South African Psychiatry - November 2018

POLICY GUIDELINE
Furthermore, Section 72(6) of the MHCA allows for
national or provincial departments of health (DOH)
to “enter into agreement with any non-governmental
organisation …to exercise powers and perform
functions and duties under this Act”.
THIS IMPLIES THAT DESIGNATION OF NGOS
TO PROVIDE PSYCHIATRIC OR MEDICAL
CARE SHOULD BE DONE IN AGREEMENT
WITH THE NGO. ADDITIONALLY, SECTION
45(2) OF THE NATIONAL HEALTH ACT
NO.61 OF 2003 (NHA) ALLOWS THE DOH
AND MUNICIPALITIES TO ENTER INTO AN
AGREEMENT WITH NGOS TO ACHIEVE
THE OBJECTIVES OF THE NHA.
However, the Minister has not yet classified NGOadministered
facilities into health establishment
categories, as provided for in Section 35(a)(vi) of
the NHA, and such a process would surely involve
stakeholder agreement with the NGOs.
AGAINST THIS BACKGROUND, WE
HAVE THE FOLLOWING CONCERNS:
1. Neither mental illness nor severe to profound
intellectual disability are included in the
definitions, and other conditions and user
groups which may require similar levels or types
of care are not specified.
2. The definition of ‘‘manager” refers only to “heads
of health establishments”, which may not be
relevant to the socially supportive NGOs with
which this document is concerned. Most of the
said NGO-administered facility managers are
lay people, and not qualified to provide health
services.
3. Related to this is the confusing application of
the guidelines to day-care facilities, defined to
include home-based care, protected workshop
and support groups and means a facility that
offers services, day time activities and social
contact for an individual mental health care
user and groups of mental health care users
for treatment, rehabilitation, prevention and
promotion activities. On this definition, day
care centres would fall within the definition of
a care and rehabilitation centre. But, care and
rehabilitation centres are not within the purview
of these guidelines.
Protected workshops and support groups
only function with the voluntary attendance
of PLWMI and/or ID. Neither are intended, by
their very nature, to provide health services.
The assumption seems to be that all service
users included under the guidelines are in
constant need of medical care, which in itself
is problematic. While ‘home-based care’ may
constitute health care, it cannot be regarded as
a ‘facility’. The Guidelines fail to account for the
range of different services and activities needed
by different individuals, in different contexts and
at different stages of the life course. They also
fail to address the area of overlap between daycare
centres (as described above) and Early
Child Development (ECD) centres. In most rural
and peri-urban communities, community-based
ECD centres offer the only possibility of day-care
for children and youth with disabilities, including
those with severe and profound intellectual
disabilities. Enforcement of the guidelines would
render this impossible, driving either the reinstitutionalisation
of rural children and adults
with disabilities, or the overburdening and
collapse of fragile family and social networks.
Further, South African educational policy
and international best practice promote the
inclusion of children and youth with disabilities
in mainstream educational institutions wherever
possible. The requirements imposed by these
guidelines would increase barriers to inclusion
and powerfully discourage organisations and
services from accepting PLWMI, including
children and youth. A similar effect is likely to
occur with homeless and ‘abused person’
shelters, which frequently provide housing and
support for PLWMI.
4. The requirement of a Service Level Agreement
(SLA) with the District Health Services in 8.2 is
circular – districts are unlikely to enter into an SLA
with an unlicensed NGO, and yet the SLA is a
pre-requisite for licensing of the NGO.
5. Under 12.2, the guidelines do not specify who
is responsible for the transfer of users out of a
non-compliant NGO, and where they should
be placed. We note there is no plan in place for
government run supported housing of PLWMI
and/or ID. Our observation is that there is a
high demand for NGOs, with a mushrooming
of illegal facilities and no alternative social care
setting. We anticipate that adherence to these
guidelines will result in the mass transfer of users
to government hospitals as well as an increase
in the high numbers of incarcerated or homeless
PLWSMI and/or ID already experienced in South
Africa.
6. In clauses 15, 17, and 18, and in Annexure B, the
Policy Guidelines expect:
a. PLWMI and/or ID to be admitted to residential
and/or day care facilities under the MHCA
(15.4, 17.2(e), Annexure B page 15 and 20).
The MHCA admission and appeal processes
for assisted and involuntary users are
designed to protect the PLWMI and/or
ID from unjustified restrictive hospital or
institutional care, as under the colonial
era mental health system in South Africa.
As the guidelines refer to communitybased
NGOs which take in PLWMI and/or
ID after discharge from a hospital or care
and rehabilitation centre, and which do
not themselves provide restrictive, hospital-
SOUTH AFRICAN PSYCHIATRY ISSUE 17 2018 * 87