South African Mental Health Process Indicators.

BACKGROUND

In post-apartheid South Africa the organisation and delivery of mental health care is undergoing significant change. With the heritage of an under-resourced, fragmented, racially inequitable service, heavily reliant on chronic custodial treatment in large centralised institutions, this change is long overdue. New policy has set out a vision for a community-based, comprehensive, integrated mental health service. In order to realise this vision a review is required of the way in which care is currently delivered, or the 'process' of mental health care. To date, no national research has been conducted regarding process of care indicators in South African mental health services. AIMS OF THE STUDY: This study documents four public sector mental health service process indicators in South Africa: bed occupancy rates, admission rates, average length of stay and default rates. METHODS: A questionnaire was distributed to provincial mental health co-ordinators, requesting numbers of occupied and available beds in psychiatric inpatient facilities, annual mental health admissions, average length of stay (ALOS), and default rate in ambulatory care settings. The information was supplemented by consultations with mental health co-ordinators in each of the 9 provinces. RESULTS: The national bed occupancy rate is 83% (range: 63-109%). The national annual rate of admission to psychiatric inpatient facilities is 150 per 100 000 population (range: 33-300). The national average length of admission is 219 days in psychiatric hospitals, 11 days in general regional hospitals and 7 days in general district hospitals. On average 11% of psychiatric patients who attend ambulatory care services on a monthly basis fail to keep their appointments. DISCUSSION: Although the national mean bed occupancy is compatible with international figures, there is considerable discrepancy between provinces, indicating both over- and under- utilisation of inpatient resources. Admission rates are low, relative to developed countries, though comparable to developing countries. Low admission rates are associated with a range of factors including inadequate service provision, unmet need, inaccessible services, cross-border flow between provinces and custodial patterns of care. There is evidence of long periods of admission relative to international settings. There is also considerable diversity between provinces, with certain institutions continuing to provide long term custodial patterns of care. Default rates are low relative to international settings and past reports default in South Africa. IMPLICATIONS FOR HEALTH POLICIES: In keeping with current policies there is an urgent need for local level evaluation and reform of chronic custodial care. The ongoing monitoring of process indicators is important in the transition to community-based mental health care. IMPLICATIONS FOR FURTHER RESEARCH: Limitations of the data, and problems of collecting information on mental health care within an integrated health system indicate the need for further research in this area. There is also a need for further research into unmet need for mental health care in South Africa.