Public health advocacy: How can we grow a national advocacy movement for mental health in South Africa?

There is growing international awareness of the importance of mental health as a public health and development issue in low and middle-income countries. This new prominence owes a great deal to the effects of advocacy, by a variety of individuals and organizations, and through a variety of methods. Following the launch of the first Lancet series on Global Mental Health in 2007 (1), an international movement was established: the Movement for Global Mental Health. This has joined with other international initiatives, including those driven by the World Health Organization, the World Federation for Mental Health, the World Network of Users and Survivors of Psychiatry, as well as national initiatives in Australia, Canada, New Zealand, Uganda, the UK, and the USA, among others. This international movement has been supported by the United Nations (UN) Convention on the Rights of Persons with Disabilities (2006), which includes mental disabilities, and a recent UN General Assembly resolution on Global Health (A/65/L.27), which recognises the burden of mental health problems and their social and economic costs.

These advocacy initiatives are diverse in terms of their membership (including people living with mental illness, their families, carers and health professionals) and their messages (including some who are openly critical of certain mental health professions). Yet these initiatives retain certain core features that are common. These include a concern for the human rights of people living with mental illness, a commitment to greater public education and awareness about mental health, and a belief that people have a right to adequate mental health care, regardless of gender, socio-economic status, age or ethnicity. Many of the initiatives have grown out of grassroots experiences of stigma and discrimination, and build on local community participation and empowerment programmes (2).

In South Africa, there have been important advocacy initiatives by non-governmental organisations (NGOs) such as the South African Federation for Mental Health, the South African Depression and Anxiety Group and Ubuntu. Government has also played a key role in advocacy for mental health, particularly the Directorate: Mental Health and Substance Abuse in the national Department of Health; and academic groups have also contributed, for example through the Mental Health Information Centre at Stellenbosch University, and the newly established Centre for Public Mental Health. However, the development of a fully-fledged advocacy movement for mental health is still in its infancy in this country.

There is an urgent need to grow and sustain a vibrant mental health advocacy movement in South Africa. Neuropsychiatric disorders are ranked third in the national burden of disease (3), and 1 in 6 South Africans suffer from a common mental disorder (4). Yet mental health is given scant attention on the national health policy agenda. There is wide variation in the provincial health budget allocations to mental health (from 1% to 8%) and a 45-fold difference in the psychiatrist/population ratios between provinces (5). The variation is partly driven by the lack of clear national direction on budget allocations to mental health and the lack of an official national mental health policy (6). Stigma and ignorance continue to inform public opinion (7) and mental health is poorly integrated into primary health care (8).

If we are to grow our fledgling mental health advocacy movement in South Africa, it is important that we learn from the experiences of others, and not re-invent the wheel. There are several important lessons that can be learnt from mental health advocacy initiatives in other countries, and from our own health advocacy movement in South Africa, as exemplified in the Treatment Action Campaign (TAC). These lessons may be valuable in developing our own advocacy work for mental health, and may also be relevant for other public health advocacy initiatives:

  1. Develop a united and consistent message. Those involved in mental health include a broad range of stakeholders, with diverse opinions on priorities, approaches to mental health care and roles of providers, government and NGOs. If a broad-based advocacy movement is to be established, it is essential to set aside at least some of these differences and agree on common ground for advocacy messages. Like international initiatives, it would make sense to include the human rights of people living with mental illness, stigma reduction, public education and the right to adequate care as core messages.
  2. Choose focused issues for advocacy. The TAC provides an inspiring example of how the complex area of HIV/AIDS, its associated stigma and a variety of different stakeholders can be united around the focus on a single issue, namely the right to treatment. This provides a second lesson for mental health advocates; there is value in choosing a single issue that unites the diverse range of stakeholders involved in mental health. This issue may be the right to treatment (e.g., improving access to essential psychotropic medicine in the community), or public education to reduce stigma, but would need to be agreed upon by a range of stakeholders. Once the issue is agreed upon, there is a need for concerted, sustained and consistent efforts to push the issue on the public agenda.
  3. Build alliances across a range of sectors. In order to mobilize sufficient public sentiment and political will, it is essential that advocacy messages are seen to emanate from a range of sectors. This requires the building of alliances between a variety of sectors within government, NGOs and civil society. Often a single forum to initiate such an alliance (such as a national mental health conference), and to sustain it through a structure (such as a national mental health commission) have been crucial to the success of advocacy initiatives in other countries.
  4. Involve mental health service users at all stages. The slogan “nothing about us without us” is no less salient in South Africa than elsewhere. In semi-structured interviews with 96 mental health stakeholders from a range of sectors in all provinces, it was found that most participants supported the involvement of mental health service users in policy development and implementation (9). A number of strategies to create an enabling environment for service user participation were identified, and these included: social action directed at reducing stigma, advocating for acceptance of users’ rights to participate, crafting a supportive regulatory framework and equipping providers and policy makers to support inclusion.
  5. Use evidence-based public education and stigma reduction strategies. Attempts to educate the general public are too often based on hearsay, rather than proven strategies. Proven successful strategies from other countries include personal testimonies by people living with mental illness; targeting young people with public education messages; educational programmes that target specific stakeholder groups, such as the police; and national anti-stigma campaigns with high levels of media coverage (7).
  6. Evaluate the outcomes of public education and stigma reduction campaigns. In a key South African study a number of public education and stigma reduction campaigns that are being conducted for mental health in South Africa were identified, but very few evaluated their impact (7). It is vital that such initiatives evaluate their impact, and that research capacity is developed to conduct such evaluations.
  7. Build on existing initiatives and opportunities. The links between mental ill-health and HIV/AIDS have been well demonstrated in research (10). There are therefore good opportunities to build on the progress made with ARV roll out in South Africa to demonstrate that providing mental health treatment will also improve HIV outcomes for the large number of South Africans living with HIV, and hence resources should also be allocated to mental health care.
  8. Find mental health champions. In the USA, the death by suicide of the son of a prominent US Senator (Senator Gordon Smith) led to him and his wife becoming committed advocates for mental health, and contributing substantially to the passing of the mental health parity legislation through the United States Congress in 2008. Similarly in Norway, the Prime Minister of Norway, Kjell Bondevik had a major depressive episode while in office in 1998, and instead of hiding the issue or resigning, he took leave from office and publicly shared his experience. Through supportive care and medication he was able to make a full recovery, and was elected again for a second term in 2001. His honesty led to strengthening of mental health advocacy work in Norway and in many other countries where he has told his story. If prominent South African public figures had the courage to share their personal experiences in this manner, this could have a major impact on the national mental health advocacy movement.

These lessons from a range of health advocacy initiatives around the world provide useful insights for those wishing to strengthen mental health advocacy in South Africa. We hope that by presenting them in this format, we can stimulate debate and add further impetus to advocacy work for mental health in South Africa.

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