PUTTING A NUMBER ON MENTAL HEALTH COSTS
Mental health costs should be counted in people, not rands and cents. CHARLOTTE MATTHEWS
“T
he thought of suicide is a great consolation: by means of it one gets through many a dark night,” said Friedrich Nietzsche, one of history’s known depressives. From depression (termed by Winston Churchill, another sufferer, as the “black dog”) to anorexia, epilepsy, bipolar mood disorder and schizophrenia, the prevalence of mental illness in South Africa is probably widespread and possibly even increasing, but no-one knows exactly what the numbers are. What is known is that more than 90% of those who need public healthcare for mental illness are not getting it. As South Africa is caught in the grips of the Covid-19 pandemic and government takes the first steps towards implementing a broader health system, National Health Insurance (NHI), it is essential to ensure that the economics of good-quality treatment for mental disorders are properly understood and an affordable, appropriate service is delivered across the country.
QUANTIFYING THE PROBLEM
The last time the prevalence of mental health and neurological disorders, such as epilepsy, in South Africa was quantified in detail was in the 2002-04 South African Stress and Health Study. This showed SA’s level of anxiety, depression and substance-use disorders was higher than in most other low- to middle-income countries, except for Nigeria and Ukraine, where there was likely to be underreporting. The reasons could have ranged from postapartheid trauma to what was then the rapid spread of untreated HIV/Aids. However, the study did not cover more severely disabling illnesses, such as bipolar disorder and schizophrenia. Dr Lesley Robertson, a Lecturer in the Psychiatry Department at Wits, says there are other sources of data on prevalence of depressive symptoms in South Africa, such as the National Income Dynamics Survey and the South African National Health and Nutrition Examination Survey, but there is no data on psychiatric illness. Obviously, this poses a challenge for the government in trying to set a budget to treat severe mental illness.
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The 2016/17 national survey, Mental Health System Costs, Resources and Constraints in SA, commissioned by the Department of Health, showed that the department was spending about five percent of its total public health budget on mental healthcare, which is in line with similar economies. However, there were big disparities between provinces. The study showed that just over eight percent of those requiring public in- or out-patient care were receiving it. While 86% of spending was on in-patient care, about a quarter of those patients were re-admitted to hospital within three months. This suggests hospital care has limited efficacy on its own. It needs to be supplemented with community-based care, says Robertson.
COMMUNITY CARE
Community-based services are considered the most effective approach to dealing with mental illness, as shown in a 2019 paper, Strategies to strengthen the provision of mental healthcare at the primary care setting: An Evidence Map, led by Witness Mapanga from Wits’ Centre for Health Policy in the School of Public Health. Yet, in most health systems in the world, community-based services are underfunded. Dr Paul Stiles, Associate Professor in the Department of Mental Health Law and Policy in the Louis de la Parte Florida Mental Health Institute at the University of South Florida, US, who visited Wits University on the Fulbright Specialist Roster in March, said the US de-institutionalised mental healthcare in the 1960s and 1970s. Caring for the mentally ill in their homes and communities is widely regarded as the most successful treatment option, but it is not cheaper than institutionalisation, says Stiles.
THE COST OF NOT CARING
In South Africa’s most notorious reported case of the de-institutionalisation of mental care, largely aimed at saving costs, over 1 500 people with severe mental illness were transferred from Life Esidimeni hospitals to community-based care in 2015. As a result, almost 150 died.