Table 2.

Mental health system governance challenges, facilitators & recommendations: overview

Principle	System level	Sub-theme	Challenges	Enabling factors	Recommendations
Rule of Law	Governance	Legislation	Mental health care act lacks guidance on people with disabilities	Synergy between mental health care act & mental health policy	Clarify roles & responsibilities with respect to the act, particularly across sectors
		Enforcement	Insufficient training affects compliance & implementation		Provide sufficient training on mental health legislation & policies
Strategic Direction	Governance	Development of policies & plans	Lack of communication about the policy at district level	Including strategic planners in development of plans	Build capacity to translate policies into plans at provincial and district levels
			Insufficient capacity to translate policies into plans due to shortage of staff and skills	Champions who can advocate for mental health Support from national office	Include strategic planners in development of mental health plans
				District mental health teams used as a unit for planning	Use district mental health teams as a unit for planning at local level, provided they are sufficiently capacitated and supported
		Implementation of policies & plans	Poor coordination in terms of planning & service provision between national, provincial & district levels	Clear understanding of roles & responsibilities with respect to implementation	Capacity building of managers in change management to facilitate the implementation of integrated collaborative chronic care, including mental health
			Disparity between provincial mental health units in terms of capacity	Coordination between different stakeholders	Clarify roles & responsibilities of different stakeholders & improve coordination
			Lack of qualified managerial staff to push implementation at ground level		Address resource and capacity disparities between provinces
			Insufficient budget & inadequate infrastructure
Responsiveness & Integration	Governance	Prioritisation of mental health	Mental health still not a priority in the face of many other health needs	Drive by national to develop policy seen as a step towards prioritisation of mental health by national government	Providing training and support in PC101 can facilitate integration of mental health into primary health care
			Mental health seen as separate from other health needs		Education & awareness raising about the benefits of integration among service providers & service users could facilitate buy-in
	Service Delivery	Integration at facility level	Uncoordinated planning & lack of intersectoral collaboration hinders integration Negative or misinformed perceptions about mental health and integration Insufficient involvement of service providers in planning, leading to lack of buy in Lack of training on mental health among health professionals & lack of patient-centred orientation Inadequate follow-up between primary care facilities and tertiary institutions Resistance from mental health care users	PC101 can facilitate integration Recognition of benefits of integration in terms of patient outcomes & addressing comorbid conditions	Establish collaborative arrangements between the Department of Health, Social Development, Housing and other sectors at national, provincial and district levels, that establish clear roles and responsibilities with respect to community-based psychosocial rehabilitation (service provision & funding) Redistribute resources from tertiary-level institutions to community-based services
		Integration at community level	Services still concentrated at institutional level Lack of coordination and role clarification between sectors Shortage of community-based centres & poor accessibility Shortage of human resources to deliver community-based services Resistance from families & communities	Redistributing resources from hospitals to communities Utilising DSD social workers, community health workers and NGOs in delivery of services, but need to be sufficiently capacitated Committed leadership driving this
Effectiveness & Efficiency	Human resources	Human resources capacity	Shortage of health professionals & specialists to implement policy High workload and high staff turnover Inflexibility of existing staff structures to accommodate creation of new posts for district mental health teams Budget not sufficient to appoint more staff Negative attitudes and resistance among staff to treating mental health	Building staff confidence & competence to treat mental health Creation of district mental health teams facilitated by using existing systems Flexibility & using existing resources more efficiently could facilitate establishment of district teams Adapting training to be more primary health care focused Entering into agreements with local universities to train graduates	Given shortage of mental health specialists, particularly in rural areas, need flexibility in creation of district mental health teams (e.g. pooling resources across districts) Collaborate with Department of Education to adapt training and train more graduates An orientation to comprehensive care and change management is needed
		Task sharing	Insufficient specialist capacity to provide training and support in PC101	In-service, on-site & continuous training for health professionals	Task sharing can relieve pressure on health professionals
			High workloads mean poor uptake of PC101 Lack of clarity regarding responsibility for supervising & monitoring implementation of PC101	District mental health teams could provide supervision & support Community health workers, home-based care workers and ward-based outreach teams to provide screening & follow up Role clarification for counsellors to include mental health	PHC personnel trained in PC101 need mentoring and support in implementation of mental health aspects Use lay counsellors as they will relieve pressure on health care professionals, but provide adequate role clarification, training and supervision Use community health workers, home-based care workers and ward-based outreach teams for screening, referral and follow up
	Financing	Financing	Funding for mental health is inadequate Disparity between provinces in terms of resource allocation for mental health Historical budget allocation is problematic	Using existing resources more efficiently – phased approach and piggy backing onto other programmes	Use existing resources more efficiently through, for e.g. a phased approach and piggy-backing onto other programmes Revise way of budgeting from historical to activity-related allocation of funds
	Infrastructure	Infrastructure	Quantity and quality of existing infrastructure not sufficient Lack of coordinated planning between relevant sectors Lack of adequate counselling space in primary care facilities Breakdown in communication between hospitals, clinics and pharmacies results in inconsistent provision of medication Inadequate availability of PC101 guidelines	Creative ways of making more counselling space available – e.g. gazebos and park homes Extra steps taken to ensure patients get medication (e.g. delivering to patients homes) Master file of guidelines available at facilities	Include planning for counselling space within PHC facilities Improve communication between clinics, hospitals and pharmacies with respect to drug prescriptions and delivery systems Ensure availability of master file of protocols and guidelines in each facility
Participation & Collaboration	Governance	Inter-sectoral	Lack of coordination & collaboration between sectors due to different roles and mandates Coordination does not filter down from planning to implementation level Reluctance of some departments to get involved in implementation of mental health policies & legislation		Clarify roles & responsibilities of different departments with respect to mental health Build capacity & commitment at leadership level to create stronger partnership between DSD & DoH; formalise structures to improve collaboration Train managers in stakeholder engagement
		DoH – DSD	Lack of coordination in terms of planning & provision of psychosocial rehabilitation services Lack of clarity of roles and mandates	Capacity building & commitment at leadership level could help to build stronger partnership NGOs are the implementing arm of DSD – DoH could work through them	Build capacity among health professionals and managers to advocate for mental health
	Governance	With service users & service providers	Inadequate consultation with service providers Some resistance to policy directives among service providers	Service users consulted through clinic committees and advocacy groups and through holding imbizos to get community input	Improve consultation with service users through service user groups and communication with caregivers
			Uncertainty about how to best consult with service users Need for greater involvement of families & service users in treatment decisions		Build capacity of service user groups to engage in advocacy, and allow for formal inclusion in collaborative structures
Equity & Inclusiveness	Governance	Access	Size & remoteness of some provinces & districts make access to services difficult Disparity between districts in terms of number of facilities and community centres Lack of qualified staff to provide mental health services a barrier to access	Integrated care increases access Public education programmes a means to increase awareness; helplines a means to increase access	Integrating mental health into primary health care could increase access Raise awareness among service users regarding how and where to access services
		Stigma	Policy framework is not clear on how to address stigma Disparity between provinces in terms of how stigma is addressed Shortage of staff to drive these programmes Negative perceptions, driven by ignorance, lack of awareness and fear, a barrier to reducing stigma	Integrated care could reduce stigma Support from provincial and district managers could facilitate implementation of stigma programmes Using different forms of media to reach communities Support groups can empower users	Integrating mental health into primary health care could help to reduce stigma Implement anti-stigma campaigns in the community, with support from district and provincial managers Mass awareness campaigns using different forms of media, role models and support groups to reach and empower service users; clarify whose responsibility it is to do this
Ethics & Oversight	Governance	Ethical treatment	Disparity between provinces in terms of functionality & effectiveness of Mental Health Review Boards Staff shortages a hindrance to carrying out inspections & following up grievances Lack of indicators against which to evaluate performance	There are a number of mechanisms for ensuring quality/standards in health services in general, applied to mental health	Address disparity between provinces in terms of functionality and effectiveness of Mental Health Review Boards Introduce the WHO Quality Rights project and capacitate Mental Health Review Boards to use the toolkit to ensure that standards are being met
		Ethical research		Research units and ethics committees at provincial and national levels oversee health research National Health Act provides guidance on procedures for conducting research with health care users
Intelligence & Information	Information		Lack of monitoring mechanisms/systems at all levels Indicators for mental health in the health information system are not sufficient in terms of quantity or quality Inadequate human resources to carry out M&E		Provincial and district officials need to play a role in monitoring quality of mental health services Build M&E capacity at all levels and improve the use of indicators to inform policy and service planning
					Include indicators for mental health in the health in the health information system that provide sufficient information to inform intervention decisions and assess quality improvements