Mental Health II – National Health Insurance
23 April 2020
As indicated in the previous brief, the realities regarding mental health care are bleak. However, the way forward seems to be paved by the National Health Insurance Bill (“Bill”)[i]. This brief will consider the content of the Bill as well as possible implications that it may have on the state of mental health care.
It is advisable to read the Memorandum on the Objects of the National Health Insurance Bill (“Memorandum”), which accompanies the Bill, with the Bill itself.
The Preamble to the Bill states that it recognizes the rights associated with the enjoyment and realisation of mental health as housed in Article 12 of the United Nations Covenant on Economic, Social and Cultural Rights, 1966, as well as Article 16 of the African Charter on Human and People’s Rights, 1981. This is confirmed in the Memorandum[ii].
Section 57 deals with Transitional Arrangements and states that legislative reforms regarding the introduction as well as the implementation of the NHI need to be enacted within the Mental Health Act (“MHA”) within Phase 1, which is from 2017 to 2022.[iii]
These proposed amendments are housed within the Schedule dealing with the Repeal and Amendment of Legislation Affected. The only legislation relevant to mental health care that is to be amended is the Medical Schemes Act (131 of 1998). The proposed amendments include the revision of the definition of “relevant health service” to mean[iv]:
“any health care treatment [of any person by a person registered in terms of any law] that is not covered by the provisions of the National Health Insurance Act, 2019, which treatment is complementary to health care services funded by the State and has as its object—
(b) the diagnosis, treatment or prevention of any physical or mental defect, illness or deficiency;
(e) the prescribing or supplying of any medicine, appliance or apparatus in relation to any such defect, illness or deficiency [or a pregnancy, including the termination thereof];”
This would make the provision of mental health care available outside of the NHI, if the care is not obtainable within the NHI framework.
The Memorandum highlights strengthening the Primary Health Care Services (“PHC”).[v]The Memorandum states that the delivery of these services will be “population-orientated with extensive use of community and home-based services in addition to PHC facilities” to improve the mental health of school going children.[vi] In light of the Life Esidimeni tragedy one wonders why no mention is made of the provision of these services for adults.
The projected expenditure regarding the provision of mental health care which will be recovered by Conditional Grants in terms of the NHI. The 2019 allocations would see the expenditure of these grants at levels between 100 and 150 million rand.[vii]
WHAT ABOUT MENTAL HEALTHCARE?
The World Health Organisation (“WHO”) releases information obtained from the Department of Health (“DoH”) in its reports, with the most recent data being for 2017.[viii] The Mental Health ATLAS 2017 Member State Profile (“Atlas 2017”)[ix] for South Africa leaves a lot to be desired, both in terms of the DoH’s reporting and the provision of crucial healthcare services.
In both Atlas 2017 and Atlas 2014 the DoH could not account for how many inpatients were tended to in mental hospitals or the duration of their stay. A possible exception would be the Kimberley Mental Health Hospital which is presently operating at less than 50% capacity as a result of a lack of funding.[x]
Atlas 2017 notes that there is no multisectoral collaboration between the DoH, service users and advocacy groups.
Atlas 2017 states that government spends 3% of its health budget on mental healthcare. The government did not report on human resources for mental health in the respective years. There was a reduction in both mental hospitals as well as psychiatric units in general hospitals between 2014 and 2017, as well as a reduction in numbers admitted to mental hospitals.
There is a continuing absence of a suicide prevention strategy, and it would seem that screening for mental disorders has replaced mental health education and awareness programmes.
A search for information proves difficult despite the various departments trying their best to provide it. The DoH contracts entities to assist with data collection and yet makes this available nowhere or even mentions its existence. The only way one knows of the existence of data collection is due to the Health Information Support Program acknowledging the importance of projects[xi] and the NHI.
If data are unavailable, the concern becomes the adequacy of currently provided mental health services and one wonders how the provision of quality mental health care will be improved by the implementation of the NHI. Much more light needs to be shed on this important aspect of our healthcare system.
By Chris Pieters, Legal Researcher, HSF, 23 April 2020
[i][i] The National Health Insurance Bill was gazetted on 26 July 2019 http://pmg-assets.s3-website-eu-west-1.amazonaws.com/1/B11-2019_National_Health_Insurance.pdf
[ii] The Memorandum notes at item 1.4 that the Preamble recognises the importance of Article 12 of the United Nations Covenant on Economic, Social and Cultural Rights, 1966 as well as Article 16 of the African Charter on Human and People’s Rights, 1981.
[iii] Section 57(4)(h)(vii) Mental Health Care Act (17 of 2002)
[iv] 1. The amendment of section 1—
(b) by the substitution for the definition of ‘‘relevant health service’’ of the
‘‘ ‘relevant health service’
[v] Item 4, Strengthening Primary Health Care (“PHC”) Services.
[vi] Item 4.4.4.
[vii] Item 8.7 of the Memorandum deals with the Financial Implications for the State and contains the 2019 MTEF Fund Conditional Grant allocations.
[ix]https://www.who.int/mental_health/evidence/atlas/profiles-2017/ZAF.pdf?ua=1 and for good measure Mental health Atlas country profile 2014 (“Atlas 2014”) https://www.who.int/mental_health/evidence/atlas/profiles-2014/zaf.pdf?ua=1
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