[intro]I was deeply touched when the Life Esidimeni tragedy emerged in media reports. The death of more than 140 resulting from the reckless implementation of ‘deinstitutionalisation’ of the country’s mental health policy is deeply troubling. We need to think long and hard about our mental health policy as South Africans.[/intro]
Earlier this month, the Gauteng Health Department updated the death toll of the Life Esidimeni tragedy. As it stands, at least 141 adult psychiatric patients died due to the reckless decisions of the Gauteng Health Department when they decided to terminate their contract with the Esidimeni group, essentially de-institutionalising mentally ill patients by moving them from Esidimeni to the care of ill-equipped NGOs. Many of the patients died from starvation, dehydration and poor care. When Life Esidimeni patients were moved from the facility many of them did not have any medical records, and family members were often not told where they were being relocated to. It is a harrowing story that says much about the state of our current public healthcare system, specifically when it comes to mentally ill patients.
Looking back on the successes and failures of our public health system and our government’s proposed National Health Insurance (NHI) scheme, we must question whether the powers that be are capable of delivering the necessary healthcare to those who need it most.
The National Health Insurance (NHI) policy is a plan by the South African government to ensure health security for all its citizens, irrespective of class or income. But looking at the government’s track record, and specifically the recent Life Esidimeni tragedy, we must ask ourselves about the consequences of the government pushing for the NHI and its support for community-based Primary Health Care (PHC), in a capitalist, neoliberal context. What are the structural factors such as poverty and unemployment that prevent people from healthy livelihoods? Does the NHI take this into consideration, and can it successfully exist alongside a robust private healthcare industry and big pharmaceutical companies.
The status quo gravitates towards marketing strategies aimed at promoting the notion of the healthy, economically active citizen. In this environment, individuals have to stay healthy to remain relevant to the neoliberal order. Individuals enmeshed in a global neoliberal order are pressured to become consumers of products offered by multinational pharmaceutical companies to become healthy and economically active citizens.
The Life Esidimeni tragedy and the particular decisions that were taken in the transfer of the mentally ill patients highlights the challenge of policy implementation within a neoliberal context. The policy of deinstitutionalisation of mental illness was implemented within budget constraints with the hope that families would also support their next of kin who are under the mental health care system. Another expected outcome of deinstitutionalisation was that patients would eventually be rehabilitated and accepted back into the communities within which their families also lived. The result was the loss of very many lives. If government gets its way and the NHI goes ahead, could there be more consequences for mentally ill patients who rely on government structures for medical support?
The “new mental health policy” of deinstitutionalisation, which arose from a critique of “the asylum”, pitches the language of community-based care. However, the challenges of grassroots implementation of this policy should be acknowledged. The first challenge presented by the implementation of deinstitutionalisation of mental health care could be the lack of service infrastructure, such as community-based care facilities as well as specialised knowledge. The South African National Mental Health Policy Framework acknowledges this lack of community-based care facilities. For example, there are no community-based care centres for adolescents in the Limpopo Province – due to the skewed distribution of health care facilities inherited from the Apartheid era. Other provinces like Gauteng Province, with a historical advantage, have few adolescent mental health care centres. However, most provinces in South Africa experience a shortage of mental healthcare service for adolescents, as explained in the South African Mental Health Policy Framework.
The individualisation of mental health care and its relegation to the family, the community and the individual diverts attention from the need to deliver social-structural interventions of mental health. So, what have we learned from the Life Esidimeni tragedy, and more importantly, what has the current government learned from the decisions they took? If the health of citizens allows a society to function, and a society understands healthcare (including mental healthcare) as a basic human right, then how do we as citizens ensure that our public healthcare system and the NHI to come, meets the rights of all?