Heal by numbers: We can fix mental healthcare by spending smart – but will the state buy in?
Mental health does not have its own ring-fenced budget and given huge inefficiencies in our mental health spending, we need to be strategic in where and how we spend the little we have. Alicestine October unpacks what a new government-commissioned mental health investment case framework can mean for access to equitable and quality mental health services in the country.
Commemorating World Mental Health Day on 25 October, acting director-general in the National Department of Health Dr Nicholas Crisp, in a department-hosted webinar, used the word “frightening” to describe the current investment in mental health services while very low numbers of people receive the care they need.
Based on recently published data, the government spends about 5% of the country’s total health budget on mental health, but these services only reach about one in 10 people who need them. There are huge inefficiencies in how and where we spend the little we have.
This must change.
Over the past month, in a Spotlight special series of articles on mental health in South Africa, we unpacked the concerns and challenges around access and mental health policy implementation. We found an inherently lopsided mental health spending structure that does not speak to the lived realities of those depending on public sector health services. The bulk of public investment in mental health is channelled towards hospital-level psychiatry services, while some health economists have warned of huge inefficiencies. This is because data indicate that about 24% of those treated at the hospital level are readmitted, mostly due to a lack of community-based mental health support and care.
Our reporting and analysis showed, among other things, that mental health support services at schools are wholly inadequate and that in some parts of the country rural residents seeking mental healthcare services are stonewalled at clinic level simply because there are not enough human resources and mental health training at primary healthcare level is limited. The series also highlighted the need to integrate mental health screening and support for people living with HIV and the need for adequate infrastructure upgrades to mental health facilities.
However, none of these concerns is new.
In fact, in some provinces we found long histories of interventions, investigations of complaints about mental health services and reports with recommendations published by statutory bodies. So, it is safe to say that the provincial and national health departments are aware of these challenges, but as was the case with the lapsed National Mental Health Policy Framework, policy implementation has been poor, often due to a lack of political will, a lack of adequate resources, and increasing and competing service delivery needs vying for a piece of the budget.
Various mental health stakeholders such as the Psychological Society of South Africa have been calling for, among others, increased human resources for health, equitable access and that mental health should be more effectively integrated into South Africa’s proposed National Health Insurance (NHI) system. In an article in the Journal of Psychology in 2020, Head of Division: Intellectual Disability Psychiatry at Groote Schuur Hospital Professor Sharon Kleintjes and colleagues stressed that “the mental health impact of health disparities has been exacerbated during the pandemic, resulting in immense psychological distress for individuals, communities, and health workers”. “The lens of our current experiences during the pandemic,” the authors argue, clarifies and strengthens the case for “adequate funding for and integration of mental health services into primary health services, the link between systemic inequalities and (mental) health status of communities, and the need for widely accessible psychosocial interventions”.
There have, however, at least been some positive developments.
Following the Life Esidimeni tragedy, the Gauteng health department established a task team to develop a mental health recovery plan for addressing the health ombud’s findings. Professor in psychiatry Lesley Robertson was part of that task team and unpacks the strategy in an article she co-authored and published in the South African Medical Journal in June 2021. According to the article, there was an acknowledgement and a clear strategy “to strengthen district mental health services to deliver community-based care for people with any type and severity of mental illness”. This strategy also allowed for “a district specialist mental health team to develop a public mental health approach, a clinical community psychiatry team for service delivery, and a team to support non-governmental organisation governance at district-level”, but, the authors conclude, “their effectiveness and sustainability [will] depend on supportive, collaborative relationships among all stakeholders” to survive the pitfalls that often dog implementation efforts.
What we spend our money on
At present, mental health does not have its own ring-fenced budget and over the past two financial years the government has been playing musical chairs with some aspects of mental health funding. For example, among the changes proposed to the structure of provincial conditional grants was a mental health component introduced as part of the HIV, TB, malaria and community outreach grant in 2020. In the recent Medium-Term Budget Policy Statement it was announced that this component will now be shifted to the direct NHI grant. Not having mental health funding ring-fenced also means funding priorities for mental health are allocated as part of other bigger programmes such as infrastructure, district health services and health training.
During the webinar commemorating World Mental Health Day, health economist Sumaya Docrat from the University of Cape Town (UCT), who is part of a team that did a costing study for the government’s planned mental health reforms, shared some “frightening” numbers.
The figures show that almost half (45%) of the country’s expenditure on mental health is on specialised psychiatric hospital services. According to Docrat, the readmission rate (about 24%) – often within three months after discharge – also fuelled costs. This consumed about 18.5% of what the country spends on mental health services. Based on 2016/17 figures (when the study started), this readmission rate translates into about R1.5-billion for that year. Other health system challenges, such as medicine stockouts for first-line treatment (conditions such as bipolar disorder and depression), also add to this risk of relapse.
In contrast to the huge spending on inpatient care at hospital level, less than 8% of what the country spends on mental health is allocated to primary health services where the need is greatest for community-based care and support which can help with preventative screening and continued care to avert relapse.
The figures also show that among hospitals there are inefficiencies in mental health spending. For example, whereas 45% of the total mental health budget is spent on specialised psychiatric hospitals, only 11.7% of this expenditure goes to district hospitals, which according to the Mental Healthcare Act is the first port of call for hospital treatment.
What this means, according to Docrat, is huge inefficiencies in our mental health spending.
Where we can get to with spending reforms
During the commemoration event, professor of public mental health at the Alan J Flisher Centre for Public Mental Health at UCT, Crick Lund, who drew up the investment case framework, along with Docrat and health economist Donela Besada, provided a glimpse of the mental healthcare coverage we could have with the right kind of investment and political will. The study followed the costing study. Both were commissioned by the national Health Department for intended mental health reforms. It provides a detailed modelling of the costs and the impacts of scaling up mental healthcare in the country, and more importantly, provides a vision for universal health coverage and for human rights protection through integrated investments in mental health.
Lund was quite frank about the cost of inaction. “Currently, the treatment gap is estimated to be over 90% and we modelled treatment coverage of around 7.5%. Throughout the 15-year period, the cost of inaction increases from R460-billion to just over R500-billion per period and this is an immense loss, especially considering that these analyses are already quite conservative, and are likely underestimated,” he said. “The combined economic value of lost productivity really greatly exceeds the estimated cost of current mental health expenditure and a projected scale-up budget of R326-billion (over 15 years).”
Put simply, it costs the South African economy more to not invest in mental health than it does to invest in it.
Lund shared some of their findings, which have now been submitted to the Health Department, for the first time publicly during the webinar. He said the findings will be crucial to support a budget bid for a conditional grant for mental health in the medium term, but also, very importantly, to inform our ongoing development of the NHI benefits framework, the drafting of the next National Strategic Plan for the Control and Prevention of Non-Communicable Diseases, and the National Mental Health Policy Framework and Plan that is under way.
The ‘how’ behind the framework
Explaining their methodology, Lund says they worked on a benefit-to-cost ratio, which is calculated by taking the value of increased wellbeing and increased productivity and dividing by the intervention costs. This enabled them to “calculate the social and economic returns of improved mental health”.
“So, how many additional gains do you get in terms of productivity, capacity to learn, capacity to participate in social activities as a result of improved mental health, and we can then quantify that in terms of contributions to gross domestic product.”
In the framework, they also considered the unique costs that different sectors or departments will have to carry for mental health service delivery, since mental health cannot be the purview of the Health Department alone. So, departments including Social Development, Education and Human Settlements are roped in. Lund says they enumerated the needs and costs of preventative actions, including social and emotional learning programmes for school pupils. They then calculated the costs for the Department of Basic Education, which would be expected to fund and deliver these programmes, at about R3.22-billion over the scale-up period of 15 years.
The costs for the Department of Social Development for subsidies to individuals living with a mild to moderate intellectual disability, for example, was estimated at R476.32-million over the scale-up period. The department’s investments in substance abuse rehabilitation centres would amount to about R34-million annually – a relatively small proportion (about 0.02%) of the 2022-23 budget. Human Settlements was tasked with meeting the housing needs of vulnerable populations and had its own costs.
They estimate that over the scale-up period there could, on average, be a 5.3-fold increase in the number of people who receive care – an increase from the current estimate of 731,000 cases to about 3.8 million. At schools, with investment in social and emotional learning programmes we could see a twofold increase in pupils reached, to about 5.9 million.
A vision for community-based mental healthcare
The findings also underscore the importance of investment in community-based care. According to Lund, they included in the investment case framework a community-based daycare service as well as community-based residential services. “We’ve estimated only a very small proportion of what we think is a modest but achievable proportion of people living with bipolar disorder, psychosis, dementia and intellectual disability which would require these services. We calculated the staff composition and certain costs associated with those, as well as the implementation of facilities that are required for these daycare and community services and then costed those accordingly.”
What will it all cost?
Lund said they estimate the total cost will be about 11.6% of the current health budget of R224-billion. By the end of the scale-up period in 2035 it would amount to about 9%.
This “will require a shift in the existing model of care from a predominantly psychiatric hospital and inpatient model towards more emphasis on primary healthcare and community-based care. For example, at the end of the 15 years we envisage a shift from 8% to 16% of expenditure on primary health and at the district hospital level a shift from 12% to 19%. This will also require a downscaling of investment in tertiary hospitals, national centralised hospitals and specialised psychiatric hospitals, which currently receive the bulk of mental health funding.”
Referring to the expected efficiency gains, Lund said these reforms and shift in spending priorities on mental health would mean a substantial number of healthy life years gained. “By the end of the scale-up period, approximately 2.2 million years of healthy life would be restored through the provision and scale-up of treatment and rehabilitation services, with close to 2.5 million prevalent cases averted and more than 44,000 deaths avoided. And this amounts to a return on investment through restored productivity over the 15 years of about R60.2-billion, which increases to R117-billion when quantifying the social value of the investment as well.”
But reforms in mental health service delivery are not limited to budgets.
Some of the recommendations in the framework include more intersectional collaboration, not just among government departments but also the NGO sector, which will be key in the envisioned community-based care.
“We also need to invest in governance structures, especially at the provincial and district level, and our investment case provides for establishing mental health directorates in each province, as well as district mental health teams at the district level. These are really important governance structures for driving and providing oversight,” said Lund. The framework also stresses the need to invest in human resources for mental health as well as in infrastructure, particularly at district and regional hospitals to provide care closer to the community.
The team will now work with the national and provincial health departments on an implementation plan for the framework, and it is here that political buy-in will be crucial.
Crisp said the framework shows “that if we don’t spend on getting our primary healthcare system properly responsive, we are just creating a bigger and bigger challenge for ourselves at the end of the day”. He added: “You have to invest to save. Healthcare is an investment and not an expenditure.”
But for now, it is wait and see. DM/MC
This article was published by Spotlight – health journalism in the public interest.
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