Mental health care for persons with psychosocial disabilities has historically been under-prioritised. Globally, there has been a shift away from institutionalisation as the primary response to psychosocial disability towards community-based mental health care.
In South Africa, however, people with psychosocial disabilities are still being left behind because of under-resourcing and a lack of relevant and accurate data on the prevalence of such disabilities and trends in the use of mental health care services. These deficiencies have had dire consequences, as the ongoing Life Esidimeni Inquest demonstrates.
“Although our legislative and policy framework that governs community-based mental healthcare for adults with psychosocial disabilities largely aligns with the relevant constitutional and international norms and obligations, its implementation leaves much to be desired. This is largely due to major deficiencies in the system," says Marietjie Booyens who is a consultant at the Stellenbosch University (SU) Law Clinic. Booyens recently obtained her Master's degree in Law at SU under the supervision of Prof Sandy Liebenberg, the HF Oppenheimer Chair in Human Rights Law.
As part of her study, Booyens analysed section 27 of the Constitution which acknowledges everyone's right of access to health care services. She also examined policy documents and legislation relating to mental healthcare as well as selected international human rights instruments that focus on the normative standards of availability, accessibility, acceptability and quality for community-based mental healthcare. According to the World Health Organisation, people with psychosocial disabilities have received a mental health diagnosis, and have experienced negative social factors including stigma, discrimination and exclusion.
Booyens says her study shows that mental healthcare remains underfunded, investment in community-based mental healthcare is lacking, and significant disparities in resource allocation exist between provinces, between rural and urban areas and between the public and private health care sectors.
“Because of poor resource allocation, people with psychosocial disabilities don't have access to facilities, goods and services they so desperately need.
“Monitoring and information systems are also ineffective, safeguards for the quality and acceptability of care are lacking, and there is insufficient engagement with people with psychosocial disabilities and their representative organisations when policy is made, and its implementation evaluated.
“There is also a lack of clarity on the applicable standards for quality, ethical care; and poorly functioning oversight and accountability mechanisms."
Booyens adds that the sparse resources available for mental healthcare remain concentrated in psychiatric institutions and even where funding for institutionalised care has been reduced, that funding has not been ring-fenced for community-based mental healthcare.
She says this severe under-resourcing is unlikely to be addressed if we do not see an improvement in our monitoring and information systems.
“If relevant and accurate data are not collected regularly and processed reliably, we cannot ensure that sufficient resources are allocated, we cannot target the most vulnerable groups for urgent intervention, and we cannot determine whether further reform is needed to meet the mental health needs of persons with psychosocial disabilities.
“The state must invest in improved monitoring and information systems so that accurate, relevant, and quality data can be collected to improve the community-based mental healthcare system."
Booyens emphasises that people with psychosocial disabilities who live in rural areas must have the same access to the necessary resources as their counterparts in urban areas.
“We must address inequities in the distribution of infrastructure and human resources, and set clear and measurable targets nationally, provincially and locally for improved access to community-based mental healthcare goods, facilities and services. We also need special measures and more resources to improve the quality, acceptability and availability of community-based mental healthcare in rural areas.
“A clear and comprehensive set of standards for the provision of community-based mental healthcare at all relevant facilities must be developed and consistently implemented.
“People with psychosocial disabilities and their representative organisations must also be included in decision-making processes, the development of community-based mental healthcare programmes, as well as the monitoring of such programmes when they are implemented."
According to Booyens, community-based mental healthcare must follow a rights-based approach to improve the health of people with psychosocial disabilities and to empower them to pursue their own goals.
“We cannot consider psychosocial disability as some isolated corner of 'health care' only."