Community/hospital indicators in South African public sector mental health services.

BACKGROUND The need to balance resources between community and hospital-based mental health services in the post-deinstitutionalisation era has been well-documented. However, few indicators have been developed to monitor the relationship between community and hospital services, in either developed or developing countries. There is a particular need for such indicators in the South African context, with its history of inequitable services based in custodial institutions under apartheid, and a new policy that proposes the development of more equitable community-based care. Indicators are needed to measure the distribution of resources and the relative utilisation of community and hospital-based services during the reform process. These indicators are potentially useful for assessing the implementation of policy objectives over time. AIMS OF THE STUDY To develop and document community/hospital indicators in public sector mental health services in South Africa. METHODS A questionnaire was distributed to provincial mental health coordinators requesting numbers of full-time equivalent (FTE) staff who provide mental health care at all service levels, annual patient admissions to hospitals and annual patient attendances at ambulatory care facilities. The information was supplemented by consultations with mental health coordinators in each of the 9 provinces. Population data were obtained from preliminary findings of the 1996 census. The community/hospital indicator measuring staff distribution was defined as the ratio of staff employed in community settings to all staff, expressed as a percentage. The community/hospital indicator measuring patient service utilisation was defined as the ratio of the annual ambulatory care attendance rate per 100,000 population to the sum of this rate and the annual hospital admission rate per 100,000 population, expressed as a percentage. RESULTS Of psychiatric public sector staff, 25% are located in community settings in South Africa (provincial range: 11-70%). If hospital outpatient services are included in the definition of ' 'hospital' ', this figure is reduced to 17% (provincial range: 3-56%). In terms of service utilisation, 66% of patient contacts with mental health services occur through ambulatory care services in South Africa (provincial range: 44-93%). DISCUSSION Community/hospital staff distribution indicates an overemphasis on centralised hospital-based care in most provinces and inadequate hospital care in certain provinces. Patterns of patient service utilisation indicate an over-reliance on central hospital-based services and substantial unmet need. The findings draw attention to problems in information systems for mental health care in South Africa. IMPLICATIONS FOR HEALTH POLICIES The community/hospital indicators developed for this study form a useful measure for assessing the implementation of mental health policy over time. For the South African context, the community/hospital indicators are a measure of the extent of resource redistribution from hospital to community services and changing patterns of service utilisation over time. Currently, patterns of resource distribution and service utilisation are inconsistent with government policy. IMPLICATIONS FOR FURTHER RESEARCH Further research is needed into the development of mental health information systems, refining service indicators and improving methodologies for assessing the implementation of mental health policies in service delivery.