title: Mental health nurses in South Africa's public rural primary care settings: a human resource crisis.
abstract: South Africa is a middle-income country with serious socioeconomic risk factors for mental illness. Of its population of 52 million, 53% live below the poverty line, 24% are unemployed and 11% live with HIV/AIDS, all of which are factors associated with an increased burden of neuropsychiatric disease. The negative social implications due to the mortality caused by AIDS are immense: thousands of children are being orphaned, increasing the risk of intergenerational mental illness. Ensuring sufficient mental health human resources has been a challenge, with South Africa displaying lower workforce numbers than many low- and middle-income countries. It is in South Africa's public rural primary healthcare (PRPHC) areas where access to mental healthcare services, especially medical prescribers, is most dire. In 1994, primary healthcare (PHC) was mainstreamed into South Africa's public healthcare system as an inclusive, people-orientated healthcare system. Nurses provide for the majority of the human resources at PHC level and are therefore seen as the backbone of this sector. Efforts to decentralize mental healthcare and integrate it into the PHC system rely on the availability of mental health nurses (MHNs), to whom the task of diagnosing mental illness and prescribing psychotropic medications can be shifted. The goal of this situation analysis was to fill knowledge gaps with regard to MHN human resources in South Africa's PRPHC settings, where an estimated 40% of South Africa's population reside.
  
  
  
  Both primary and secondary data were analysed. Primary data was collected by inviting 160 (98%) of South African rural hospitals' clinical heads to participate in an interview schedule regarding mental health human resources at their institutions. Primary data were collated and then analysed using descriptive quantitative analysis to produce lists of MHNs per institution and per province. Secondary data was obtained from an extensive literature review of MHNs in South Africa, but also of mental healthcare services in other low- and middle-income countries. The literature review included reports by the National Department of Health and the South African Nursing Council, academic publications and dissertations as well as census data from Statistics South Africa, including findings from the 2011 general household survey. International secondary data was obtained from the WHO's most recent reports on global mental health.
  
  
  
  The findings suggest a distressing shortage of MHNs in South Africa's rural public areas. Only 62 (38.7%) of the 160 facilities employ MHNs, a total of 116 MHNs. These MHNs serve an estimated population of more than 17 million people, suggesting that MHNs are employed at a rate of 0.68 per 100 000 population in South Africa's PRPHC areas.
  
  
  
  Secondary data analysis indicates that MHNs are practicing in South Africa at a national rate of 9.7 per 100 000 population. This unequal distribution calls for a redistribution of MHNs to PRPHC areas. Further recommendations are made to address the mental healthcare workforce crisis by upscaling human resources in PRPHC areas. Revisiting policy surrounding training programs and the current evidence-based approach of task shifting is advised. Innovative approaches such as extending mental healthcare professions' roles and scopes of practice at PHC level are necessary to ensure adequate mental health care for all South Africans.
authors.affiliation: Department of Behavioural Medicine, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa. jhdk.dekock@gmail.com.
authors.forename: Johannes H
authors.initials: JH
authors.lastname: De Kock
authors.affiliation: Department of Behavioural Medicine, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa. pillayb@ukzn.ac.za.
authors.forename: Basil J
authors.initials: BJ
authors.lastname: Pillay
mesh_terms: D000328:Adult; D044383:Black People; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D008605:Mental Health Services / Q000458:organization & administration* / Q000706:statistics & numerical data*; D008875:Middle Aged; D011320:Primary Health Care / Q000458:organization & administration* / Q000706:statistics & numerical data*; D011568:Psychiatric Nursing; D019035:Rural Health Services / Q000458:organization & administration* / Q000706:statistics & numerical data*; D012959:Socioeconomic Factors; D013019:South Africa; D000078329:Workforce
keywords: Africa; Allied Health; Evidence-based Care; Health Needs Assessment; Health Service reform; Medical; Mental Health; Nursing; Postgraduate; Public Health; Workforce