Integrated, interdisciplinary mental health care for South Africa: An overview1

August 2017

ContentsAbbreviations..............................................................................................................................................2

Executive Summary.....................................................................................................................................2

Context........................................................................................................................................................3

Why use this approach?..............................................................................................................................3

Human rights of MHCUs: Access and outcomes......................................................................................4

Challenges...........................................................................................................................................5

Cost-effectiveness...................................................................................................................................5

MHC professionals...................................................................................................................................6

Challenges...........................................................................................................................................7

Applicability: Is this approach suitable for South Africa?.............................................................................7

Adaptability and community involvement..............................................................................................9

Barriers: Implementation, monitoring and evaluation................................................................................9

Legal and policy environment....................................................................................................................10

Comprehensive Mental Health Action Plan 2013-2020: WHO..............................................................10

Mental Health Care Act, 17 of 2002......................................................................................................10

Mental Health Policy Framework 2013-2020: South African National Health Council..........................11

National Health Insurance: White Paper 2017: Department of Health, South Africa............................11

Role of the SAPC: Way forward.................................................................................................................12

Why would the SAPC be well placed to explore an integrated health strategy?...................................12

Why would such an approach be particularly suited to conditions in South Africa?.............................13

Conclusion.................................................................................................................................................13

Works Cited...............................................................................................................................................14

1 Prepared by Matthew Clayton for the South African Psychoanalytic Confederation

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Abbreviations

CMD: Common Mental Disorders

IIMHC: Integrated, Interdisciplinary Mental Health Care

LMICs: Low and Middle Income Countries

MHC: Mental Health Care

MHCU: Mental Health Care User

MHPF: Mental Health Policy Framework

NDP: National Development Plan

NHI: National Health Insurance

SAPC: South African Psychoanalytic Confederation

Executive SummaryThis document gives an overview of the integrated, interdisciplinary mental health care (IIMHC) model and discusses its applicability in South Africa. Despite high disease burden levels and a large and growing proportion of the population reporting mental health concerns, treatment remains limited and, for the most part, unintegrated. This has led to the existence of a large and unsustainable treatment gap that will continue to cause huge negative effects both economically and societally and continues to negatively impact the lives of millions in South Africa. Through an IIMHC model, South Africa and other developing countries can work to narrow the treatment gap with innovative use of resources and the integration of various interlinked disciplines including those outside of the current Western-centric medical system and knowledge. By using examples from other developing nations – including those in Southern Africa – IIMHC can be seen to work where it has been implemented. In fact, there is an argument to be made that, not only can IIMHC work in South Africa, it is one of the only viable options for narrowing the treatment gaps in the face of limited resources and a severe lack of human resources in particular that cannot be ameliorated in the medium term.

South Africa’s legal and policy context also lends itself to an IIMHC approach which is rights based, intersectional and aware of various historical facts that shape our current interactions; including the multiple disease burdens our health care system must manage.

In the same way that IIMHC advocates for an interdependent response to mental health care (MHC) the benefits of its application will also be interlinked and generate a virtuous cycle to continually improve cost-effectiveness, working environments, service uptake, treatment uptakes and more.

IIMHC would not be without its challenges including those of implementation from the side of the state. In order for IIMHC to work, the participation of mental health care users (MHCUs) mental health care workers or professionals (MHCW/P) and other stakeholders must be ensured.

In short; South Africa shows a clear need for IIMHC, has a legal and policy framework which calls for it and has examples of its efficacy at home as well as in other similar contexts.

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ContextMental health disorders represent a large and growing proportion of the disease burden of Sub-Saharan African countries due to shifts in demographics and epidemiology. As of 2014, 16.5% of adults in South Africa have a condition listed in DSM 4 within the previous 12 months, with 4.9% of adults having severe depression. Neuropsychiatric disorders were found to be the third most disabling illness in the country and represented a significant number of lost productivity days each year. Perhaps as alarming is the fact that various mental disorders serve as predictors for other disease burdens in Sub-Saharan Africa including risk-taking behavior which increases risk of HIV contraction as well as increases the likelihood of non-adherence to HIV treatment regimes (Lund, et al., 2012). The levels of common mental disorders (CMD) are met with vastly inadequate resources which see just one in for people presenting with CMD receiving any kind of treatment (Petersen, et al., 2016) (Marais & Petersen, 2014)

Various plans and strategies for South Africa’s long and medium term development such as the National Development Plan (NDP); National Health Insurance (NHI); National Strategic Plan on HIV/AIDS and TB are all premised on a South African population which is more healthy and productive than it currently is. For this and other reasons, mental health is gaining importance as a public health priority (Petersen, etal., 2016). With policymakers understanding the links between mental ill-health, lost productivity and various overlapping issues such as substance abuse and increased risk of communicable diseases such as HIV; what should also be clear is that the model best suited to South Africa’s context is one of integrated and interdisciplinary mental health care (IIMHC).

The SAPC’s role in bringing together practitioners from a wide range of disciplines around a common paradigm (rather than one profession or one target population) makes it an uncommon grouping and one that could be well placed to advocate for the further adoption and implementation of IIMHC in South Africa.

Why use this approach?Due to the social determinants of health, mental health is especially important to address in an intersectional manner and various developments including our understanding of the human rights of mental health care users (MHCUs), the detrimental effects of institutionalization and the increased push for cost-effectiveness have made a multi-disciplinary intersection more pertinent than ever (MentalHealth Commission, Ireland, 2006) (Marais & Petersen, 2014).

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Funk & IvBijaro (2008) 1

The table above demonstrates how an IIMHC model combines various elements to produce better health outcomes for patients. While all of these elements interact to produce good outcomes, they also interact with one another so that cost effectiveness improves access which is bolstered by respect for human rights and so on in a virtuous cycle. Where authority and responsibility is being devolved or shared, it is essential that this includes appropriate human and financial resources to meet this demand. This is a particular risk in communities which already suffer from under-investment in their health infrastructure and which may struggle to attract and retain skilled staff; for example in rural areas (Caxaj, 2016).

Human rights of MHCUs: Access and outcomesAs stated above, South Africa continues to languish under a large and unsustainable treatment gap for MHCUs where just one in four patients are receiving the care they need. South Africa’s Section 27 right to access to health care as well as various other legal and policy provisions set out below, make it clear that the human rights of MHCUs is the central point of any intervention in the health care system. An IIMHC model helps more people get access to MHC, provides better health outcomes, involves more

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patients in the development of treatment plans and helps combat stigma within and outside of the health care system.

An IIMHC model also allows for patient-centric care and encourages more active participation of patients – and where relevant, their families – in the delivery and operation of the care (Mental HealthCommission, Ireland, 2006). In a South African context where some health care providers have few shared lived experiences with their patients, this provides a valuable opportunity to have input to shape care in a way that best suits particular patients.

Integrated and interdisciplinary teams have been shown to deliver better health outcomes and also to have specific application in contexts where patients present with multiple and concurrent health problems, including substance abuse. Being able to access the diversity of care they need is often difficult for even those patients possessing resources and social capital. For patients who are more vulnerable (for example, people who are homeless) accessing this care becomes practically impossible (HCH Clinicians' Network, 1999). Without an integrated and interdisciplinary model, access to health care will continue to be most difficult for those who most need it. There is significant evidence to suggest that where services have been integrated and have included task sharing methods such as community health care workers, there is evident help-seeking behavior relating to common mental disorders. (Petersen & Lund, 2011).

Stigma surrounding mental health remains a challenge in South Africa as in other countries around the world. South Africa’s particular history and current context serve to create an environment which is conducive to poor mental health and also creates barriers to seeking treatment in addition to resource and geographic limitations. One of the drivers of stigma surrounding MHC is the current compartmentalization that sees patients being clearly identifiable as seeking treatment and somehow removed from the rest of the health care system. Integrating these services will work to reduce general community stigma around mental health treatment but may also play a role in improving help-seeking behavior (Lund, et al., 2012).

ChallengesWhile patient outcomes are improved by the IIMHC model, there are some potential negatives with this framework. While stigma is a problem in the general population, it is also a problem in that it impedes help-seeking behviour. Perhaps internalized stigma gives a reason for the finding that in test sites surveyed in Marais and Peterson, some MHCU were resistant to being integrated into the ‘mainstream’ treatment at their facility (in other words, they did not want integrated and interdisciplinary care). Some of this may be from a perception that they receive superior care as an extension rather than part of the current system while another may be that internalized stigma leads some to believe that their illness necessitates a specialized and isolated treatment (Marais & Petersen, 2014).

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Cost-effectivenessCost effectiveness remains a primary concern for the provision of MHC in South Africa, with roughly 4% of the national budget being spent on MHC. This despite the fact that at least 16% of adults surveyed identified as having a CMD (Herman, 2009). In order to meet the goals set out in various policies and to meet over-arching goals around reducing the treatment gap, integration is the only feasible answer. The World Health Organisation (WHO) 2014 World Health Atlas finds that Africa has a median of 1.4 mental health workers per 100,000 of the population. This is far below the global average of 9 workers per 100,000 and just above the 0.9 ratio for all low income countries (WHO, 2014). This is part of the reason that Ivbijaro holds that “we will never have enough” when it comes to trained mental health workers (Ivbijaro, 2017). Save for a massive and unprecedented influx of funding to the MHC system, the current gap cannot be closed without new thinking and approaches.

Integration has obvious cost-saving advantages through, among others, reducing referrals to costly specialized services (Lund, et al., 2012). However, the goal is not to cut the available funding to MHC but rather to increase it and reinvest these savings back into the MHC system. Peterson and Lund’s 2011 paper however found that where integration had significantly reduced the admittance of patients to psychiatric facilities, none of the studies which formed part of their review identified an increase in funding to community-based initiatives as a result of this (Petersen & Lund, 2011).

MHC professionals Formation and management of teams of professionals is an essential part of the integrated interdisciplinary model. A team in this respect is defined as “a group of people with complementary skills who are committed to a common purpose, performance goals, and approach, for which they hold themselves mutually accountable (Mental Health Commission, Ireland, 2006). It is this element of planning and coordination which sets a multidisciplinary and integrated model apart from a model where various practitioners may have a working knowledge of the fields of their colleagues, but that expertise is not brought to bear on the planning, implementation and monitoring of the care provided (HCH Clinicians' Network, 1999).

The benefits of these teams extend beyond those directed to the MHCU but also encompass the MHC workers who benefit from the exposure to different skills and the ability to deal with increasingly complex cases involving multiple impacting factors that their single specialization may not be equipped to deal with in isolation. This has lead studies to show that, while the work is demanding, job satisfaction is higher within these groups than outside of them (Mental Health Commission, Ireland, 2006).

When combining individuals into a holistic and interdisciplinary team several important considerations must be taken into account, in order to ensure that individual practitioners feel their contribution is being valued and to ensure that right mix of skills and personalities is used (Mental Health Commission,Ireland, 2006). Core skills, knowledge and attitudes required for inter-disciplinary working include:

Assessment; Treatment and care management; Collaborative working; Management and administration; Interpersonal skills (Sainsbury Centre for Mental Health, 1997).

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The general view is that an interdisciplinary team should consist of at least the following core skills: nursing, medicine, social work, psychology and occupational therapy.

Once these core skills were present, teams could be composed of people who reflect the local context and needs of their population of patients (Mental Health Commission, Ireland, 2006). For South Africa, this could present a welcome opportunity to broaden the scope of applicable MHC strategies including better coordination with traditional healers, for example.

Peterson and Lund presented four key recommendations in their 2011 review of mental health care in South Africa. In order to improve the decentralization and integration of services and care it was important to:

1) Ensure that decentralized care included a concomitant increase in resources to facilities and programmes, especially those who were providing the 72 hour observation;

2) Increase community-based interventions which incorporate task-shifting and which have been shown to deliver results in developing countries;

3) Include Public education which sought to reduce stigma of mental health care and also increase knowledge of mental health care;

4) Establish collaborative arrangements with traditional healers and develop culturally congruent care; which takes into account various cultural and language obstacles to service provision (Petersen & Lund,2011).

ChallengesThe need for properly trained and equipped staff within the health care sector is vital and particularly so in an IIMHC model where authority is partly devolved to PHCs. Here, the medical staff working at PHCs can either be gatekeepers or facilitators of adequate mental health care (Caxaj, 2016). However, staff in PHC facilities which do offer IIMHC have reported that there is often insufficient training and coordination between the different levels of the health care system as well as inter-departmentally. This leads to a situation where PHC workers are given increased responsibilities and workloads and seldom the resources needed to actually meet these new demands (Marais & Petersen, 2014).

Applicability: Is this approach suitable for South Africa? There is much to suggest that an IIMHC model can work well in South Africa and, as discussed elsewhere, it (or rather, a version of it) is envisioned in many of this country’s guiding documents and plans as well as those other countries in the region. Some essential elements of the IIMHC model (such as task-sharing and community involvement) have found great success in trials in Zimbabwe with 80% of patients experiencing a ‘friendship bench’ approach reporting that they were free of mental health symptoms in the six months following (Chibanda, How a community-based approach to mental health ismaking strides in Zimbabwe, 2017). There is, however, still some concern about its over-all applicability in low and middle income countries (LMICs) in general as highlighted by Stein and others.

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A study by Janse Van Rensburg and Fourie examined the mental health policy documents of the five SADC member countries which have such plans available. The authors found that an IIMHC model (including clinical, professional and organisaitonal, system and normative integration) ran through the national documents of all five of the countries surveyed, which include South Africa, Namibia, Zambia, Malawi, Botswana and South Africa.. Two key elements emerged which explained how each country conceptualized integration, the first is a more standard understanding of the IIMHC model that sees bolstering of PHCs, task-shifting or sharing and other methods to streamline and integrate services within the health care system. A second element spoke to the need to integrate and collaborate with stakeholders outside of the state including NGOs, the private health care sector and traditional healers. This second element was found to be especially important in the SADC context – as well as the context of many LMICs – because of the lack of resources to provide adequate health care and especially adequate mental health care. (Janse van Rensburg &Fourie, 2016).

There also remains tremendous untapped potential for regional collaboration in Southern Africa, if SADC takes initiative and works with member states to develop integrated regional strategies for mental health. While SADC does have a Protocol on Health, this does not substantively speak to mental health and SADC does not have any dedicated body which deals with mental health in the region. In light of the importance of regional collaboration highlighted in various SADC documents as well as the 2010 WHO report, coordinated work on IIMHC could have excellent results if SADC finds this impetus. Furthermore, as highlighted by Janse van Rensburg and many others, the IIMHC model is designed with high-income countries in mind, and often does not take into account various overlapping factors which LMICs and their public health sectors contend with. The development of a coordinated IIMHC framework which takes into account the specific contextual issues of LMICs and SADC member states is therefore important (Janse van Rensburg & Fourie, 2016).

PRIME (PRogramme for Improving Mental health care) and AFFIRM offer excellent insights into the applicability of the IIMHC model in LMICs. In a lessons learned document published in 2017, Davies and Lund distilled seven key lessons for integrating MHC into primary health care: Engage actively and collaboratively with local stakeholders;

1. Use primary care systems to access vulnerable populations;2. Use cultural concepts of distress and narrative based vignettes to identify persons with potential

mental health problems;3. Set up systems of ongoing supervision and support; 4. Adequately compensate NSWs for their services;

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While the plans in the surveyed countries do cover much of the framework for IIMHC, key elements are missing. The most troubling of these is the lack of attention paid to patient-centrism in the design and implementation of mental health care; furthermore, despite varying levels of importance given to collaboration – both within and outside the system – the importance of trust and communication between these stakeholders is not given adequate attention. Without this trust and shared commitment, collaboration, and therefore integration, cannot occur on a sustainable scale. (Janse vanRensburg & Fourie, 2016).

Can IIMHC work in LMICs?

5. Respond to crisis by ‘building back better’;6. Make use of policy windows (Davies & Lund, 2017).

The countries involved in the above work are South Africa, India, Nepal, Ethiopia and Uganda; demonstrating the applicability of the IIMHC model across a wide range of contexts within LMICs.

Adaptability and community involvementA central part of IIMHC is the shifting and sharing of roles which were once practiced only by highly specialized professionals. This process not only allows for more people to get access to MHC but also creates a layer of flexibility which can respond to local contexts and incorporate local expertise and knowledge.

South Africa and countries all over the world have a layer of health care workers who are generally described as ‘community health workers’. CHW’s play an important role in encouraging health-seeking and performing follow up work that would otherwise be too costly for nurses or social workers to conduct and are a cost-effective way to increase access to mental health care services in contexts where there is a scarcity of resources (Petersen & Lund, 2011). While CHWs do important work, some of this work is not properly integrated into the wider health care system or even the mental health care system; adding an additional layer of health care which may act as a barrier or which may not be acting in concert with others. In an IIMHC model, CHW would form an important part of any intervention, playing a role in the early detection as well as the provision of ongoing care for mental health treatment. This is a strategy known as “task-shifting” or “task sharing” which sees the delivery of low-cost interventions by non-specialist health care workers who are in turn supervised by health care specialists. (Lund, et al., 2012).

The South African Society of Psychiatrists of (SASOP) has also cautioned that, while CHWs and community-based care have been effective, integration should not mean the dismantling of expert mental health care teams. They add that there is need for flexible cooperation and effective cooperation between different levels of providers within the health care system (Stein, 2014) (Marais & Petersen,2014). This intervention involved the use of CHWs at the primary level and increased education and awareness of mental health care in the wider community. Part of the success of the model in Zimbabwe was its ability to harness local contexts and understanding of mental health such as using local terms for mental health treatment and involving the local community in the provision and advertising of the services they offered. (Chibanda, et al., 2016)

A strength of our study was the use of tools with local cultural validity, together with well-known measures that had been rigorously tested in our setting. The intervention, developed in consultation with stakeholders, was designed to be delivered with available resources in the primary health care system. (Chibanda, et al., 2016)

Barriers: Implementation, monitoring and evaluationThere is no shortage of innovative and progressive policy on MHC in South Africa, all of which highlights the numerous benefits of IIMHC models in some way. One of the key problems is governance; where plans do not receive the kind of monitoring and evaluation, funding, human resources and infrastructure which they need (Marais & Petersen, 2014). IIMHC has been South Africa’s de-facto policy since 2002

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and more formally since 2013. Now 15 and four years later respectively, many of the same problems in terms of staffing, resourcing, bottlenecks and accessibility continue to persist in light of poor governance. This is a worrying sign for the NHI’s implementation, which involves a much larger implementation and the coordination of many times the number of stakeholders than previous plans – including what looks to be a contentious relationship with the private health care sector.

Many of the perceived problems with the approach of multi-disciplinary working are not problems with the method as much as poor implementation of it (Mental Health Commission, Ireland, 2006). In a South African context plagued by maladministration and poor implementation, this particular issue needs to be taken most clearly into account to prevent dysfunctional working teams which only aggravate the worst inefficiencies present the health care system. For example, despite the clear importance of stigma in the provision of MHC, the mental health policy framework (MHPF) does not give sufficient guidance about how stigma should be addressed. This lack of clarity, linked to other problems with governance, means that few MHC workers at the District and Provincial levels knew of programmes dealing with stigma in MHC in their areas. (Marais & Petersen, 2014)

As stated above, resourcing remains the main problem in achieving the goals set out for IIMHC in South Africa, particularly ensuring that funds flowed to more local and community-based interventions, especially where these interventions relieve financial burdens on other parts of the MHC system. Where obligations have been created without sufficient investment, it is clear that patient outcomes suffer. The 72 hour observation period which forms part of the Mental Health Act is such an example; where increased strain on resources and inadequate training of staff could actually be leading to an increase in the human rights abuses against patients that the act sought to combat (Petersen & Lund, 2011).

Legal and policy environmentPreviously the applicability of IIMHC in South Africa was discussed, in the section which follows, the legal and policy framework will be set out. Through this, it can be seen that IIMHC can is suitable for South Africa and is indeed the outcomes of most of the law and policy which regulate health care in South Africa.

Comprehensive Mental Health Action Plan 2013-2020: WHOAdopted in 2013, the CMHAP commits all UN member states to take specified actions to reach agreed upon targets. It has four key objectives, which are:

1. To strengthen leadership and effective governance for mental health;2. Provide comprehensive, integrated and responsive mental health and social care services in

community-based settings;3. Implement strategies for promotion and prevention of mental health; 4. Strengthen information systems, evidence and research for mental health. (Stein, 2014)

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Mental Health Care Act, 17 of 2002The Mental Health Care Act plays two important roles by firstly situates MHC within broader public health and by articulating MHC within South Africa’s human rights framework. In this way, it aims to highlight the rights of MHCUs including the right to access MHC in the first place (Marais & Petersen,2014). The basic aims of the Act are to make quality mental health care available to the population equitably, to coordinate access to services to various categories of mental health care users, to integrate the provision of mental health care services into the general health services environment, to classify the rights and obligations of patients and providers, and to regulate and provide mental health care access to various classes of mental health care users. The Act provides that health establishments must provide mental health care to those who require it, or refer mental health care users to a health establishment that provides the appropriate level of care.

Mental Health Policy Framework 2013-2020: South African National Health Council This seven year plan was developed following extensive national and provincial consultations, and operationalizes many of the country’s obligations under the WHO action plan. The policy framework contains eight key provisions:

1. District-based mental health care services and primary-based care reengineering;2. Building institutional capacity;3. Surveillance, research and innovation;4. Building infrastructure and capacity at facilities;5. Mental health technologies, equipment and medicines;6. Intersectoral collaboration;7. Human resources for mental health;8. Advocacy, mental health promotion and prevention of mental illness (Stein, 2014).

National Health Insurance: White Paper 2017: Department of Health, South AfricaA clear strain of IIMHC runs through South Africa’s legal framework as well as our international obligations. The introduction of the NHI holds promise for IIMHC models, in part because the NHI envisions a restructuring of health delivery in South Africa including, inter alia, a bolstering of the PHC at the district level as well as the introduction of Integrated Chronic Disease Management (ICDM) (Petersen, et al., 2016)

The NDP envisions the following vision for South African health in 2030: “South Africa will have a life expectancy of at least 70 years for men and women; the generation of under-20 should be largely free of HIV; the quadruple burden of disease will have been radically reduced compared to the two previous decades, with an infant mortality rate of less than 20 deaths per 1000 live births, and the under 5 mortality rate of less than 30 per 1000 live births”i.

The principles upon which NHI is based are the following:

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1. Right to access health care2. Social solidarity3. Equity4. Health care as a Public Good5. Affordability6. Efficiency7. Effectiveness8. Appropriatenessii

These principles, and NHI itself, seek to address the issues of inequality in South Africa and particularly in South Africa’s health care system. This is envisioned to be achieved through improving access to health care, improving the quality of such health care, and to make such provision more affordable to both the state and individuals.

NHI encompasses seven key features:

1. Universal access2. Mandatory prepayment of health care3. Comprehensive services4. Financial risk protection5. Single fund6. Strategic purchaser7. Single-payer

As discussed under the previous section, NHI seeks to address inequality through the access, quality, and cost of health care. This is achieved through:

Targeting and alleviating major cost drivers in the public and private health sectors arising from payment models, inefficiencies, lossiii

Improving quality of health care which currently cannot handle the high burden of disease and patient loads

Challenging the current curative hospi-centric focus in lieu of predominantly preventative health care

Redistributing and addressing inadequacies in human resources in order to alleviate the two-tiered system between the private and public health systems. This is especially prevalent as the population dependent on public health continues to grow.

Dismantling the current fragmented funding pool (private, public, individual and medical scheme funding) and consolidate a single funder (the NHI fund) in order to reap the benefits of such, as well as avoiding the cost (financial and social) of the current fragmentation.

Reduce out-of-pocket payments that currently characterize the current system in favour of a mandatory prepayment system so that services can be provided free (or very cheaply) at the actual point of treatment.

Produce a financing system that does not punish the poor, or exclude them from accessing quality health care.

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Role of the SAPC: Way forward

Why would the SAPC be well placed to explore an integrated health strategy?The SAPC is a collection of over 50 groups of mental health service providers from a range of disciplines sharing a common pursuit of the Psychoanalytic paradigm. Such a collection of disciplines and projects gathered together under a common paradigm (rather than a common profession or target population) is relatively uncommon and, in its rich diversity, is a micro-analogue of the national mental health services offering the unique opportunity of piloting how to coordinate diverse psychoanalytic approaches and practices into a collaborative or integrated biopsychosocial health strategy.

If the SAPC is able to effectively harness its two core strengths – numbers and diversity – it can position itself to play a substantive role in shaping MHC in South Africa and advance the interests of its members as well as MHCUs. This is of particular interest in light of the progression of the NHI and its envisioned restructuring of the health care system in this country. The current NHI pays does not pay attention to MHC in any real way and this lack of clarity could be useful to shape a new system which is committed to depth, integration and interdisciplinary working.

Why would such an approach be particularly suited to conditions in South Africa?Psychoanalytic work distinguishes itself from other psychological interventions in its deeper engagement with the causes and patterns of difficulties. Rather than being content with merely addressing conscious or apparent symptoms or thoughts or behaviours, psychoanalytic work unearths the root of these difficulties in our adaption to difficult personal histories (Peters, 2017). This focus on depth, context and the long term lend itself to South Africa where inter-generational mental and emotional trauma remains mostly unresolved. This focus furthermore honours South Africa’s commitments to substantive equality and an understanding of access to health care that extends beyond mere equal access but demands equal outcomes.

A psychoanalytic and integrated approach to MHC may be more time consuming but, as detailed above, the resources needed for an IIMHC model are minor when compared to the costs of our current non-intervention. Through this model, longer term benefits are prioritised over short term symptomatic alleviation and this approach will have better long term outcomes for not just the MHCU but the MHC system in particular and wider society in general.

ConclusionThe IIMHC model which was detailed in this document is one that can work in a South African context and can deliver the kind of long term and sustainable outcomes that MHCUs, MHCPs and the country as whole wish to see.

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The SAPC finds itself at the intersection of several strengths – Strength in numbers, strength in experience, strength in diversity – and these strengths can be brought to bear on a unique opportunity through the NHI to reshape MHC in a way that protects the rights of MHCUs and improves the working lives of MHCPs.

It also presents an opportunity to truly take up the challenge of integrated and interdisciplinary work including those health and wellness interventions which fall outside of the Western paradigm and which can enable South Africa to bridge a cultural divide in destigmatising mental illnesses and the seeking MHC.

The MHC system is not static and neither is the health care system in general or any of the other factors such as the economy or the government that impact on it. The MHC system will continue to evolve in structured and unstructured ways; whether practitioners take up that challenge or not. It is therefore important for all practitioners to consider the MHC system they want and which best meets the values of our country and their commitment to their patients.

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