Policy and its (failed) implementationInsight
South Africa, like many middle income countries, has robust and technically sound policies but struggles with their implementation. In my opinion, the first step to understanding how the Life Esidimeni crisis and many other similar incidents happened, is to understand the disjuncture between policy and its implementation.
Using the Life Esidimeni (LE) case as an example, we can look at South Africa’s Mental Health Care Act, 2004 and its strategic plan, relevant from 2013 to 2020. The strategic plan places a heavy focus on the concept of deinstitutionalisation. This means that there is a push to reintegrate mentally ill patients back into their communities as soon as possible after hospitalisation/interaction with the system. Decentralisation, which is a prerequisite for deinstitutionalisation, requires the public health sector to ensure primary health care facilities are well equipped enough (resources, staffing mix etc.) to provide support to mental health care users and their families.
Therefore, following this policy, it would make sense that the Gauteng Department of Health (GDoH) explored options for care for these patients that allowed them to be closer to their communities and families. This is aligned to the decentralisation and deinstitutionalisation approach. The LE contract was entered into in 1979. Recently, the Auditor-General found the contract to be irregular. In what has turned out to be an incorrect cost analysis, GDoH was advised that the cost per patient per day at LE was more than double that in a public psychiatric hospital. Therefore, on this basis too, it made sense that GDoH wanted to look at alternatives. Lastly, records showed that the death rate at LE was unnaturally high, even taking into account the higher mortality rates in this sub-population. In 2011, 78 MHCUs died, in 2012 97 and in 2014 90.
So how were these sound policies and decisions so poorly implemented? Here are three reasons that appear high on my list. Firstly, a lack of understanding of realities on the ground. In order to decentralise patients there should be sufficient support at the PHC level. Due to a scarcity of mental health trained nurses, doctors and allied professionals, there was no way the communities could cope. Secondly, a lack of accountability. Despite GDoH writing reports on how the NGOs were insufficient and required major overhaul, nothing was done about the findings. In fact, the patients were moved despite these findings being widely available in the mental health directorate, in charge of the move. Thirdly, a culture of fear in departments that stifles discussion and debate. The recommendations from the ombudsman’s report are clear. The entire mental health directorate at GDoH was scared to speak out even though they were aware of the problems and disagreed with the orders given from above. This culture is rampant from facilities right up to the National Department of Health.
So, I do have sympathy for the GDoH. They seemingly were trying to follow policy, decrease wasteful expenditure and act decisively and quickly. If we take just the three issues highlighted above, what is the solution to prevent another crisis like this one? In my opinion, it is certainly not to introduce more policies or operating procedures. The solution lies in the people tasked to realise policy. More communication and face-time between facilities and head offices is a start to avoiding actions that are completely impractical in the current health system. More space for discussion and debate, between officials (at all levels) and between officials and communities, can assist in improving accountability in the sector, and promote critical thinking within the often rigid departments.
Needless to say this tragedy was avoidable, and while there are certainly individuals who are implicated, it’s the health workforce as a whole that requires introspection and intervention.
 The term Mental Health Care Users (MHCUs) has been adopted to align with the deinstitutionalisation approach. Seeing as mental health issues are mostly lifetime issues, public health policy has chosen to take away the patient/”sick role” given to this group and label them as something less disease-oriented.