Open access peer-reviewed chapter
Abstract
Despite the reported increase in the prevalence of mental disorders, including substance abuse disorders, required services in South Africa have not been improved to meet the demands for these challenges. Although South Africa has invested in a process to conduct a re-engineering of primary health care services to address a range of common health challenges in communities, this process has not demonstrated adequate policy and practice changes toaddress emerging challenges in providing services for mental health disorders at primary health care level. In particular, primary health care services do not include routine screening for common mental disorders, which include depression, anxiety, postnatal depression and substance abuse, although there are easy to use tools for such screening. This has resulted in a failure for early detection of these mental health challenges by the health system. The chapter argues that making moderate changes to the current offerings of primary health care can result in major achievements in offering mental health services, which in turn will benefit the patients and assist health services to address the increasing scourge of mental disorders, which include substance abuse.
Keywords
- Primary health care re-engineering
- South Africa
- mental health
- substance abuse
- screening
1. Introduction
The increase in the prevalence of non-communicable diseases has been widely reported, and among these is the category of mental disorders. Recent literature has reported that mental disorders have been on the rise exponentially, and account for an estimated 25% of all health-related disability worldwide [1], which highlights the need to prioritize treatment for this group of disorders. Although some health systems in some world regions and countries have acknowledged and have started to respond to this need, others lag behind. Health care systems are generally ideally organized to treat more people at lower levels of care, and decrease the proportion as the level of care increases. This is feasible because the less severity of illness can be easier managed at lower levels of care, where the illness requires less specialization and treatment costs are less because at this level most illnesses have not yet complicated. This approach has resulted in the globally accepted and promoted approach of placing Primary Health Care (PHC) services to offer optimal health services to the majority of citizens of a country. Primary healthcare (PHC) is thus acknowledged to be the foundation of well-functioning healthcare systems, and is the success indicator of attempts to improve health provision services. In fact, the 1978 Alma Ata declaration confirmed this view, by establishing and promoting PHC as a cornerstone of global health services provision [2]. The significance of the position of PHC services applies despite differences in regional and country wealth, and if well resourced and well run, PHC services can improve the offering of health services for the poor, and so decrease the differences in health outcomes across wealth bands. The South African government envisages the provision of primary health care as a service that should be provided to the whole population, which includes communities of low socio-economic status. During the Millennium Development Goals (MDG) era, and transcending to the Sustainable Development Goals (SDG) era, countries that were able to make strides towards achieving their goals, such as Brazil and Thailand, are those that prioritized the improvement of their PHC systems [3]. It is for that reason that PHC should be the focus of service provision for the increasing scourge of mental illness.
1.1 Substance abuse within mental disorders
The use of psychoactive substances affects mental function at both the short and long- term basis, hence the treatment of substance abuse disorders by mental health professionals. Moreover, literature also shows a bilateral association between the use of psychoactive substances and mental disorders [4], which implies that not only is mental illness a risk factor for later substance abuse [5], but substance abuse is also a risk factor for the development of mental illness [6]. This makes interventions for the prevention of substance dependence an important secondary outcome of interventions for early-onset mental disorders. For purposes of this chapter, reference to mental disorders includes substance abuse.
2. Cues and guidelines from the National Development Plan 2030
The South African National Development Plan (NDP) is the blueprint of how the South African government plans to improve the quality of services to achieve transformation that will improve the lives of the majority of people who were previously marginalized [7]. The NDP further identifies the need for a functional monitoring process as the basis of offering and improving the envisaged outcomes because without monitoring, it is not possible to determine the progress made towards any one goal. Chapter 10 of the National Development Plan acknowledges the promotion of health as a key to speed up transformation. The NDP further proposes to address a variety of social determinants of health, including mental health and substance abuse trends. The NDP further acknowledges the importance of considering the needs of the community, as well as embracing and elevating the role of society in addressing community needs. The scourge of mental disorders fits the category of community needs, and addressing them is an example of using the NDP to guide government responses to service delivery. The NDP further promotes the systematic use of data incorporating community health, prevention and environmental concerns, which is a focus area of the Primary health Care programme.
3. The scourge of mental disorders
As the prevalence on non-communicable diseases increase, mental health and wellbeing have been identified as central to reducing the global burden of this group of diseases [8]. The World Health Organization’s mental health action plan for 2013-2020 advocates for this integration because of the significant associations between common mental health disorders and other cardio cardiovascular diseases and common mental disorders, as well as the two groups sharing risk factors. The integration of mental health services seems to be so natural that their separation is regarded as a false divide [1]. Primary health care services present opportunities to offer universal health care to Africa [9]. However, this can be achieved if such services are well planned and adequately resourced with the right quantity of the right categories of staff [10].
3.1 Substance abuse in schools as a mental health issue
There are reports of an increasing prevalence of substance abuse in schools in South Africa [11], both in rural [12], as well as urban areas [13, 14], which calls for prevention as well as treatment interventions to address the challenges of substance abuse in schools. However, the focus of schools is mainly on academic development and outcomes. This often leaves both short and long-term impacts of other behaviors such as substance abuse, not receiving adequate attention.
On their own, schools are not equipped to deal with substance abuse, which identified a gap, which can and should be met by primary health care services. The inability of the school system to address the challenges related to substance abuse is demonstrated by the existence of the National Policy on Drug Abuse Management in Schools of 2002, which was meant to counteract the use of substances by learners. However, a study to assess the extent to which this policy was being implemented by schools found that the policy is not even known, let alone used by schools [15]. For most communities and schools, there is nothing that has been put in place for the prevention, screening or treatment of substance abuse, and upgrading primary health care services to provide these services will be a highly beneficial asset.
4. The urgency of addressing mental disorders
As the prevalence of mental disorders increase, related mental health services remain chronically under-resourced. The impact of mental illness is not limited to the patient, but also extends to the family, as mental distress has been identified among family members of psychiatric patients [16]. Additionally, those family members also need health care services, thus a continuous addition of people who need mental health services. On the other hand, the high prevalence of substance abuse in South Africa increases demands for mental health services [17]. Mental health services remain chronically under-resourced [18], which implies major unmet needs for mental health care. The lack of adequate resources has been interpreted as apathy by governments and funders to mitigate this human, social and economic costs of mental illness [19].
As in other countries, and in the absence of a well developed primary health care system to address mental illness, the current system of relying on mental hospitals as a mode of service provision is dominant in South Africa. Not only is this mode unrealistic for resource-constrained countries, but it limits the extent to which mental illness needs are met, as these hospitals are too few and expensive to meet the needs of the people who need such services. Moreover, the dependence on this mode contributes to non-prioritization of development of community-based resources and infrastructure.
Primary care delivery platform has been identified as ideal to address behavioral health, including substance abuse and mental disorders, as this level can be enhanced to effectively address these conditions [20]. Due to inadequate access to specialty substance use disorders, it is estimated that only 10% of people with substance use disorders (SUD) actually receive treatment [21], and this could be improved if such disorders were treated at primary health care levels, which is, by design, able to treat a greater proportion of the population. Delays in treating such patients contributes to major poor prognosis.
5. Qualities of a responsive health care system
Optimal health systems are those that respond to the needs of the people who rely on such services, which explains the regional and country variations of availability of services. As an example, when the global number of HIV infections were rising, HIV related services at primary health care levels were strengthened, which enabled an increased number of patients to access treatment nearer their homes and communities. Primary health care services were also improved to offer comprehensive HIV related services, which were not limited to the contracting the virus, but included services such as prevention of HIV, promotion of positive behavior change and health literacy about HIV [22]. The development of extensive community health services were also trained at this level, which further increased access to PHC services and cater for community health needs [23]. This approach was effective because it utilized local community workers who were able to identify relevant community needs [24], and the model can be duplicated for the promotion of mental health and prevention of mental disorders.
6. The appropriateness of primary health care services for mental health services
The advantages of the PHC as appropriate for the delivery of health services are many, including that most of such facilities are in communities and many clients are within walking distance to the nearest clinic. However, the availability of a structure does not necessarily guarantee optimal health services, as some of the clinics fall short of providing intended basic services. This implies that there is a need to continuously assess the functionality of primary health care services, to determine their relevance and effectiveness in providing services that are determined by community needs and priorities. An example of this gap is the increase in substance abuse and mental health challenges that have been prevalent in the last few years, and the failure of the health system to respond to the needs in the context of related services. As with other African countries, the South African Primary health care (PHC) nurse led [25], which is confirmed by the proportion of nurses compared to other health professionals, and the services rendered at PHC levels. It is for that reason that government can afford to offer services at no cost to the client as the State bears such costs [26].
What substance abuse and mental health have in common is that both are significantly impacted upon by social issues, which means that failure to respond appropriately may subject more members of the affected communities to similar challenges, which just increases the community burden of substance abuse and mental disorders. The increasing prevalence in both substance abuse and mental disorders has been well documented, but there is silence on how the PHC system has been prepared to respond in the appropriate manner. On the contrary, there is inequitable access to substance abuse treatment services in South Africa, and that, even among those that have access, the quality of services is often not ascertained. This is demonstrated by the action of government limiting itself to ensuring access but not putting adequate efforts to ensure quality that will improve treatment outcomes [27, 28]. The strengthening of PHC services in the area of mental health will thus increase access to the benefit of those that lacked such access. The monitoring of substance abuse services at PHC level, which is essential for making decisions, is not optimal [29].
7. The importance of the 1978 Alma Ata declaration in health service provision
The 1978 Alma Ata declaration envisaged primary health care to be the vehicle to achieve health for all. However, this outcome can only be achieved if the key principles of the Alma Ata are implemented, which include the requirement that services be driven by community needs and priorities, which will encourage and enable community participation, and the strengthening of the capacity of the district management system [30]. Because the cost of care increases with the level of care, primary health care services are at the most cost effective level for offering health care, which is ideal for a resource-constrained country like South Africa. However, failing to offer such services increases health care costs because of additional complications which needs to be addressed at a higher level of care, and which comes with higher costs and requires longer treatment periods.
8. Re-engineering of primary health care
Although the health budget of South Africa is on the upper end if compared to some of its neighbors, its health outcomes do not reflect that. This discordant has been attributed to a weak primary health care system [31]. The purpose of the re-engineering of Primary Health Care (PHC) is to improve both access and quality of health services to the general public. The need for the re-engineering was identified when the South African government acknowledged that although PHC services have been in existence for many years, they did not meet acceptable levels of both access and quality of services. The re-engineering of PHC was based on the three pillars as described below:
Ward based PHC outreach teams, which supports the provision of home and community based health services, which are linked to the fixed PHC facilities.School health services , which supported health services in schools.District based specialist teams , which supports the provision of district level specialists to improve health services at clinic level.
Evaluation of PHC services in South Africa have reported psycho-social support to be low [32], which can be improved by the integration of community health workers, who were specifically tasked with providing follow-up clinic and hospital care, as well as psychosocial support for patients and their family members [33]. Moreover, the re-engineering of primary health care purposed to, among others, to offer health promotion and prevention services at community level, which is needed for all disease categories offered at PHC level [34].
Primary healthcare is the first contact a person has with the health system for any health problem, and if well functional, the PHC re-engineering was expected to be a mechanism of relieving overburdened tertiary hospitals in South Africa [35] as most patients’ problems will be resolved at that level. A well-functioning district health system is the intended outcome of the re-engineering of primary health care process, which will result in a greater emphasis on health promotion, disease prevention, and community participation and empowerment [36]. Mental health services should therefore benefit for these intended good.
9. Advocating for primary health care for mental disorders
Traditionally, substance use services have not been provided by South African primary health care facilities, which has led to chronic limiting of access to treatment for people who use such services. A lack of mental health workers has slowed plans to integrate these services into the primary health care system [37]. However, careful consideration of how service delivery for mental disorders can be obtained for the majority, confirms the PHC model as being ideal for the prevention and management of mental disorders. Moreover, the low cost and increased access are advantageous for services at this level.
9.1 The cost
Primary health care services are offered at a lower cost, which is important for resource- constrained country like South Africa. This low cost can therefore enable more people to access mental health services. Institutionalization model of mental health services is much more costly, even for well-resourced countries like the USA, compared to primary health [38].
9.2 Improved accessibility of services
By its nature, PHC services are designed to be accessed by the majority of citizens, and resourcing and integrating extending such services to mental health will contribute to the improvement in treatment outcomes for the patients who need such services. That is why the need for interdisciplinary models of primary healthcare is likely to improve accessibility and quality of care for the broader population [39].
10. Examples of success of treating mental health disorders at PHC level
A number of countries have successfully integrated mental health services to mainstream primary health care services, with tremendous gains for both the country health system and the patients who receive such care. In Zimbabwe, the primary health care services for mental disorders include the use of lay health workers, which is advantageous for resource-constrained countries. The services they offer include screening for mental health disorders and administering primary care-based problem solving therapy with education and support for the clients [40]. In India, a similar program has been used for several years, and it has been found to be not only cost-effective, but also cost-saving [41]. The use of a lower cadre of health workers require task-shifting which, if properly utilized with effective training of the workers, can substantially reduce the number of high level health professionals, and thus close the mental health service gaps at primary health care level in South Africa at a minimal cost [42, 43].
10.1 Status of PHC services for mental health
Despite the high prevalence of mental health disorders in South Africa, mental health services at primary health care level are not prioritized. With the high level of stigmatization of mental illness, the health-seeking behaviors are compromised, despite the high prevalence of such disorders. This low prioritization also contributes to poor capacity planning and implementation of mental health care plans, scarcity of trained generalists in mental health care, poor integration of mental health into integrated care, and lack of dedicated mental health budget [44]. Specifically, the resource limitations need to be addressed, by allocation of more funding for PHC services and to upgrade mental health legislation and policies [45].
In order for primary care providers to diagnose substance abuse and mental illness among clinic attendees, they need to receive specific training, specifically in the use of self-reported screening tools which are easy to administer and efficient to make a substance abuse diagnosis in primary care settings. Early diagnosis and a brief behavioral change counseling are effective in managing substance abuse before it develops into dependency.
The acknowledgement of increasing prevalence of mental disorders which include substance abuse in South Africa, renders them to be a priority in the offering of primary health care services, and literature has reported that mental health care can be effectively integrated into primary health care [46]. However, in order to do this, governance should be improved [44]. This improved governance is what this chapter regards as a major intervention to improve PHC services and to set them to adequately address mental health matters.
10.2 Integrating mental health into mainstream primary health care services
Integration of mental health services into mainstream services has been recommended globally [47], and this has been found to be both effective for intended treatment outcomes, as well as economically cost-effective [21, 48]. While treatment effectiveness benefits the patients, cost-effectiveness has a direct benefit on the health system and an indirect benefit to the patients as the quality of treatment can be improved as more resources are available. Although compared to other African countries, South Africa is reported to be doing better in offering mental health services [49], a lot still needs to be done to implement integration of mental health services to reap envisaged health system benefits. With the high prevalence of mental disorders, which are ranked third as contributors to disability-adjusted life-years [50], integration of mental health into primary health care remains incomplete, which contributes to inconsistent care and difficulties such as unidentified symptoms, defaulting treatment and the revolving-door phenomenon [47, 51].
The integration of mental health services requires a vision contained in the South African Mental Health Policy and Strategy Plan, whose implementation can make a difference to the quality of services required by mental health care users [52]. Additionally, strong political will can assist in providing the resources required.
11. Recommended primary health care mental health services
A functional primary health care system should provide adequate services for most patients, so that only a selected few of these need referrals to higher levels of care. For that reason, primary healthcare services should be able to provide the following comprehensive mental health services:
11.1 Screening
The purpose of screening is for early detection, which is essential for both substance abuse and mental disorders, because if left unattended, these conditions tend to worsen and complicate, with poor treatment outcomes. Screening is therefore essential as it can assist with the early identification of both substance-related problems and mental illness, and guide the provision of appropriate services [53].
One of the key examples of failure to screen for pregnant mothers is the Fetal Alcohol Spectrum Disorders, which are often only detected after the child is born [54]. Specifically, the continuous neglect of screening for maternal depression has major negative implications for the children of such mothers, to the extent that the children’s constitutional rights are violated [55].
11.2 Prevention of mental illness and promotion of mental health
Both the prevention of mental illness and active promotion of mental health interventions are public health interventions for holistic approach for positive health outcomes [56]. This requires the identification of associated risk factors, and act on them. Because key contributors to mental illness are mostly socially derived, the negative social factors operational in communities need to be considered as points of attention. Prevention of mental illness and promotion of mental health has an economic value [57], hence the need to put efforts for their promotion.
11.3 Treatment
Although a few PHC clinics offer some mental services, the quality of treatment received does not meet the recommended mental health guidelines, and is therefore compromised [58]. In particular, promotion of mental health is often missing. Within the re-engineered primary health care package, which includes the utilization of a well-resourced district-based specialist teams, primary health care services will be enhanced to offer quality and effective treatment. However, not all clinics have functional district-based specialist teams, which needs to be improved.
With political commitment and following the spirit of the National Development plan and the core principles of Primary Health care, PHC services in South Africa can be an effective strategy in achieving the goal of health for all, including mental health services. This also applies to other African countries, which can use this strategy to coordinated efforts to achieve the health care components of the SDGs [9].
11.4 Ongoing support
A key success indicator for the treatment of chronic mental illness is the ability of the health system to provide ongoing support. This is necessitated to counteract possible relapse, which is common as the patients often experience treatment fatigue. Patients with chronic mental illness also often move residence, due to various social problems, which exposes them to discontinuity of treatment [59]. In the absence of any efforts for ongoing support, they are often lost to follow-up, with negative outcomes. In the South African setting, the existence of the Ward based PHC outreach teams can be effectively utilized for this service.
12. Conclusion
The chapter acknowledges the major problem of high prevalence of mental disorders in South Africa, as well as inadequate resources to address the problem. However, moderate changes to the primary health care model currently used in South Africa can result in major achievements in offering mental health services, which in turn will benefit the patients and assist health services to address the increasing scourge of mental disorders. This can be achieved by utilizing community health workers (CHWs), who are able to work effectively with marginalized communities, where the need for services is greatest [60]. With proper training, these community health workers can change the landscape of provision of mental health services, with resultant positive health outcomes for affected communities [61].
It is recommended that primary health care services be strengthened to provide comprehensive mental health and mental health services that include screening, brief interventions, referral to treatment and ongoing support [62], which will go a long way in addressing mental health and substance abuse needs for South Africa. Such services are likely to improve the mental disorder treatment needs across the spectrum, and provide the much needed continuity of care across levels [3]. With the integration of community health workers in primary health care service provision, the broader community participation is enabled, which is likely to result in an increased number of mental health activists, and better treatment outcomes for patients.
Acknowledgments
This chapter was jointly-funded by the National Research Foundation, through the NRF Chair in Substance Abuse and Population Mental Health grant, as well as the South African Medical Research Council, through the Substance Abuse and Adolescent Mental Health grant.
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