Report on Provider Core Competencies for Improved Mental Health Care of the Nation launched

The Academy of Science of South Africa (ASSAf) launched a consensus study report on Provider Core Competencies for Improved Mental Health Care of the Nation on 9 March 2021.

ASSAf has recognised the significant impact that mental, neurological and substance use (MNS) disorders have on the health of the South African population. Research conducted in South Africa has shown that approximately one in six South Africans suffer from such disorders at any one time.

Research has also demonstrated a significant treatment gap with less than 25% of people who suffer from such conditions receiving treatment. South Africa has a shortage of specialist mental health care providers to meet the treatment need. National policies for the promotion of health, prevention, treatment and rehabilitation of ill-health and disability due to MNS disorders, therefore, promote the concept of task shifting to address the treatment gap. This means that lay and general health care providers need to be equipped with the necessary skills and specialist support to be able to address some of the burdens of MNS disorders. For this policy to be successful, training and support programmes need to be appropriate to the South African context.

Since 2012, the Academy of Science of South Africa has engaged in several processes to address this issue. In 2012, ASSAf attended and contributed to an Institute of Medicine Workshop and Report: Strengthening Human Resources through development of candidate core competencies for mental neurological and substance use disorders in Sub-Saharan Africa. In 2014, the Academy organised a South African workshop, which produced a report on the proceedings of the workshop on the implementation of core competencies for mental, neurological and substance use disorders.

A key recommendation of this workshop was that an audit of existing training curricula be undertaken in South Africa to determine whether these training programmes are preparing providers for the needs of the South African population.

In 2015, the Academy established a multi-professional expert panel to undertake a consensus study on Provider core competencies for improved mental health care of the nation. This report is the outcome of these activities. While working within significant time and resource constraints, the emphasis has been on the formal health sector. However, the panel recognises that addressing MNS disorders requires a multisectoral approach and an attempt has been made to reflect this in the report.

The members of the panel were Prof Rita Thom, panel chairperson, University of the Witwatersrand (Wits), Dr Robin Allen, University of Cape Town (UCT), A/Prof Madeleine Duncan, UCT, Prof Crick Lund, UCT, Prof Bronwyn Myers, South African Medical Research Council (SAMRC), Prof Inge Petersen, University of KwaZulu-Natal (UKZN), Prof Solomon Rataemane, Sefako Makgatho Health Sciences University (SMU), Ms Bharti Patel, South African Federation for Mental Health (SAFMH) and Dr Gayle Langley, University of the Witwatersrand (Wits) (now retired).

The study presents a vision for a workable and appropriate system of health promotion, prevention, treatment, care and rehabilitation for people with MNS disorders, which is in line with national policies, including those addressing the social determinants of mental health and human development. Key findings and recommendations of the systematic review of training curricula of a range of health service providers, from community health workers, to generalist health care providers, allied health professionals and specialist mental health (and neurologist) providers include:

1. Community health workers and emergency medical service providers are trained in generic skills but lack sufficient appropriate mental health content knowledge and treatment-specific skills. It is recommended that specific training in general screening for mental disorders and management of chronic mental disorders (specifically around adherence to medication as well as how to access recovery-oriented rehabilitation) be included in community health worker training, Emergency service providers should be trained in recognition and management of acute psychiatric emergencies, including methods of de-escalation, calming and restraint.
2. Traditional healers play an essential role in the lives of many people with MNS disorders but have not yet been formally integrated into the healthcare system. Ongoing dialogue between traditional healers and formal health service providers should be encouraged to ensure collaboration between the two approaches for the benefit of people with MNS disorders.
3. There is an emerging nursing crisis in South Africa, and serious deficiencies in the proposed new nursing curriculum will result in graduates not being equipped to play their role in implementing the national policies around MNS disorders. However, the addition of mental health into the Adult Primary Care Manual will equip primary care nurses with some of the recommended competencies to provide adult primary mental health care, if there is training and mentoring to enable nurses to implement the guidelines. It is recommended that the new curriculum be reviewed in light of the significant treatment gap for MNS disorders in South Africa.
4. It is possible for lay/community health workers with appropriate training, mentoring and supervision to be able to provide task-shifted psychosocial interventions such as basic behavioural counselling, recovery-orientated rehabilitation and inclusive development for persons with disability arising from MNS disorders. However, necessary scope of practice and medico-legal issues of accountability need to be addressed. Staff in various categories would have to be audited in order to establish and certify their basic competencies, the missing essential skills addressed in their initial training and a programme of continuing education be afforded to all workers to maintain, refine and upgrade these skills. Supervision of their clinical practice by the mental health team and re-certification on a regular basis (5 yearly) is recommended. Where Continuing Professional Development (CPD) has been mandated by the professional body, these competencies could be included in the CPD requirements. A standardised curriculum with appropriate oversight mechanisms must be developed for this cadre of worker with due consideration of the limits of their scope of practice, including quality assurance.
5. While undergraduate and post-graduate medical training curricula for general medical practitioners and specialists such as Family Physicians, Psychiatrists (and subspecialist Psychiatrists) and Neurologists are of an appropriate and high standard, there is a lack of emphasis on equipping specialists to play the significant training and mentoring role required in a task-shifting environment. Specific training in this regard is recommended.
6. Across all categories of provider training curricula, there is insufficient training in the effective prevention and management of substance use disorders. Evidence-based interventions which include non-judgemental medical approaches as well as psychosocial interventions are recommended.

More detailed recommendations are made, as well as an outline of areas for further study, including addressing the particular needs of children, adolescents, the elderly and persons with intellectual disability. The report notes the need for significant societal and health-system transformation to realise the implementation of the recommendations.