| Summary: | Deinstitutionalisation - the movement of psychiatric inpatients out of hospitai - has been promoted internationaily on the precept that care in the community leads to better treatment outcomes and a better quality of life for people with mental illness. It currently forms a key element of proposals to transform the provision of mental health care in South Africa.
Experiences with deinstitutionalisation in other countries have, however, been mixed and while some efforts have demonstrated positive results, others have resulted in a worse state of affairs for patients and their families. In too hasty deinstitutionalisation processes, hospitals have been closed and people moved into the community in an ad hoc and random manner. With scarce or inadequate community services, many patients have been left to wander the streets, joining the ranks of the homeless (Krupinski 1995) and are often abused by unprepared and prejudiced communities. Further, the assumption that all patients with mental illness respond favourably to deinstitutionalised care may not be justified, with some patients achieving better outcomes within institutional settings (Lawrence et al 1990). Moreover, cost savings, a major motivation for deinstitutionalised care for the mentally ill, have not materialised. There is a clear understanding that community services need to be developed either ahead of or in conjunction with patient
discharge, necessitating additional resources.
These are the challenges facing mental health services in South Africa, which are currently highly institutionalised and based on an outdated, custodial model of care. It is made more complex by a context of limited community mental health care resources, restricted health budgets and competing community development needs.
A comparison between the existing levels of p r o v in r i-j! psychiatric services against recommended national norms for psychiatric care (Flisher et al 1965) suggests that there is no over provision of psychiatric beds or staff, but rather a need io transfei :ong term bed resources to acute and residential beds, over time. The implication is that ad^l.cno! resources will have to be found if community services for people with a mental illness are to be developed.
In a review of existing non-governmental services conducted in KwaZulu-Natal, McClaren and Philpott (1998) found that community based services were poorly developed and where they existed, were threatened by the lack of emphasis given to mental health in the overall health agenda, inadequate financial assistance and limited communication between government and non-government sectors. The absence of a guiding framework for mental health services in these provinces served to further perpetuate the apparent ad hoc and fragmented nature of the development of these services.
In light of these findings, it seems that a decrease in bed numbers - a traditional focus of a
deinstitutionalisation thrust - would serve to further deplete an already under resourced service.Using deinstitutionaiisation as a vehicle for transformation of the mental health services in these provinces may put the services at risk of losing what little resources they do possess.
A more considered approach to a discharge oriented policy is needed. To better guide mental health sector transformation, a study of psychiatric institutions in the Eastern Cape and KwaZulu Natal Provinces was conducted in order to answer the following questions: Who is actually being cared for in these institutions, what is their discharge potential and what services might they need in the community if they were to be discharged?
The study was funded through a research grant from the Health Systems Trust.
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