in primaryhealth care facilities was identified as a hindrance to theimplementation of the PC101 guidelines. Having a mas-ter file in each facility and then seeing what could bemade available in each consulting room was identified asa potential strategy to address this problem.

Participation & CollaborationOriginally participation and consensus orientation, thisprinciple focused on the participation of stakeholders indecision making in health. We expanded this definitionto include the collaborative planning and decision mak-ing that underscores effective service provision.Participants were asked about whether the Department

of Health (DoH) engages in consultation with othersectors, particularly the Department of Social Develop-ment (DSD), regarding the provision of psychosocial


rehabilitation and community-based services. The ma-jority of responses concerned the lack of collaborationand delineation of roles between the two departments,with one provincial participant describing the contactbetween the two departments as “erratic or not reallyorganised” (PR4). From a national perspective, variationin the degree of collaboration between provinces anddistricts was highlighted as indicated by a nationalparticipant:

“There are areas that are already involved with SocialDevelopment in terms of providing community-basedresidential and day care services, including servicesfor children with intellectual disabilities…but in otherprovinces and districts, Social Development doesn’treally play the role that is prescribed in that plan”(NR3).

A general problem regarding collaboration across allsectors was the lack of coordination due to differentroles and mandates, such that collaboration does not fil-ter down from planning to implementation level:“Provincial health has got to get cooperation from otherdepartments…so it becomes much more complex be-cause of the different mandates that the different depart-ments have” (NR2). This seems to be compounded bythe reluctance of some departments to get involved inthe implementation of mental health policies andlegislation. In relation to strategies to address the prob-lem of collaboration, the need for a memorandum ofunderstanding between departments, particularly theDepartment of Health and Department of Social Develop-ment, was suggested to assist with formalising collabor-ation and clarifying roles and responsibilities with respectto mental health. A national representative spoke aboutthe establishment of the National Health Council, whichwould formalise collaboration between sectors. However,one participant felt that discussions around collaborationactually usually take place at operational level, but whatwas needed was

“this kind of collaboration to take place at all levels,whereby even the executive managers, like heads ofdepartment, are to meet and talk about particularissues, they need to do that so that they can agree tosay, for our Department this will be the way forward.So that when the implementers come in, it’s not aboutthem having to pave the way forward for how they aregoing to work, it should have been cleared at a highlevel” (PR4).

This would require capacity building and commitmentat leadership level to build stronger partnerships, as wellas building capacity among health professionals and

managers to advocate for mental health within their pro-grammes and departments.There was also acknowledgement that consultation

with service providers and service users was notadequate. “Even the involvement of service, you know,other service providers, the private sector, users them-selves, families themselves, it is very poor” (NR2). As aresult of this lack of involvement, there is some resist-ance to policy directives among service providers. Therewas no question among participants about the need forgreater involvement of families and service users both inpolicy development and service planning, and in treat-ment decisions. However, there was uncertainty regard-ing how to increase involvement: “we regard that as animportant element, but it has not as yet happened. Andwe are not so sure even in terms of the modus operandi,how to achieve that” (PR4). Capacity building in stake-holder engagement was also suggested as a strategy toaddress this problem as indicated in the followingquotation:

“I was talking to a Prof from the University…and hesaid, but yeah but first of all you have to train peoplehow to do local engagement! I said why? He said no,people don’t automatically know how to do this, youknow, we assume, it’s just talking but it’s not justtalking” (DR8).

Service users could also be consulted through cliniccommittees and advocacy groups, as well as throughholding imbizos (gatherings) to get community input.This would require building capacity of service usergroups and allowing for formal inclusion in collaborativestructures.

Equity & InclusivenessOriginally equity, we expanded this principle to empha-sise inclusiveness, as we considered this critical to ensur-ing equal opportunities to improve or maintain health.In South Africa, the notion that all men and womenshould have equal opportunities to improve or maintaintheir mental health and well-being centred on two mainissues: access to services and stigma.Responses about access to services were a mixture of

positive and negative perceptions. On the one hand, par-ticipants spoke about integrated care as a mechanismfor increasing access to services for mental health careusers. There was emphasis, from participants at nationallevel, on the plans for increasing access to services, suchas public education programmes, help lines and allocat-ing funds to improve access for families and communi-ties and combat the lack of awareness among serviceusers regarding how and where to access mental healthservices. Responses from provincial and district level


participants, however, focused more on the challengesassociated with service provision, which limit accessi-bility. One issue is the geography of the North WestProvince, which is a “vast and rural province. So we’restill not at a point where we can say, look, services are,you know, readily accessible” (PR2), with mental healthservices concentrated in the urban areas. There is alsodisparity between districts in terms of the number offacilities and community centres, and a lack of qualifiedstaff to provide mental health services, both of whichwere identified as barriers to access.With regard to stigma, respondents suggested that

the mental health policy framework does not providesufficient guidance on how stigma should be ad-dressed, with provincial and district level respondents,not being aware of any specific anti-stigma pro-grammes for mental health and variations betweenprovinces in terms of prioritising addressing stigma.Furthermore, there is a shortage of staff to drive theseprogrammes. However, integrating mental health intoprimary health care services, and particularly chroniccare, was seen as having the potential to reduce stigma.Support from provincial and district managers wasseen as a facilitative factor in the implementation ofanti-stigma programmes. Suggestions for strategies toreduce stigma in communities included campaigns,mass media and the use of testimonials of role modelsto create awareness and improve mental health liter-acy. It was suggested by one participant that peer edu-cators or people of the same age and gender would bebest suited to convey anti-stigma programmes because“for me, most children or adults better listen to peoplearound that they know” (DR3). The importance of tar-geting all levels, including the community, employers,service providers and the patients themselves, whohave internalised or “self imposed stigma” (DR2) wasmentioned by a number of participants. Supportgroups were seen as important forums for empoweringservice users.

Ethics & OversightWe redefined this principle as ethics and oversight(originally ethics) to operationalise ethical principlesacross treatment and research. We considered that theethical treatment of mental health care users in theprovision of services was contingent on ensuring thatthe quality of services was closely monitored, and thatsafeguards were in place to protect against unethicaltreatment and redress grievances. Conducting ethicalresearch with mental health care service users alsonecessitated that there be safeguards against unethicalresearch. Thus, quality assurance, addressing griev-ances, monitoring services and safeguarding the ethical

conduct of research were major issues consideredunder this principle.The Office of Health Standards Compliance is an inde-

pendent body which is responsible for ensuring qualityin all health services, including mental health. Thesecore standards “prescribe that each health establishmentor health facility must display the patients’ rights charterand also what type of mechanisms should be followed interms of lodging a grievance or complaint” (NR3).According to a district representative, “there is a compli-ments and complaints mechanism in the Department ofHealth” (DR1) which seems to be replicated at eachlevel, from national down to facility level. However,some felt that more could be done, such as setting uphotlines as part of the Office of Health StandardsCompliance, and introducing QualityRights – a WHOprogramme for inpatient and outpatient psychiatric andcare facilities – to all facilities. A participant at districtlevel acknowledged that, while there are sometimesquality improvement projects and while NGOs occasion-ally help with quality assurance, “it’s not happening on aregular basis” (DR6). Part of the problem was seen to bea lack of indicators against which to evaluate perform-ance and quality.The Mental Health Review Boards also have a role to

play in ensuring ethical treatment and service user satis-faction. However, there is variation between provinces interms of the effectiveness of the Mental Health ReviewBoards. As suggested by a national representative, someprovinces “are really not doing so well in terms of theestablishment of the Mental Health Review Boards.Some boards are not even complete” (NR3), while someMental Health Review Boards are not functioning “aswell as they should” (NR1), because of lack of budgetand staff to carry out inspections and follow up on griev-ances. The disparity between provinces in terms of thefunctionality and effectiveness of Mental Health ReviewBoards needs to be addressed.There were very few responses to questions about

what safeguards against unethical research were inplace. This seems to be because the process for review-ing and approving research with mental health careusers is seen to be the mandate of the research units atnational and provincial levels. As one provincial repre-sentative said, “that comes down to the researchapproval process and the process in various ethicscommittees” (PR1), while another noted that “we’vegot a unit in the provincial office. You know, everysort of research you want to do, it must go via thecommittee for permission. So nobody can just walk inand just start doing research” (PR2). The NationalHealth Act was also highlighted for the guidance itprovides on procedures for conducting research withhealth care users.


Intelligence & InformationWith its emphasis on information, a major focus of thisprinciple was on monitoring and evaluation, and theassociated barriers and facilitative factors. The adequacyof mental health indicators and the mental health infor-mation system were also explored.The necessary structures for monitoring and evalu-

ation seem to be in place, although many felt that theindicators for mental health were not sufficient. As indi-cated by a national representative,

“we would request more indicators and data to beadded. But we are competing with other programmes.And the health information system unit indicated tous that they are planning at reducing the number ofindicators for all the programmes….it’s not convincingfor them that we do use the indicators at all thelevels” (NR3).

According to one participant, one reason for thiscould be that the district health information system is“under the custody of a different unit” (PR4) and so, to“avoid inundating it with information” (PR4), mentalhealth programme managers need to make a strongcase for why a particular indicator should be includedon the system.A number of challenges associated with monitoring

and evaluating (M&E) mental health were raised by par-ticipants. In addition to the poor quality and quantity ofmental health indicators included on health informationsystems, inadequate human resources to carry out moni-toring and evaluation also emerged as an issue. It wassuggested that provincial and district officials need toplay a greater role in monitoring mental health services.Building M&E capacity at all levels was necessary toimprove the use of indicators to inform policy and ser-vice planning.Some participants expressed concern about the

amount of information that is collected that sits in thesystem and is not pulled together to “get a picture ofwhat is happening in a district or province” (NR2). Thequality of indicators captured, and their ability to accur-ately reflect quality of services, was also a concern: TheDoH has so many indicators that are “absolutely mean-ingless”….There are cases where “quality is useless butindicators are just put there to make you feel better”(PR1). Some spoke about the difficulty of establishing in-dicators for mental health because there are not easilymeasurable outcomes on which to base them: “If youcan think of an indicator that will definitely will be abarometer of how care is happening, that would be fine.But that will take a different thought process to do that.I can’t suddenly come up with one” (PR1). It is thus crit-ical to include indicators for mental health in the health

information system that provide sufficient informationto inform intervention decisions and assess qualityimprovements.

Accountability & TransparencyThese two principles were relatively under-developedand did not get a lot of responses from all participantsat national, provincial and district level. Rather than thisbeing an indication of poor accountability and transpar-ency processes or mechanisms, it is more likely that thequestions around accountability and transparency werefrequently not asked. Some of the issues could be arguedto have been covered in other sections, particularlyaround monitoring and evaluation.A comprehensive overview of the challenges, facilita-

tors and recommendations pertaining to each of thegovernance principles is provided in Table 2 below.

Discussion & conclusionsThe application of the analytical framework to assessmental health system governance at the national, provin-cial and district levels in South Africa has revealed somepositive elements, and a number of areas requiring inter-vention. The challenges identified at governance levelare reflective of the challenges encountered at imple-mentation level, suggesting that strengthening aspects ofthe health system – such as human resources andinfrastructure – could enhance governance. The weak-nesses were particularly in relation to the governanceprinciples of strategic direction, responsiveness &integration, effectiveness & efficiency, and participationand collaboration. In particular, the findings suggested astrong need for: i) capacity building at all levels of thehealth system, ii) greater coordination and collaborationin planning and service provision, iii) consultation withstakeholders, iv) training and supervision in PC101, v)infrastructural improvements, vi) streamlined deliverysystems of drugs and treatment protocols, vii) imple-mentation of quality improvement programmes, viii)better indicators for mental health in the health informa-tion system and ix) advocacy and awareness raisingcampaigns. Despite having a new mental health policythat supports integration of mental health into primaryhealth care, in South Africa, as elsewhere, a weak healthsystem and health system governance make it difficult toimplement this policy and deliver cost-effective interven-tions for scaled up mental health care [37,38]. Based onthe findings of the current study, recommendations areprovided for improving health system governance tosupport integrated mental health in South Africa.Mental health legislation, policies and plans are

needed to integrate mental health into primary healthcare [10]. South Africa has a Mental Health Care Actwhich has been in place since 2002. The findings of this

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

Principle System level Sub-theme Challenges Enabling factors Recommendations

Ruleof Law

Governance Legislation Mental health care act lacksguidance on people withdisabilities

Synergy between mental healthcare act & mental health policy

Clarify roles & responsibilities withrespect to the act,particularly across sectors

Enforcement Insufficient training affectscompliance& implementation

Provide sufficient training on mentalhealth legislation & policies

StrategicDirection

Governance Development ofpolicies & plans

Lack of communicationabout thepolicy at district level

Including strategic planners indevelopmentof plans

Build capacity to translate policies intoplans at provincial and district levels

Insufficient capacity totranslate policiesinto plans due to shortage of staffand skills

Champions who can advocatefor mental healthSupport from national office

Include strategic planners indevelopmentof mental health plans

District mental health teams used asa unit for planning

Use district mental health teams as a unitfor planning at local level, provided theyare sufficiently capacitated and supported

Implementation ofpolicies & plans

Poor coordination interms of planning& service provisionbetween national,provincial & district levels

Clear understanding of roles &responsibilitieswith respect to implementation

Capacity building of managers in changemanagement to facilitate theimplementationof integrated collaborative chronic care,including mental health

Disparity betweenprovincial mentalhealth units in termsof capacity

Coordination between differentstakeholders

Clarify roles & responsibilities of differentstakeholders & improve coordination

Lack of qualifiedmanagerial staff to pushimplementation at ground level

Address resource and capacity disparitiesbetween provinces

Insufficient budget& inadequate infrastructure

Responsiveness& Integration

Governance Prioritisation ofmental health

Mental health still nota priority inthe face of many otherhealth needs

Drive by national to develop policyseen as a step towards prioritisationof mental health by nationalgovernment

Providing training and support in PC101can facilitate integration of mental healthinto primary health care

Mental health seen asseparate fromother health needs

Education & awareness raising about thebenefits of integration among serviceproviders & service users could facilitatebuy-in

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

ServiceDelivery

Integration atfacility level

Uncoordinated planning & lack ofintersectoral collaborationhinders integrationNegative or misinformed perceptionsabout mental health and integrationInsufficient involvement of serviceproviders in planning, leading tolack of buy inLack of training on mental healthamong health professionals & lackof patient-centred orientationInadequate follow-up betweenprimary care facilities and tertiaryinstitutionsResistance from mentalhealth care users

PC101 can facilitate integrationRecognition of benefits ofintegration in terms of patientoutcomes & addressingcomorbid conditions

Establish collaborative arrangementsbetween the Department of Health,Social Development, Housing and othersectors at national, provincial and districtlevels, that establish clear roles andresponsibilities with respect to community-based psychosocial rehabilitation (serviceprovision & funding)Redistribute resources from tertiary-levelinstitutions to community-based services

Integration atcommunity level

Services still concentrated atinstitutional levelLack of coordination androle clarification between sectorsShortage of community-basedcentres & poor accessibilityShortage of human resourcesto deliver community-based servicesResistance from families &communities

Redistributing resources from hospitalsto communitiesUtilising DSD social workers, communityhealth workers and NGOs in delivery ofservices, but need to besufficiently capacitatedCommitted leadership driving this

Effectiveness& Efficiency

Humanresources

Human resourcescapacity

Shortage of health professionals &specialists to implement policyHigh workload and high staff turnoverInflexibility of existing staff structuresto accommodate creation of newposts for district mental health teamsBudget not sufficient toappoint more staffNegative attitudes and resistanceamong staff to treating mental health

Building staff confidence & competence totreat mental healthCreation of district mental health teamsfacilitated by using existing systemsFlexibility & using existing resources moreefficiently could facilitate establishmentof district teamsAdapting training to be more primaryhealth care focusedEntering into agreements with localuniversities to train graduates

Given shortage of mental health specialists,particularly in rural areas, need flexibility increation of district mental health teams(e.g. pooling resources across districts)Collaborate with Department of Educationto adapt training and train more graduatesAn orientation to comprehensive care andchange management is needed

Task sharing Insufficient specialistcapacity to providetraining and support in PC101

In-service, on-site & continuoustraining for health professionals

Task sharing can relieve pressure onhealth professionals

High workloads meanpoor uptake of PC101Lack of clarity regarding responsibility forsupervising & monitoring implementationof PC101

District mental health teams could providesupervision & supportCommunity health workers, home-basedcare workers and ward-based outreachteams to provide screening & follow upRole clarification for counsellors toinclude mental health

PHC personnel trained in PC101 needmentoring and support inimplementation of mental health aspectsUse lay counsellors as they will relievepressure on health care professionals, butprovide adequate role clarification,training and supervisionUse community health workers,home-based care workers andward-based outreach teams for screening,referral and follow up

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Financing Financing Funding for mentalhealth is inadequateDisparity between provincesin terms ofresource allocation for mental healthHistorical budget allocation is problematic

Using existing resources more efficiently –phased approach and piggy backing ontoother programmes

Use existing resources more efficientlythrough, for e.g. a phased approach andpiggy-backing onto other programmesRevise way of budgeting from historicalto activity-related allocation of funds

Infrastructure Infrastructure Quantity and quality of existinginfrastructure not sufficientLack of coordinated planningbetween relevant sectorsLack of adequate counsellingspace in primary care facilitiesBreakdown in communicationbetween hospitals, clinics andpharmacies results in inconsistentprovision of medicationInadequate availability ofPC101 guidelines

Creative ways of making morecounsellingspace available – e.g. gazebosand park homesExtra steps taken to ensurepatients getmedication (e.g. delivering topatients homes)Master file of guidelinesavailable at facilities

Include planning for counselling spacewithin PHC facilitiesImprove communication between clinics,hospitals and pharmacies with respect todrug prescriptions and delivery systemsEnsure availability of master file of protocolsand guidelines in each facility

Participation& Collaboration

Governance Inter-sectoral Lack of coordination & collaborationbetween sectors due to differentroles and mandatesCoordination does not filter down fromplanning to implementation levelReluctance of some departments to getinvolved in implementation of mentalhealth policies & legislation

Clarify roles & responsibilities of differentdepartments with respectto mental healthBuild capacity & commitmentat leadershiplevel to create stronger partnershipbetween DSD & DoH; formalise structuresto improve collaborationTrain managers instakeholder engagement

DoH – DSD Lack of coordination in terms of planning& provision of psychosocial rehabilitationservicesLack of clarity of roles and mandates

Capacity building & commitment atleadership level could helpto build strongerpartnershipNGOs are theimplementing arm of DSD –DoH could work through them

Build capacity among healthprofessionals and managers toadvocate for mental health

Governance With service users& service providers

Inadequate consultation with serviceprovidersSome resistance to policy directivesamong service providers

Service users consulted through cliniccommittees and advocacy groups andthrough holding imbizos to getcommunity input

Improve consultation withservice users through serviceuser groups andcommunication with caregivers

Uncertainty about how to best consultwith service usersNeed for greater involvement of families& service users in treatment decisions

Build capacity of service usergroups to engage in advocacy, andallow for formal inclusion incollaborative structures

Equity &Inclusiveness

Governance Access Size & remoteness of some provinces& districts make access to services difficultDisparity between districts in terms ofnumber of facilities and communitycentresLack of qualified staff to provide mentalhealth services a barrier to access

Integrated care increases accessPublic education programmes ameans to increase awareness; helplines ameans to increase access

Integrating mental health into primaryhealth care could increase accessRaise awareness among serviceusers regarding how and whereto access services

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Stigma Policy framework is not clear on how toaddress stigmaDisparity between provinces in terms ofhow stigma is addressedShortage of staff to drive these programmesNegative perceptions, driven by ignorance,lack of awareness and fear, a barrier toreducing stigma

Integrated care could reduce stigmaSupport from provincialand district managerscould facilitate implementation of stigmaprogrammesUsing different forms of media toreach communitiesSupport groups can empower users

Integrating mental health intoprimary health care could help toreduce stigmaImplement anti-stigma campaignsin the community, with supportfrom district and provincial managersMass awareness campaigns usingdifferent forms of media, role modelsand support groups to reach andempower service users; clarifywhose responsibility it is to do this

Ethics &Oversight

Governance Ethicaltreatment

Disparity between provinces interms of functionality &effectiveness of MentalHealth Review BoardsStaff shortages a hindrance tocarrying outinspections & following up grievancesLack of indicators against whichto evaluateperformance

There are a number of mechanismsfor ensuring quality/standards in healthservices in general, applied to mentalhealth

Address disparity between provincesin terms of functionality and effectivenessof Mental Health Review BoardsIntroduce the WHO Quality Rightsproject and capacitate Mental HealthReview Boards to use the toolkit toensure that standards are being met

Ethicalresearch

Research units and ethics committees atprovincial and national levels overseehealth researchNational Health Act provides guidance onprocedures for conducting research withhealth care users

Intelligence& Information

Information Lack of monitoring mechanisms/systemsat all levelsIndicators for mental health in the healthinformation system are not sufficient interms of quantity or qualityInadequate human resources to carryout M&E

Provincial and district officials needto play a role in monitoring qualityof mental health servicesBuild M&E capacity at all levels andimprove the use of indicators toinform policy and service planning

Include indicators for mental healthin the health in the health informationsystem that provide sufficientinformation to inform interventiondecisions and assess qualityimprovements

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study suggest that, although this Act has a strong humanrights focus and is generally viewed positively, insuffi-cient training has affected compliance and implementa-tion of the Act, as has poor coordination betweensectors. The Rule of Law principle requires that legalframeworks pertaining to mental health should be fairand impartially enforced. In order to improve govern-ance of this aspect, it is recommended that further train-ing be provided on the enforcement of the MentalHealth Care Act and that all departments responsiblefor enforcing the Act be included in this training. Simi-larly, there seems to be a lack of capacity to push imple-mentation of the new mental health policy framework atground level. The Strategic Direction principle is basedon the notion that leaders should have a “broad andlong-term perspective on (mental) health and human de-velopment, along with a sense of strategic direction forsuch development” [30]. Although the South Africanmental health policy framework seems to capture this vi-sion and provide such strategic direction, findings heresuggest that there is a need for capacity building totranslate plans at provincial and district levels, consistentwith studies suggesting that sound mental health policiesor legislation do not necessarily translate into improve-ments in services at local levels [39]. Building capacity toimplement policies and plans would include using thenew district mental health teams as a unit for planningat local level, as well as training managers in changemanagement for the implementation of integratedchronic care, including mental health. The capacity andresource disparities between provinces also need to beaddressed in order for the policies and plans to be effect-ively operationalised. We would add to these principlesthe WHO [10] guideline that integration is a process,not a once-off event. Thus, implementation of the policytowards integrated mental health care will take time anda concerted effort to secure buy in through involving allstakeholders in the process.The principle of Responsiveness captures the idea that

institutions and processes in the health system shouldserve all stakeholders and ensure that the policies andprogrammes that are put in place are responsive to theneeds of all health care users. Because integration is fun-damental to adapting the health system to respond tothe needs of mental health care users, we amended thisprinciple to Responsiveness and Integration. We foundthat mental health is still not prioritised across variouslevels of the health system, and is still seen as separatefrom other health needs. There is resistance on the partof primary health care providers and users and theirfamilies to integrated care at both facility and commu-nity levels. As in other areas, there is also uncoordin-ated planning and poor intersectoral collaboration androle clarification. Services are still concentrated at

institutional level, and there is a shortage of community-based services. Service providers are also not sufficientlytrained in dealing with mental health issues and continueto be trained in a biomedical orientation towards acutecare, rather than holistic, patient-centred care. Thus,although South Africa is committed to moving towardsintegrated mental health care, there are a number of sys-temic factors that hinder the realisation of the principle ofResponsiveness and Integration. This can be improved byestablishing collaborative arrangements between theDepartments of Health, Social Development and othersectors that outline clear roles and responsibilities, par-ticularly with respect to community-based psychosocialrehabilitation. There is a need to redistribute resourcesfrom tertiary level institutions to community-based ser-vices, which would require the provision of training andsupport in PC101 to facilitate integrated care. This isechoed by Petersen et al. [40], who suggest that the injec-tion of mental health resources into primary health careand more efficient use of existing resources is needed toachieve deinstitutionalisation and comprehensive inte-grated primary health care in South Africa. In addition,education and awareness raising about the benefits of inte-gration among service providers is likely to facilitate buy-in to integrated chronic care for mental health.Making the best use of resources while ensuring that

processes and institutions in the health system meetpopulation health needs underscores the principle ofEffectiveness & Efficiency. Here, health system buildingblocks of human resources, financing and infrastructurecome into play, as well as the provision of essentialdrugs and treatment protocols. A number of challengesrelating to human resources for integrated care wereidentified in this study. These included a shortage ofhealth professionals and specialists to implement thepolicy and insufficient budget to appoint additional staff;inflexible staff structures limiting the creating of newposts for district mental health teams; and poor uptakeof PC101 and limited capacity for supervision and moni-toring of PC101 implementation. There is a need forflexibility in the creation of the district mental healthteams, including adapting existing staff structures to cre-ate the relevant posts. Pre-service training of PHCnurses should include PC101, while existing staff needtraining and mentoring in PC101 to support the imple-mentation of mental health aspects. The importance oftraining primary health care workers in the recognitionand treatment of mental disorders and ensuring theyhave adequate supervision and support has been recog-nised elsewhere [4,13]. Furthermore, task sharing shouldbe promoted to extend mental health services at facil-ities by using lay counsellors and in communities byusing community health workers. This builds on previ-ous research that task sharing can be effectively


extended to lay health workers, particularly when inter-ventions are simplified and proper supervision isprovided [3,41,42]. It is thus critical that these non-professionals receive adequate training, role clarifica-tion and supervision in order to effectively carry outtheir duties.There was widespread recognition in this study that

funding for mental health is inadequate, which echoesresearch showing that there is a gap between the burdenof mental illness and the budget allocated to it [43]. Thisis exacerbated by disparities between provinces in termsof resource allocation. In order to improve governancethrough Effectiveness & Efficiency, therefore, it is rec-ommended that existing resources be used more effi-ciently – for example, through a phased approach topolicy implementation, or by piggy backing onto otherprogrammes. Maximising the effectiveness of limited re-sources by reducing redundancies as well as making useof other programmes has been suggested elsewhere [4].Participants in this study also believed that revising theway that budgeting is done in the Department of Healthfrom an historical to an activity-based allocation, wouldhelp to direct more resources towards mental health.Governing in an effective and efficient manner to inte-grate mental health into primary health care is furtherconstrained by the inadequate quantity and quality ofexisting infrastructure for mental health serviceprovision. This continues to be identified as a weaknessin the response of the health system to the provision ofmental health care [44]. It is critical for planning toinclude counselling space within primary health carefacilities in order to shift from a biomedical to a psycho-social model of care. Evidence based psychosocial inter-ventions to treat, promote health and prevent illnessneed to be taken seriously and included in infrastructureplans. This is important for recovery, as opposed to justproviding symptom management which is currently thedominate practice with regards to chronic illness andmental illness [45]. In terms of consistent provision ofmedication, there is a need to improve communicationbetween clinics, hospitals and pharmacies with respectto drug prescriptions and delivery systems. Previousresearch has shown that irregular supply of medicationremains a challenge in many low- and middle-incomecountries [39], and requires strengthening of supplychain management systems and training of health carestaff [6]. If patients do not receive their medicationtimeously, they are at risk of relapsing, which has aknock-on effect for the effectiveness of the service. Simi-larly, making a master file of treatment protocols andguidelines available in each facility could contribute toadherence to PC101 and the holistic treatment ofpatients for all their health needs. Integrating psycho-social assessments and interventions into management

protocols can further assist with promoting a holisticmodel of care [4].Due in part to the varied nature of the social determi-

nants of mental health, mental health is essentially anintersectoral issue [6]. Moreover, “all men and womenshould have a voice in decision making for health…(while) good governance of the health system mediatesdiffering interests to reach a broad consensus on what isin the best interests of the group” [30]. The principle ofParticipation and Collaboration highlights the need toinvolve all stakeholders in planning and provision ofservices, consistent with recommendations that effectiveintegration requires collaboration with other govern-ment non-health sectors, nongovernmental organisa-tions, community health workers, service users andcommunities [10,46]. Findings from this study indicatethat this is an area of weakness in the health system inSouth Africa. There is a lack of coordination and collab-oration between sectors due to different roles andmandates, which filters down from planning to imple-mentation level. There is thus a need to clarify roles andresponsibilities of different departments with respect tomental health. It is also recommended that capacity andcommitment be built at leadership level to create stron-ger partnerships with other sectors and to formalisestructures to improve collaboration. Part of this mayentail training managers in stakeholder engagement, aswell as building capacity among health professionals andmanagers to advocate for mental health and overcomethe resistance of some departments to get involved inthe implementation of mental health legislation and pol-icies. It was also evident in this study that there is inad-equate consultation with service providers regarding thedevelopment and implementation of policies and plans,resulting in resistance to policy directives. To overcomethis, mechanisms for improving participation of serviceproviders in planning need to be improved. In this study,as elsewhere, mental health care users and their familiesare seldom involved in planning and decision makingabout mental health service provision, from a macro orpolicy level [39,47] to a micro or treatment plan level[48]. There is a need to improve consultation withmental health service users through user groups andcommunication with caregivers, and allowing for formalinclusion in collaborative structures. Service users’ cap-acity to engage in advocacy should also be strengthened.The Equity and Inclusiveness governance principle is

based on the notion that “all men and women shouldhave equal opportunities to improve and maintain theirhealth and well-being” [30]. In South Africa, this is oper-ationalised as improving access to mental healthservices, and reducing individual and institutional stigmaaround mental health issues. Findings showed that thesize and remoteness of some areas can make it difficult


for users to access services. In addition, the shortage offacilities and community services, as well as the numberof staff to provide these services, was considered a bar-rier to access. It is believed that integrating mentalhealth into primary health care – the crux of SouthAfrica’s mental health policy – could increase access, aswell as serve to decrease stigma. Raising awarenessamong service users regarding how and where to accessservices is also recommended. However, it has been sug-gested that the reluctance of service users to accessmental health services is partly affected by stigma anddiscrimination [43]. Because the mental health policy isnot clear on how to address stigma, there is a need toimplement anti-stigma campaigns in the community,with support from district and provincial managers. It isrecommended that mass awareness campaigns use dif-ferent forms of media, role models and support groupsto reach and empower service users. Advocacy has alsobeen recognised as critical to the success of integratedmental health care [10].Safeguarding the interests and rights of mental health

care users and applying the ethical principles of auton-omy, beneficence and justice are fundamental to theprinciple of Ethics and Oversight for good governance.In this study, it was found that there is disparity betweenprovinces in terms of the functionality and effectivenessof Mental Health Review boards, which needs to beaddressed. There is also a lack of staff to carry out qual-ity checks and follow up on grievances, as well as a lackof indicators against which to evaluate performance. It isrecommended that the WHO Quality Rights project beintroduced and Mental Health Review Boards be capaci-tated to use the toolkit to ensure that standards arebeing met. The WHO QualityRights Project has objec-tives of improving the quality of care and human rightsconditions in mental health and social care facilities;changing attitudes and building capacity in service users,families and health workers to understand and promotehuman rights and recovery; promoting the involvementof people with mental disabilities in advocacy work; andreforming national policies and legislation in alignmentwith best practice and international human rights stan-dards [49]. The QualityRights Project has a toolkit toassist countries to assess and implement strategies tomeet key standards in inpatient and outpatient mentalhealth and social care facilities, which are in alignmentwith the International Convention on the Rights ofPersons with Disabilities. Implementing this toolkit islikely to enhance governance through the principle ofEthics and Oversight, as well as improve Participationand Collaboration efforts through empowering serviceusers to advocate on their own behalf.Finally, “intelligence and information are essential for

a good understanding of the health system, without

which it is not possible to provide evidence for informeddecisions” [30]. Being able to systematically gather andassess information about mental health issues is funda-mental to the principle of Intelligence and Information.However, results of this study suggested that there is alack of monitoring and evaluation mechanisms at alllevels of the health system, as well as inadequate humanresources to carry out monitoring and evaluation. Indi-cators for mental health in the health information sys-tem are also not sufficient in terms of both quantity andquality. This is consistent with other findings thatmental disorders or health are not adequately capturedin routine health information management systems inmost low- and middle-income countries [6] as well as inSouth Africa [44]. It is thus recommended that monitor-ing and evaluation capacity be built at all levels, toimprove the use of indicators to inform policy and ser-vice planning. In addition, provincial and district officialsneed to play a role in the monitoring of the quality ofmental health services through the systematic use ofinformation. Further, it is critical to include indicatorsfor mental health in the health in the health informationsystem that provide sufficient information to informintervention decisions and assess quality improvements.

AbbreviationsDOH: Department of Health; DSD: Department of Social Development;ICDM: Integrated Chronic Disease Management; LAMICs: Low- andmiddle-income countries; MHPF: Mental Health Policy Framework;NCDs: Non-communicable diseases; PC101: Primary Care 101.

Competing interestsThe authors declare that they have no competing interests.

Authors’ contributionsDLM participated in the design of the study materials, carried out andcoordinated data collection, analysed data and was involved in the draftingof the manuscript. IP conceived of the study, participated in the design ofthe study and study materials, and was involved in the drafting of themanuscript. Both authors read, edited and approved the final manuscript.

AcknowledgmentsThe research leading to these results is funded by the European Union´sSeventh Framework Programme (FP7/2007-2013) under grant agreement n°305968. The authors gratefully acknowledge contributions from the researchteam, specifically Tasneem Kathree, Carrie Brooke-Sumner, One Selohilwe andPalesa Mothibedi for their assistance in collecting and transcribing the data.

Author details1EMERALD project, School of Applied Human Sciences, University ofKwaZulu-Natal, P/Bag X01, Scottsville, Pietermaritzburg 3201, South Africa.2EMERALD project, School of Applied Human Sciences, University ofKwaZulu-Natal, Durban, South Africa.

Received: 12 December 2014 Accepted: 19 February 2015

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