Using All Opportunities for Improving Mental Health -- Examples from South Africa

By Freeman, Melvyn | Bulletin of the World Health Organization, April 2000 | Go to article overview

Using All Opportunities for Improving Mental Health -- Examples from South Africa


Freeman, Melvyn, Bulletin of the World Health Organization


Neglect of mental health within health systems and health policies is not new. The commitment of WHO, therefore, to devote considerable attention to the challenges of mental health is most welcome. Moreover, the eminent team assembled to set the WHO agenda for mental health have put together clear and reasonable recommendations which will undoubtedly promote improved mental health globally (1). The point in this short commentary, though, is that the team have possibly overemphasized the relative position that research, knowledge and scientific argument play in policy and programme implementation.

While evidence-based intervention is a major goal of WHO and of most public health professionals (and I include myself), as Walt and others remind us (2, 3), "evidence" is but one factor of a myriad of "power and process" issues which determine policy and its implementation. I will not dwell on this point but make the argument that, in developing countries especially, to achieve improved mental health status, strategies have to be inclusive, and "spaces" created by priorities outside of mental health need to be more effectively utilized.

I have recently had a number of opportunities to present the case to politicians and senior health planners in South Africa for giving high priority to mental health. Largely thanks to research results, including DALYs and data on the effectiveness of interventions, most of the people in these positions now take mental health very seriously. Nonetheless, their empathic responses have generally been mixed with frustration and defensiveness. It appears that though past skepticism about the importance and role of mental health has been largely dissipated, the situation for mental health has not necessarily improved.

Though the "evidence" is compelling, and there is much compassion for mental suffering, health choices are complex. In South Africa, with its extreme past neglect for even basic health services in previously black townships and in rural areas, there are concerns such as overcrowded and dilapidated hospitals, low immunization levels, poor nutrition status, and neglect for preventive and promotive programmes, all competing for limited resources. Then there are also competing facts and figures. For example South Africa is rated as one of the countries in the world with the highest HIV/AIDS infection rates, with an estimated 1500 new infections per day (in a population of 40 million). The HIV prevalence rate among women attending public antenatal clinics is over 20%, while 65% of new infections occur among those between 15 and 25 years of age. South Africa also has one of the highest tuberculosis rates in the world, with nearly 90 000 cases notified in 1998 alone (4). And so the list of competing priorities continues. In other developing countries where resources are even smaller and health problems greater, the onerousness of the choices is even more pronounced.

In the light of the resource demand, it is at times necessary and strategic to select national priorities (often Presidential priorities) and link mental health programmes to these, rather than attempting to attract resources to mental health itself. I will use two examples to illustrate how we, in South Africa, are attempting to do this.

Violence and crime are endemic in South Africa. The consequences for the country economically and socially are enormous. Not surprisingly, President Mbeki has committed the government to dealing with this as a top priority. Inter alia, a National Crime Prevention Strategy (NCPS) has been set up consisting of various government departments and involving business and nongovernmental organizations. While the human and financial resources allocated to this are fairly modest, earmarked funds have made it possible to begin certain programmes which would otherwise not have been possible. The Health Department (Mental Health Directorate) has taken responsibility for:

-- training general health workers in "victim empowerment";

-- setting up "violence referral centres" in certain disadvantaged areas;

-- setting up violence prevention programmes in schools;

-- developing mother--infant bonding programmes for violence prevention in poor communities. …

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