SHANNON MORGAN - What will it take to improving access to community and facility mental healthcare services? Insights from a rural area in the Eastern Cape Province
Atlantic Fellow at Tekano Shannon Morgan who has lived and worked in a deep rural area in the Eastern Cape for the last 10 years. She started this journey as a newly qualified Occupational Therapist who applied to do her community service year at a rural hospital. She describes her passions as rural health, mental health and inclusive development.
Whilst an Atlantic Fellow at Tekano, she was the Project Coordinator for a Community Based Inclusive Development Programme, Rural Ability, that supports the inclusion and participation of people with disabilities in their family and community life. Through the Rural Ability Programme people with disabilities have accessed opportunities related to improved health, education and livelihoods.
The programme currently support over 400 children and adults with disabilities who receive regular follow up from Community Disability Workers in six areas in the Zithulele Hospital catchment area. Children with disabilities are enrolling in mainstream schools, savings group members are building their own homes and women with depression are campaigning for mental health to be understood and supported by the wider community. For more see Rural Ability Programme.
Shannon has worked with Rural Rehab South Africa to improve access to rehabilitation services in rural areas. She was also the chairperson of the Rural Mental Health Campaign who released a report about the state of rural mental health care services in 2015. The report highlights the challenges that exist in rural mental health care through the testimonies of mental health care users in the Eastern Cape, KwaZulu-Natal, Limpopo and the North West.
In 2018, Shannon and another Fellow made a submission to the South African Human Rights Commission (SAHRC), defined in Chapter 9 of the South African Constitution as a “national institution established to support constitutional democracy”. Shannon asserts that “although there is a greater acknowledgement of mental health there is still a lot of stigma, lack of skills and knowledge, that affect communities and health care workers access to quality mental health care services.”
She shared with the SAHRC an example of a family she visited through her role as the coordinator of a Community Based Inclusive Development programme for Jabulani Rural Health Foundation.
She describes a 65-year-old man who lives with his brother, his two sons, his wife and a caregiver in a deeply rural village in South Africa. You cannot drive to his home as there are no roads. The only way to get to his home is on foot over steep hills. He was diagnosed with Schizophrenia in 2013. He was hearing people calling his name and his ears would hurt so much it would make him cry out with pain.
This person’s younger brother, is 36 years old and also has Schizophrenia. He also started becoming ill around the same time as his brother but he became very violent. With medication he is stable but struggles to interact with others and he is not able to find a job to help support the family.
Shannon further describes the eldest son becoming ill but struggling to get access to necessary services due to financial constraints, diagnosis not happening for more than a year, and not having an identity document, therefore unable to apply for a Disability Grant. This means the family’s out of pocket expenditure on his health needs will continue to affect the whole family’s livelihood and health. She describes another family member also becoming ill.
In all of this sad but prevalent example, there is one relative who has become a caregiver for the whole family. Further challenges to these persons include medication recently being out of stock at the clinic and the hospital, use of medication that is not working and the pain and hardship associated with daily living.
Shannon works for the Jabulani Rural Health Foundation, and her project is entitled “Improving access to community and facility mental healthcare services in a rural area in the Eastern Cape.”
As the WHO puts it “there can be no health for all without mental health.” Mental health is vital to the physical, emotional, social and occupational wellbeing of individuals and communities. Mental disorders are fast becoming the biggest cause of ill health globally.
By 2030 depression will be more prevalent than cancer or heart disease. In South Africa, mental health care continues to be under-funded and under-resourced compared to other health priorities in the country, despite the fact that neuropsychiatric disorders are ranked third in their contribution to the burden of disease, after HIV&AIDS and other infectious diseases.
Shannon points out that there are also glaring disparities between provinces. According to the Rural Health Advocacy Project (RHAP), rural areas fare the worst. The South African Stress and Health study found that the minority of South Africans, one in four, have access to treatment for mental disorders.
In her project’s Problem Statement, Shannon describes the catchment area served by Zithulele hospital, in the OR Tambo district of the Eastern Cape, South Africa that relies on inadequately resourced primary health care facilities for delivering mental health care services in this area.
This has resulted in an unmet need amongst people living with mental illness. Community based mental health care services are almost non-existent, with NGO’s in the area trying to fill this gap. This lack of services and support in this relatively inaccessible rural area not only results in ill-health but also reinforces community perceptions and stigma regarding mental disorders, which in turn creates further barriers to accessing services.
Her project work has begun to demonstrate and confirm that “mental health care services are under resourced and under supported in this rural area. It has helped to better understand the challenges experienced by mental health care users (MHCU) and their families in the Zithulele Hospital catchment area and within the borders of the Rural Ability Programme target areas.
It will also look at developing good relationships with Zithulele Hospital as this relationship will be important when MHCU start presenting how they would want to be treated when accessing health care services in this community.
Shannon is part of the Zithulele Mental Health Action Plan a group of health care workers at Zithulele Hospital committed to improving mental health care services in the area. She also has the support of Charlene Sunkel, a friend and mentor, in the development of her project.
Charlene is currently the CEO of the Global Mental Health peer network and has been working in mental health advocacy and human rights since 2003. Shannon invited Charlene to share her professional and personal experience with the Zithulele Hospital team.
Charlene shared openly about her diagnosis of Schizophrenia and what the Zithulele Hospital clinical team could do to ensure the rights of mental health care users are upheld when accessing services at the hospital. This has led the team to reflect on their own attitudes towards mental illness not only with their patients but in their own lives too.
The project aims to build the capacity of MHCU and their families to challenge stigma among community members and health care professionals. One of the Rural Ability Programme’s Community Disability Workers has facilitated depression groups for a few years now.
Together with an Occupational Therapist from Zithulele Hospital they have been able to support a group of women to find their own voice in challenging the stigma related to mental illness. Through Shannon’s experience with Tekano and the other Fellows she had realised the importance of creating spaces for people to develop their own voice and skills in becoming advocates for change. The project therefore hopes to support the voice of MHCU in the development of mental health care services in the area.
In motivating her Equity Argument for Rural Mental Health, she asserts that mental health care services are under resourced and this has had a particular impact on the development of facility and community based mental health care services in this rural area in the Eastern Cape.
The public health sector is struggling with human resources for health with the majority of health care workers found in the private sector (RMHC report). This creates an inequality between the mental health care service that is being offered at public hospitals in a rural area as compared to a minority of individuals who can afford medical aid coverage and have access to more doctors, nurses, occupational therapists, psychologists and psychiatrists.
She maintains that mental health services remain centralized in urban areas with the majority of the budget for mental health care being spent on specialized psychiatric facilities (RMHC report).
No dedicated budget for mental health care exists within the health budget and as a result mental health care services have been neglected and not much service development has taken place beyond institutional care. This inequality is a legacy of the colonial era when asylums were established by colonial settlers to segregate mental health care users from the rest of the population. (SA Journal of Psychiatry)
Key insights and lessons
To address this inequality and outright human rights violations there needs to be political will and my feeling is that this will only happen through pressure from civil society and mental health care users themselves.
A few organization and movements concerned with mental health in South Africa recently met to develop an alliance. This is an opportunity for this project to not only contribute through written findings but through supporting rural mental health care users to speak to the issues that they are facing in accessing services.
We look forward to reports and further insights from this important project.
The project will aim to include health care workers from Canzibe - and Madwaleni hospitals as far as possible. This includes any training presented at Zithulele Hospital or in the community.
The Rural Ability Programme may also consider supporting the project fellow Azanian Khululwa Jampo works with, in the Mankosi village.
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