Although there have been important developments in South African mental health policy and legislation, there remains widespread inequality between provinces in the resources available for mental health care; a striking absence of reliable, routinely collected data that can be used to plan services and redress current inequalities; the continued dominance of mental hospitals as a mode of service provision; and evidence of substantial unmet need for mental health care. There is an urgent need to address weak policy implementation at provincial level in South Africa.

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BackgroundThis paper outlines stakeholder views on environmental barriers that prevent people who live with psychosocial disability from participating in mental health policy development in South Africa.MethodFifty-six semi-structured interviews with national, provincial and local South African mental health stakeholders were conducted between August 2006 and August 2009. Respondents included public sector policy makers, professional regulatory council representatives, and representatives from non-profit organisations (NPOs), disabled people’s organisations (DPOs), mental health interest groups, religious organisations, professional associations, universities and research institutions.ResultsRespondents identified three main environmental barriers to participation in policy development: (a) stigmatization and low priority of mental health, (b) poverty, and (c) ineffective recovery and community supports.ConclusionA number of attitudes, practices and structures undermine the equal participation of South Africans with psychosocial disability in society. A human rights paradigm and multi-system approach is required to enable full social engagement by people with psychosocial disability, including their involvement in policy development.

Objective: To provide estimates of the prevalence of selected mental disorders in the Western Cape, based on the consensus achieved by a working group established for this purpose. Method: An expert working group was established to provide technical expertise for the project. Potential risk factors likely to influence local prevalence rates were identified. Annual prevalence rates for adults and for children and adolescents were derived by consensus, informed by a systematic literature review. Prevalence rates were derived for individual disorders and adjusted for comorbidity. Results: The overall prevalence was 25.0% for adults and 17.0% for children and adolescents. Conclusion: Prevalence rates of child, adolescent and adult mental disorders were derived in a short period of time and with the use of minimal resources. Although of unknown validity, they are useful for policy development and for planning service utilisation estimates, resource costing and targets for service development for local mental health needs. This in the absence of an existing methodologically sound national prevalence study. We recommend that policy and programme developers draw on the expertise of local academics and clinicians to promote research-informed planning and policy development in the public sector.

Objective: This paper reports on overarching strategies which supported the establishment and sustainability of 9 mental health self-help organisations in seven African countries. Method: Eleven key informants were identified through snowballing and interviewed regarding their experience in the organisations. Thematic analysis of the interview data and other documentary evidence was guided by a coding scheme derived using a framework analysis approach to defining, categorising, mapping and interpreting textual data. Results: Sustainability strategies include: commitment to members' advocating for their rights and rebuilding their lives within their communities; independent decision-making, user-led membership and leadership; financial selfsufficiency, alliances with donor organisations, non-governmental organisations (NGOs), disabled people's organisations (DPOs) and ministries which support self-determination and promote control over agenda-setting and responsiveness to members' needs. Organisations' work include advocacy to destigmatise mental disorders and promote the protection of users rights, activities to improve access to health care and to income generation and social support, participation in legislative and policy reform, and capacity building of members. Conclusion: Self-help organisations can provide crucial support to users' recovery in resourcepoor settings in Africa. Support of Ministries, NGOs, DPOs, development agencies and professionals can assist to build organisations' capacity for sustainable support to members' recovery.

There is new policy commitment to mental health in South Africa, demonstrated in the national mental health summit of April 2012. This provides an opportunity to take stock of our mental health services. At primary care level key challenges include-training and supervision of staff in the detection and management of common mental disorders, and the development of community-based psychosocial rehabilitation programmes for people with severe mental illness (in collaboration with existing non-governmental organizations). At secondary level, resources need to be invested in 72-hour observation facilities at designated district and regional hospitals, in keeping with the Mental Health Care Act. At tertiary level, greater continuity of care with primary and secondary levels is required to prevent "revolving door" patterns of care. There are major challenges and also opportunities related to the high level of comorbidity between mental illness and a range of other public health priorities, notably HIV/AIDS, cardiovascular disease and diabetes. The agenda for mental health services research needs to shift to a focus on evaluating interventions. With current policy commitment, the time to act and invest in evidence-based mental health services is now.

These findings highlight the importance of national leadership in the development of new mental health policy, communication between national and provincial levels, the need for provincial structures to take responsibility for implementation, and capacity building to enable policy makers and planners to develop, monitor and implement policy.

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