In 2017, during an investigation into the state of mental health in South Africa, the Human Rights Commission (HRC) found that mental health infrastructure in the Eastern Cape had been historically neglected. The provincial health department, in the HRC report, acknowledged that there “were shortages of human resources in rural parts of the province, that infrastructure was inadequate for the purpose, and that budgeting for mental health was not meeting the needs of users”. 

At the time, the department said it had a shortage of 1,600 psychiatry beds and the shortage was particularly acute in rural areas. In terms of human resources for mental health, there were “16 psychiatrists, 37 psychologists, seven occupational therapists, 24 social workers, and 403 psychiatric nurses”.

One of the HRC’s recommendations was for the provincial health department to staff the provincial mental health directorate in the province within six months of the report. The HRC also recommended that the department should finalise the provincial strategic plan for mental health to ensure there are resources for mental health, and the plan should address the “unavailability of psychiatric beds and [indicate] measures that will be put into place to improve access to mental healthcare in rural parts of the province”.

A year later, in 2018, another report, this time by the Health Ombud, who investigated conditions at the Tower Psychiatric Hospital in Fort Beaufort, found a systemic lack of mental healthcare in the province. Although the ombud did not find any “prima facie evidence of institutionalised, systematic or deliberate violations of human rights”, it noted that the department had failed to implement “its oversight mechanisms and has done little to raise mental healthcare quality standards at the institution”.

One of the recommendations was to appoint a mental health administrator for the province, stressing the “dire need for mental healthcare services to be overhauled”. Echoing the HRC recommendations, the Ombud said human resource shortages should be addressed and mental health services should be adequately resourced (financed).

The report also stated that the department “has many laudable plans on glossy paper; however, there was very little evidence that these plans were implemented”.

Forward another year to a different facility and this sentiment in the Health Ombud’s report about laudable plans with no evidence of implementation was once again underscored. After an unannounced visit by the Public Service Commission (PSC) to the Cecilia Makiwane Hospital’s mental health unit, one commissioner called it a “disaster”. The visit followed media reports about the neglect and disrepair of the hospital’s mental health unit.

The PSC, in its report, said parts of the old structure of the hospital’s mental health unit were in “total disrepair as they have not been maintained for years”. 

The findings included that “windows were broken, the walls peeling off and electrical wires in the passages were exposed, which posed a serious threat to staff, patients and the citizens”. 

The commissioners saw patients lying on the concrete/cement floor, stating that “this [is an] unacceptable way of treating patients” and that some secluded areas “reminded of apartheid secluded prison cells and such structures are not good places for healing and rehabilitation”.

The commission recommended upgrades, the provision of furniture for patients to rest on and that the hospital “demolish its seclusion wards and replace them with environmentally friendly rooms that are provided with the necessary equipment for the utilization of patients”.

Then, last year, in a report on the conditions at some Eastern Cape hospitals, the Deputy Public Protector recommended that the health department must ensure that an integrated mental health strategy for public hospitals be developed for the Nelson Mandela Bay Metropolitan area, “within 90 days from the date of this report”.

The report was released in August 2020.

Piecing together the department’s plans

The provincial Department of Health had not responded to Spotlight’s requests for detail on its mental health services strategy and progress in implementing the recommendations from these various reports by the time of publication. 

A closer look at its annual reports over this period, as well as the department’s strategic plan for 2020/21 to 2023/24, does, however, provide some detail.

In the departmental strategic plan, the department noted that it had “identified systemic weaknesses in the leadership and governance of mental health services in the province”. 

The department also acknowledged that the infrastructure for the psychiatric facilities “has degenerated over the time and this is coupled with a bed shortage of 1,600 in the province”. During the HRC investigation back in 2017, the department cited the same number of bed shortages, which creates the impression that more than three years later nothing has been done to increase bed capacity.

Another possible explanation is that this was simply a cut-and-paste exercise of the undertakings the department has been making for a number of years on what the Health Ombud aptly described as “laudable plans on glossy paper” without evidence of implementation.

In the strategic plan, the department sketches a grim picture of mental health challenges in the province. Among these challenges is a “critical need for facilities offering rehabilitation services” due to the rise in substance abuse in the province. There are only 91 beds available for this purpose across the province, including those from civil society/non-governmental organisations. 

“Mental illness associated with substance abuse is a public health concern,” the department states in its strategic plan, “and partnerships will be explored to render the relevant services to prevent and treat substance abuse effectively.”

Other undertakings to strengthen mental health services include implementing “community-based psychiatric services within primary healthcare, strengthening the 72-hour observation in district hospitals, as well as focusing on acute and chronic in-patient management”. 

The department also plans to increase acute bed capacity at key hospitals in the more rural eastern parts of the province.

We could not find any meaningful detail in the strategic plan on what the department’s concrete plans are to expand community-based psychiatric services.

One of the hospitals that the department singles out for plans to increase acute bed capacity is St Barnabas Hospital in Libode in the OR Tambo District. Closer inspection of the strategic plan for the five-year period shows that the plan is to “recommission and procure new medical equipment and furniture” for the mental health unit at St Barnabas Hospital. About R2.4-million is budgeted for this. The project is still at the tender stage, the report shows. 

The department also notes Madzikane Hospital, Holy Cross, St Patrick’s, and Zithulele hospitals, but projects planned and the budgets allocated provide no detail about how they will benefit the mental health programme.

However, there are some projects that the report notes are already in the construction phase. For example, R2.8-million is budgeted in this financial year for upgrading infrastructure at the Komani Psychiatric Hospital in Queenstown.

Based on the strategic plan, with the exception of Cecilia Makiwane Hospital, most of the eight major infrastructure projects (that Spotlight could identify) are still in the planning phase with no allocated budget listed. The majority of these projects were for 72-hour psychiatric observation units at district and provincial hospitals. 

At the Cecilia Makiwane Hospital, earlier labelled by the PSC as “a disaster”, a 72-hour psychiatric observation unit is still in the planning phase with an allocated budget of R62-million for each of the two financial years (2021/22 and 2022/23). The report also listed further upgrades to a “level one psychiatric unit” with a R30,000 budget in this financial year and the same amount for the 2022/23 financial year.

Infrastructure alone, of course, is only one part of the solution. Other than referring to a Human Resources for Health plan that it will develop to address staff shortages and ensure an appropriate skills mix, we could not find much evidence in the strategic plan that the department has put plans in place to ensure that there will be sufficient qualified staff to provide the required care. 

The department has on many occasions insisted it would like to appoint more staff but is battling with budget constraints. The risk is that new infrastructure might be underutilised, as appears to be happening at the multibillion-rand Kimberley Mental Health Hospital in the Northern Cape.

The department’s annual report for 2019/20 shows that by March 2020 it had a vacancy rate (reflects the posts not filled) of 13.8%. Among the highest number of vacancies were those for nurses, mainly professional nurses. No breakdown was given for specialities such as psychiatric nurses, but the then health minister Dr Zweli Mkhize, in 2019, in a response to a written question in Parliament said the department (at that time) employed 29 clinical psychologists, 10 psychiatrists and one counsellor in the Eastern Cape hospitals. In 2021, these figures changed dramatically. In the annual report, the department fingers budget cuts and the rurality of the province, along with national health worker staff shortages, as reasons for its own shortages.

Metal barriers separate patients and staff at the Cecilia Makewani Hospital, Eastern Cape in this 2019 file picture. (Photo: Kathryn Cleary / Spotlight)

Fewer beds than in 2018 

Despite various undertakings by the department over the years to address mental health service challenges, a response to a question in the provincial legislature by the Health MEC, Nomakhosazana Meth, in August this year, suggests little progress has been made on getting the department’s laudable plans from “glossy paper” to a place where users of mental health services might feel a difference.

Jane Cowley, a DA MPL and the party’s spokesperson for health in the Eastern Cape, said there are now fewer mental health beds in the province than in 2018. This followed the figures provided by Meth in response to her question in the provincial legislature in August. The figures showed that there are only two psychiatrists in the province’s public sector hospitals and 13 psychiatric nurses in the seven facilities where patients can access mental health services. Meths’ figures showed there are 1,421 mental health beds in the Eastern Cape, while some districts, such as Joe Gqabi and Alfred Nzo districts, have not a single bed for mental health patients in the public sector.

The department ‘failed my family’

Monwabisi Makhosi from Motherwell in Nelson Mandela Bay looked after his late brother, who lived with mental illness. Makhosi tells Spotlight they were turned away numerous times at Dora Nginza Hospital in 2020 where he took his brother.

“We were constantly told that there were no beds. My brother was a long-time patient at Tower Hospital.” 

Makhosi says after his brother was discharged from Tower Hospital, he cared for him. 

“We used to take him to Dora Nginza Hospital for 72-hour observation whenever he fell ill. Depending on the level of care he needed, they would refer him to either Elizabeth Donkin Hospital or Tower Hospital, but last year a doctor at Dora Nginza Hospital refused to admit him and told him to go home as there was nothing wrong with him,” Makhosi says.

“I provided doctors with his discharge report from Tower Hospital, but they ignored that and told me that his condition does not require admission. Although it is difficult to look after a mentally challenged person, especially when you are working, I used to make sure that he takes his injection regularly at the local clinic [Motherwell clinic]. I believed his condition was requiring an in-house treatment because I knew that after being discharged it doesn’t take more than two years for him to be back in hospital for treatment.

“I feel that the department failed us by not admitting my brother when he was supposed to be admitted and that could have saved his life,” Makhosi says. 

“He died of Covid-19 in 2020, which he contracted from moving around in the streets. He was loitering, and it was difficult to stop him, because if I locked him in the yard he would jump the fence because he wanted to go out and I knew it was inhumane to chain him up.

“I believe it is high time that the hospitals stop treating those with mental illness like second-class citizens and offer them the same quality care as other patients. My brother needed the care of specialists who knew how to give him the right care. It was a high risk not to admit him when he became ill, because his violent behaviour posed a threat to his life and that of community members.”

Were recommendations acted on?

Public Protector spokesperson Oupa Segalwe told Spotlight the Public Protector first released a factual report based on the observations made during the in loco inspections. These in loco inspections refer to when investigators visit the site that has a bearing on an investigation (complaint) to observe first-hand the conditions at the site to gather their own evidence.

“It was meant to provide quick wins for provincial health authorities in the Eastern Cape to take advantage of,” says Segalwe. “Subsequently, the Public Protector released an investigation report with binding remedial action on 28 June 2021.”

The remedial action at Livingstone Hospital that the Public Protector required the provincial health department to take included developing an integrated mental health strategy for public hospitals in the Nelson Mandela Bay Metropolitan area. The strategy had to be developed within 90 working days from the date of the report. This period lapsed in the first week of November, and it is unclear whether the strategy has indeed been developed.

“The Public Protector remains concerned about the state of public health facilities across the board and is paying close attention to progress in respect to the implementation of the remedial action,” Segalwe says. He says the compliance unit of the Public Protector, which is responsible for tracking progress in the implementation of remedial action, will now follow up with the Office of the Superintendent-General of Health in the province.

However, on other recommendations, some statutory bodies’ hands are tied.

Loyiso Mgengo, provincial director of the PSC, says the commission only compiles a report with recommendations, directions, and advice. It may not make any final determinations. “[So] the PSC cannot enforce its recommendations. After issuing the report about its work, it engages the affected department regarding the implementation plan. It is up to the executive authority to decide whether to implement the directions or not,” he says. 

“Therefore, recommendations of the commission are not binding and the commission relies on the legislature, which is mandated to ensure that these recommendations as presented are implemented.”

Mgengo says they are aware of the issue of staff shortages in the province that may have a history in certain pockets of the provincial administration coupled with challenges of budgetary constraints and a moratorium on the filling of certain positions. “This is a challenge nationwide,” he says.

Three years after its report, the Office of the Health Ombud says it has its own resource constraints that make it difficult to follow up on recommendations. 

Ricardo Mahlakanya, the spokesperson for the Health Ombud in the Office of Health Standards Compliance, says they can only uphold a complaint and recommend what action an organisation needs to take.

“We do not have legal powers to enforce our recommendations, but where an organisation is reluctant to implement them we will try our best to persuade it to do so.”

Mahlakanya says the ombud would ordinarily follow up on recommendations they make “until they are acted on”.

“However, there is a list of facilities that need to be inspected and investigated and the truth of the matter is we are unable to go back to all facilities due to a shortage of staff and minimal resources. We shared our recommendations with the Department of Health and respective health stakeholders to take corrective actions,” he says.

Having a mental health plan backed up with funding

Referring to the broader legal and policy framework, Michelle Donnelly, Advocacy and Awareness project leader at the South African Federation for Mental Health, says, “The National Mental Health Policy Framework and Strategic Action Plan (MHPF) have been developed to enhance mental health services in South Africa. These legislations are vital to the efforts of mental health in the country, but there were critical challenges in their implementation and the impact of the MHPF is rather unknown.”  

She attributes this to the fact that there was no concurrent budget dedicated to supporting the implementation of the plan or reporting requirements linked to its objectives. 

“We urge that they must be budgeted for prior to implementing the National Health Insurance programme,” she says.

“To make mental healthcare more accessible, we must provide services, care, and support in communities and primary healthcare settings. This will reduce the treatment gap and people who remain undiagnosed. 

“Tertiary facilities are a vital component of a strong mental healthcare system; however, it is not feasible to expect for such settings to deliver the bulk of mental health services, including prevention and promotion.”  

Attempts by Spotlight to get answers from the department were unsuccessful. We will add comments if they respond after the initial publication of this article. DM/MC

This article was produced by Spotlight – health journalism in the public interest.