South Africans face a significant burden of mental disorders compared with the rest of the world. A recent national survey found that one in every four adults suffers from a clinically significant depressive or anxiety disorder. “Clinical significance” is determined by impaired daily functioning and high levels of distress.

The Covid-19 pandemic exacerbated emotional distress, depression, anxiety and other mental health concerns, resulting in an increased demand for mental health services. Despite various attempts and commitments to prioritise public mental healthcare services, limited resources and budget constraints are often cited as reasons for the slow-paced implementation.

However, the lack of sufficient mental health treatment has far-reaching individual and societal costs – factors that are often overlooked during budget considerations.

In the South African public primary healthcare system the treatment gap for persons with HIV is estimated to be more than 90%, meaning there is only about one mental health professional for every 100,000 people.

Untreated mental illness not only negatively affects general physical health, but increases costs to the health system and reduces economic and personal productivity. On World Mental Health Day 2023, the World Health Organization called for a global unification behind the theme of mental health as a universal human right by protecting people from mental health risks and providing the necessary care.

This aligns with the principles of the universal health coverage call, urging governments to ensure that people with health needs are adequately supported through accessible and good-quality services without facing financial hardship. The societal cost of neglecting mental health far outweighs the cost of providing care and treatment, yet little progress has been made in ensuring mental health services at the primary care level.

The cost to society

The global conversation about the cost of mental health often focuses on the cost carried by governments and individuals to care for and treat mental health disorders. However, there is less focus on the cost of not treating or providing care. This includes premature death, disability and infectious diseases.

Anxiety and depression result in an estimated staggering $1-trillion global loss each year. This represents the productivity time lost because of undiagnosed or untreated mental health disorders in employees.

In South Africa, studies have shown that depression alone costs the country more than R200-billion annually as a result of absenteeism and presenteeism – when employees are at work but not productive due to being unwell.

Read more in Daily Maverick: Human mental health is deeply complex and cannot merely be reduced to a checklist of symptoms

While depressive and anxiety disorders are commonly known for causing productivity loss, it’s crucial to also consider the impact of substance use disorder and the cost it imposes on society.

South Africa has high rates of substance use – a recent review noted that nearly a third of South Africans had problematic alcohol use in the past year. Untreated substance misuse further exacerbates risks for physical and mental conditions, such as neuropsychiatric disorders and disability, but also leads to a reduction in the phenomenon of quality-adjusted life years (Qalys).  

The Qaly metric is used to describe the quality and number of years lived with a particular health condition. In this case, an increase in years lived with disability, especially in people of working age, negatively affects the country’s economic activity.

Substance use also increases risk-taking behaviours, contributing to an increase in noncommunicable diseases, injuries and trauma-related cases in emergency rooms. In the indirectly enforced experiment of government alcohol prohibition during Covid lockdowns, trauma rooms were significantly less busy, indicating the strain substance use puts on already overburdened healthcare systems.

While it is important to prioritise resources for trauma cases, mitigating or preventing incidents related to substance use disorder could reduce government spending.

Another factor to be considered is the intersection of mental illness and HIV/Aids and how it significantly increases spending on HIV/Aids treatment. A large share of the National Department of Health funds raised through tax and other sources are allocated to HIV programmes, and it has been established that up to 62% of people living with HIV/Aids suffer from mental health illness which potentially leads to treatment interruption.

The associated costs of re-engagement in care, including clinical examination, adherence counselling and, in other cases, second-line treatment to achieve viral suppression, creates additional financial demands on healthcare funds.   

Treatment costs

Research at the University of Cape Town reveals insight into the costs of South Africa’s mental health system. In the 2016/17 financial year, the public health expenditure on mental health was $615.3-million, or 5% of the total public health budget.

These costs include both inpatient and outpatient care, with 86% of the national mental healthcare budget spent on inpatient care, and specialised psychiatric hospital-level care taking up 45% of the cost. For mental health, the curative part of the care cascade has become a major cost driver. 

The system’s rigidity and inability to identify, treat and support persons with mental health disorders at lower levels of (outpatient) care is not cost-effective.

Another cost driver is the readmission of patients due to mismanagement of cases or poor continuity of care after hospital discharge. The release of patients into the care of caregivers without proper medication education, support and home-based care leads to relapse and readmission. We know that only one-fifth of people with severe mental illness attend their first outpatient clinic visit.

Moving forward

South Africa’s move towards universal health coverage through the National Health Insurance shows the government’s commitment to improve mental health coverage by including mental health services in the comprehensive services benefits. Despite concerns about funding sources, this means people from all socioeconomic backgrounds will have access to quality mental health services without any fees or co-payments.

To ensure this commitment is followed through, there is a new plan, the National Mental Health Policy Framework and Strategic Plan 2023, which requires provincial governments to develop strategic plans for mental health that include targets and timelines. It further requires inclusion of processes such as annual reviews of budget allocations to hold provincial governments accountable and ensure mental health agenda alignment with national priorities.

Read more in Daily Maverick: SA’s new mental health plan and the problem of stigma

But as has been the case with previous frameworks and policies, such as the National Mental Health Policy Framework and Strategic Plan 2013-2020, implementation tends to take a different approach than anticipated.  

South Africa needs to prioritise practical and affordable ways to address mental health issues early, mainly at primary healthcare level. By doing so, we can manage mental health conditions before they become severe and require costly specialist treatment and management. Primary preventive measures in the form of awareness, education and clear referral pathways at this level could reduce the burden on society and the health system.

We propose a greater role for peers as deliverers of this type of care. Data suggests that persons with lived experience may be more effective as supporters of a substance use recovery journey, since they tend to be more empathetic and understanding.

The plan to integrate mental healthcare into all aspects of primary care seems more feasible and achievable. Integration is not without its challenges. Task-sharing approaches to non-specialists, such as nurses or social workers, may be feasible and cost-effective, but they are not universally implementable and bring their own challenges.

Read more in Daily Maverick: Of like mind — experts stress importance of universal access to mental healthcare

Maybe we do not need to look too far: The existing HIV and antiretroviral care programme implemented by the government is an example project of huge success. Many lessons from this programme can be learnt and transferred.

Our argument is that mental health is another crisis deserving of the same attention. A failure to act will cost the country far more than confronting the mental health challenge head-on. DM

Hlombekazi Sybil Majokweni, MPH, is a Junior Research Fellow in the HIV Mental Health Research Unit, Department of Psychiatry and Mental Health, University of Cape Town.

Dr Stephan Rabie, PhD, is a Senior Research Officer in the unit.

Dr Stefani du Toit, PhD, is a Senior Research Officer in the unit.

Professor John Joska, MBChB, PhD, is a professor of psychiatry and director of the unit.