(
REVIEW
PRIMARY MENTAL HEALTH CARE: INDICATIONS AND OBSTACLES Y.G. Pillay and H. Subedar INTRODUCTION
Abstract This essay critically examines literature that has suggested the need for primary mental health care. In exploring this literature the issue o f context as a crucial variable is stressed. Context refers to both the geographic area (South Africa, urban/rural) and the particular type o f health service in use. The basic point is that the designation o f the prim ary p ractitio n er is co n tex t d ep en d en t, be h e /h er the general practitioner in the United States, the psychiatric nurse in rural South Africa-or the public health nurse in an urban context which stresses primary prevention. In articulating a response to the topic it is useful to ask the following questions: (a) what is primary mental health care? ^ ^ b ) who should practice it and where? what types o f patients would benefit from it? (d) what constraints exist which make the practice of mental health care difficult?
A BRIEF REVIEW OF TIIE HISTORICAL DEVELOPM ENT OF THE CONCEPT ‘PRIMARY HEALTH CARE’ Given that there is a thrust to re-incorporate mental health care into prim ary care, it is p e rtin e n t to tra c e b rie fly th e h is to ric a l developm ent o f primary health care within which primary mental health should be situated. We argue that the attempt is a re-incorporation b e c a u s e th e u se o f p s y c h o t h e r a p e u t ic techniques in the arm am entarium o f indigenous healers has been well documented (Buhrmann, 1983). Walt and Vaughan (1982) suggest that there were five basic issues which provided the thrust for the developm ent o f primary health care culminating in the Declaration o f Alma Ata in 1978. The first was the realization in the 1960’s that economic growth was not being equitably distributed and that with growing polarization of the social classes in society, the rich were getting richer and the poor poorer. The number of people with wealth was diminishing, the number of poor w as increasing and there was concomitant realization that the poor had very limited or no access to health care despite increasing technological sophistication in the provision o f such care. The second issue w as concern about the rapid growth of the w orld’s population associated
Curationis. Vol. 15, No. 2, 1992
This paper considers indications and obstacles for the development o f primary mental health care practice in both d e v e lo p e d and under-developed countries. Both are considered as this represents the South African reality. While a significant body o f literature has documented the need fo r primary mental health care, the obstacles (e s p e c ia lly in term s o f the commodification o f health) to its fruition are seldom addressed
Uittreksel Hierdie referaat beskou indikatore en struikelblokke vir die ontwikkeling van primêre geestesgesondheidsorg in o n tw ik k eld e-so w el as onder ontwikkelde lande. Ueide hierdie w ord verteen w oordig binne die Suid-Afrikaanse realiteit. Alhoewel ‘n a a n d u id en d e h o eve elh e id literatuur die behoefte aan primêre geestesgesondheidsorg dokumenteer, word die struikelblokke (spesijiek i.t.v . d ie g eb ru ik sw a a rd e van geson dh eid) selde tot die voile verwerkliking aangespreek.
with concern about competition for a finite amount of natural resources. While this is a real concern, it can also be demonstrated that, at least to some extent, the problem is compounded by the distribution of resources. For instance, in som e countries the real issue is land distribution and not a population explosion (Navarro, 1974). This distinction is crucial as it has obvious im plications for interv en tio n s such as the d e c is io n to in v e s t f in a n c e a n d h e a lth labour-powcr in family planning (use o f the term ‘population control’ illustrates the point well) as opposed to advocating land reform. The third issue was general disillusionmentwith mechanistic solutions to health problems and the realizatio n that, d e sp ite tcchnoligical advances in health care, the health o f the
populace was not significantly better. Although it can be argued that the tide has turned since the early 1980s, technical solutions especially in the 1960s and 1970s were viewed as being limited and the need for a holistic approach to health including social, economic, educational and political domains w as advocated. The need for community based health which incorporated all the above dim ensions w as advanced by workers such as King (W att & Vaughan, 1982). The well-publicised Chinese experiment with com m unity participation and the ‘barefoot doctor’ and its success in delivering health care to the people w as the fourth impetus to the developm ent of the notion o f primary health care. It is necessary, however, to contextualise th is e x p e rim e n t in term s o f the political economy that gave rise to it and not to view it as yet another technical innovation. The Cuban experience and the massive reduction in infant mortality rates in a relatively short period of time also added to the appeal o f primary health care. International adoption o f the concept came with the W orld Health O rganization’s decision in 1975 to strive for provision o f basic health services for all by year 2000 and the subsequent adoption by the international community of the Declaration o f Alma Ata in 1978 outlining the need for primary health care as the important methodology for reaching the goal Health for All by year 2000.
PRIM ARY MENTAL HEALTH CARE (a) T h e Need fo r P rim a ry M ental H ealth C a r e : T h eo re tic a l C on sideration In defining health the Declaration of Alma Ata stated that it w as the state of complete physical, mental and social w ell-being of a person. Also d o cu m en ted w as the fact that health w as influenced by factors beyond the control of the health sector, such as social and economic considerations. Given the contention that at least in some countries one important issue is the need for land reform, it appears necessary to add the p o litical sec to r to this list. The Declaration includes the spirit o f this suggestion in its assertion that people have the right to participate, both individually and collectively, in planning and im plementation o f health care (and, it may be argued, by extension, to all other facets o f civic life). The Declaration, by including mental health as an essential com ponent o f health, provides rationale for the existence o f ‘primary mental
5
health care’ as a legitimate concern and area of study. Goldman (1982) suggests other factors that provided the impetus for primary mental health care which are to some extent, parochial to the U.S.A. He argues that with the creation of public assistance by means o f Medicare and Medicaid, more money w as avai lable for mental health care in general health settings. Secondly, the psychopharmacological revolution made it possible for large numbers o f mentally ill people to be treated w hilst in the community with m aintenance therapy provided by prim ary mental health practitioners. Thirdly, the rise of the community mental health movement helped to partly de-m edicalize and de-stigm atize, m e n ta l d i s o r d e r s a n d p r o b a b ly m o re im portantly "...succeeded in m oving mental health concerns into public consciousness" (Goldman, 1982, 619). The need to prioritize mental health in the provision of primary health also is suggested by Sartorius(1988) w ho argued that mental illness is important because it causes suffering to the individual, the family and the community; it has s o c ia l/e c o n o m ic c o n s e q u e n c e s su c h as d e c re a s e d p ro d u c tiv ity ; in c r e a s in g life expectancy gives rise to increases in the rates of mental disorders (eg. depression and dementia in the elderly); increases in the level o f stress and the fragmentation o f the family and other traditional support systems imply the need for alternative support mechanisms and that mental health expertise can help to hum anize the delivery of health care. The nature of primary mental health may be derived from the need for mental health services that are accessible primary care level. This need has been demonstrated by numerous studies of patients presenting to prim ary health care practitioners, in both post-industrialized and partially industrialized countries, with overt manifestations o f mental disorders as well as important covert or masked mani festations such as somatization". (b)The Need fo r P rim a ry M en tal H ealth C are: E m pirical Evidence In d ev elo p e d c o u n trie s, fo r ex am p le the U.S.A. and Britain and certain sectors o f the South A frican population the regular primary health practitioner is the general practitioner, family practitioner or internist (Lachm an and Zwarenstein, 1990). K ram er et al. (in press) found that for the two year period January 1 9 8 0 to D e c e m b e r 1 9 8 1 , 4 5 .3 % o f all physician office v isits w ere to e ith er the g e n e r a l p r a c t i t i o n e r o r th e i n t e r n i s t , in c re a sin g to 56 .4 % w h en o n e in c lu d e s p ed iatrician s. T his figure b eco m es even more relevant when it is realized that general practitioners in B ritain are the main providers for 95% o f the population with psychiatric morbidity (G ask and M cG rath, 1989). The picture is further com plicated by the fin d in g th a t tre a tm e n t ra te s fo r m en tal disorders w ere very low. K ram er et al. (in press) found treatm ent rates o f 7% w hile B eigel (1983) suggested a figure o f 15% which w hile significantly greater than that found by K ram er et al., is still unacceptably low. T his suggests that a very small minority o f those w ho needed treatm ent w ere receiving
6
it. Reasons for this are com plex but limited access to care, estimated by Kramer et al. to be over 37 million or 16% of the U.S. population, must be contributory, especially if the assertion that this group represents those most vulnerable to mental illness is valid. Prevalence rates for mental disorders appear to depend in part on the sensitivity o f the sc re e n in g in stru m en t used. O rm el et al (1 9 9 0 ) fo u n d th a t p re v a le n c e ra te s o f psychological disorders in patients presenting in general practice in the N etherlands, varied fro m 4 6 % w h e n th e G e n e r a l H e a lth Q uestionnaire (G H Q ) w as used to 15% when the P resent State E xam ination (PSE ) w as used. G eneral practitioners seem ed able to identify about 56% o f the cases positively identified by the GHQ. V arious studies o f patients presenting to primary care providers in p ost-industrialized countries found that " ...o v e r a th ird o f c o n s e c u tiv e g e n e ra l p ra c titio n n e r a tte n d e rs sh o w s u b s ta n tia l l e v e l s o f m e n ta l d i s t r e s s a n d th a t ap p ro xim ately 15-25% can be assigned a sp e c ific d ia g n o sis in the d e p ressio n and anxiety spectra..." (Ormel et al., 1990, 909). The W orld Health O rganization (W H O ) in their seven country study, tried to study the is s u e in p a r t i a l l y d e v e lo p e d a n d under-developed countries. H arding et al (1980) reported that the W HO C ollaborative Study on Strategies for E xtending M ental Health C are (o f four o f the countries studied ie. C olom bia, India, P hilippines and Sudan) found that prevalence rates for consecutively presenting adults ranged from 10.6% in the S u d an ese sam p le to 17.7% in the Indian s a m p le . T h e y a ls o fo u n d , c o n tr a ry to expectation as well as priority set by the W orld Health O rganization ie. to target the anticipated large num ber o f psychotics, that o f all the patients found to have som e form o f p sy ch o lo g ical d istu rb an ce , a p p ro x im ately 86% o f them w ere diagnosed as having som e form o f n eu ro sis. An eq u ally im p o rtan t finding w as the percentage o f m entally ill p a t i e n t s w h o p r e s e n te d w ith s o m a ti c com plaints w hich w ere m issed consistently as indicators o f mental illness by the primary health care w orker. T he em p irical ev id e n c e p resen te d above covers developed, partially developed and under-developed countries. T his begs the issue as far as South A frica is concerned, given that it includes both a developed society a n d o n e th a t c a n b e d e s c r i b e d a s under-developed. Data that w ould assist the d escrip tio n o f the p ro b lem and p lan n in g responses are largely unavailable. W e have to rely on estim ates that are based on som e of the research conducted by the W orld Health O rganization. Freeman (1989) suggests that, b a s e d on a 15% p re v a le n c e o f m e n ta l disorders, approxim ately 5 million people in So u th A frica have som e form o f m ental d is o r d e r w ith 3 3 0 ,0 0 0 b e in g s e v e r e ly incapacitated. He also suggests that mental health resources arc inadequate to cope with the num bers o f people requiring help. T his supports the need for prim ary mental health services to be provided by a broad range o f health care practitioners including general practitioners, nurses, paraprofessionals and
indigenous healers w ho are integrated into the health care system. (c) F orm o f P rim a ry M en tal H ealth C are W hile there is considerable agreement about the need for primary mental health care there is less agreem ent about the form that it should ta k e , s u g g e s t i n g th a t th e r e is so m e d isag reem en t ab o u t the nature o f primary mental health skills necessary. This issue is sum m arized adequately by G ask and McGrath (1 9 8 9 ). T h e c o n tro v e rsy larg ely centres around the issue o f theoretical orientation (eg. the applicability o f psychodynam ic theory as opposed to a problem-focused approach) and the related issu e o f w h o sh o u ld practice primary mental health care. T h e f ir s t is s u e fo c u s e s o n th e ty p e o f intervention primary health care practitioners sh o u ld be ex pected to provide. It is the contention of this paper, supported in part by Schurm an et al (1 985), th at prim ary care practitioners, be they village workers, nurses or general practitioners should not be expected to provide the type o f diagnostic or therapeutic intervention w hich specialist mental health practitioners provide. N evertheless, primary care practitioners should be trained to make a d e q u a te firs t level d ia g n o se s o f m ental disorders, make appropriete referrals where possible and possess a therapeutic attitude that perm eates their practice and helps humanize the practice o f health care. D e s p ite c o n tr o v e r s y a b o u t th e o r e tic a l orientation, there is some agreem ent about a few issues. The im portance o f a therapeutic attitude has been articulated (Schurman et al., 1985; G ask and M cGrath, 1989). This can be a fairly n e b u lo u s c o n c e p t but is seen as c o n s i s t i n g o f a t le a s t th e f o llo w in g c o m p o n e n ts :- a d e q u a te lis te n in g sk ills , attention to both verbal and non-verbal cues and an em pathetic attitude. In terms o f im proving the diagnostic ability of primary health care workers, the use o f such standardized scales as the GHQ, PSE and the S h o rt R eporting Q u estio n n aire (SR Q ) can in c re a se the p e rc e n ta g e o f p a tie n ts w ith p sy c h o lo g ic a l p ro b lem s id entified by the prim ary care practitioner. M any o f these instrum ents such as the PSE,GHQ and SRQ have been standardized for use in developing countries. W hat is more difficult to achieve is the change in attitude o f primary health care practitioners to mental disorders. The historical relationship betw een m edicine and psychiatry has been docum ented by, am ongst others, G oldman (1982). I Ie suggests that these two branches of health care only recently have begun to talk the sam e language, with the m edicalization of mental disorders facilitated by advances in b iological psy ch iatry . The view o f these reviewers is at odds with Goldman w ho appears to consider this necessarily advantageous. It is possible that as psychiatry becom es subsumed by technology, psychiatry may becom e as mechanistic as the rest o f medicine rather than becom ing humanised.
Curationis, Vol. 15, No. 2, 1992
(d) Some obstacles to the development of Primary Mental Health Care These authors are not optim istic about the p o s s ib ility o f m a k in g h e a lth c a re le ss mechanistic and more humanistic. This pessimism rests on the nature o f the health c a re d e liv e ry sy ste m in m o st c o u n trie s, including South Africa. The treatment o f health as a commodity on which an exchange value is placed and the degree o f professionalization o f the health care providers, tw o related issues, are advanced as reasons for such pessimism. In terms of the commodification o f health and ill-health, the form o f the output of services rendered by health practitioners is expected to be som e physical entity such as drugs or surgery. This parallels all other com m odities on which an exchange value has been placed, resulting in what M arxcalleda m aterialisteconom icsystem (Karasek, 1991). This type of econom icsystem , w here the commodity being sold or bought must be physically packaged and transferred from the producer to the consum er, creates obvious difficulty for the sale and purchase o f mental health, with its nebulous and intangible quality. The possible exception is the sale o f drugs but not even this is entirely true given the nature of mental disorders - unlike physically-damaged tissue, mental illness cannot be demonstrated in a form consistent with the expectations o f a material isticsociety. the provision of mental health services (and ^ A e a l t h generally) is to be widely available and ^ ^ is e d , the need arises for an alternate form of economy within which the provision o f health services may be more adequately provided and used. Karasek has suggested the need for a new form o f output value which is related to the use o f skill: "In the New Value production ...the producer provides the kind o f output that can facilitate the developm ent o f new skills or capabilities in the user" (Karasek 1991, 170). Such suggestion postulates the replacement o f exchange value with a form of output transfer that does not alienate the producer (in terms o f loss o f control over his skills) and involves the c r e a tio n o f n ew s k i l l s in th e u s e r . De-mystification o f knowledge and skills is implied as one cannot help create new skills without sharing the essence of that which is being transferred. It is this that provides the link between the issues o f forms o f output value and professionalization. The nature of professionalism is alluded to by Louw (1988) w ho argues that professionals are la rg e ly s e lf-d ire c tin g in th a t th ey have significant autonom y over the content and practice of their area o f expertise. Goulder (1979) supports and extends this thesis by p r o p o s in g th a t th e e litis m in h e r e n t in p r o f e s s i o n a lis m u n d e r m in e s p u b lic d e c is io n -m a k in g as it b e c o m e s th e only legitimate authority. The ‘legitimate’ authority which G ouldner discusses is in part bestowed by su c h a c tiv itie s as a c c re d ita tio n an d m em bership o f professional organizations. These activities serve to regulate and ‘privatize’ knowledge in the hands o f a few w ho thereby acquire enorm ous power in terms o f the use value and exchange value which they are able to generate from the commodity over which
Curationis, Vol. 15, No. 2, 1992
they have developed hegemonic control. These p r o f e s s io n a l b o d ie s th e r e f o r e p la y a gate-keeping role, making it difficult for true skill-sharing to occcur. It may be argued too, that the narrowly based professional health field m akes real collaboration between the various members o f the health team difficult. There is yet another aspect to the delivery of health care that requires consideration and w hich is related to the former two and this is the e ffe c t o f w h a t S a lm o n (1 9 8 5 ) c a lls the industrialization o f health. Hereby reference is made to the wholesale take-over o f hospitals by multinational and transnational corporations whose primary interest is to extract the largest possible p rofit m argins. Such strategy is exem plified by the privatization o f health s e rv ic e s in S o u th A fric a by th e c u rre n t government. This would mean that only the barest minimum, in terms of short-term costs, of health care will be provided and then only to those w ho can afford to pay. The role o f health care workers in this situation will be limited as decision making will be made by administrators on the basis o f profit margins. Additionally, the use o f cost/benefit ratios, which cannot take into c o n s id e r a tio n in ta n g ib le s su c h as ‘th e th e ra p e u tic a ttitu d e ’, c o u ld ru le out any incentives for health care systems to provide a labour force sensitive to the mental health care needs o f their patients.
G OU LD NER, A.W . (1979). The future of intellectuals and the rise o f the New Class. New York: Continuum. HARDING, et. al. (1980). Mental disorder in p rim ary h ealth care: a study o f their frequency and diagnosis in four developing c o u n tr ie s . P s y c h o lo g ic a l M e d ic in e 10:231-241. K A R A S E K , R. ( 1 9 9 1 ) . T h e P o litic a l I m p li c a ti o n s o f P s y c h o s o c ia l W o rk Redesign: A Model of the Psychosocial Class Structure. In J.V. Johnson and G. Johansson (eds.) The Psychosocial Work E n v ir o n m e n t: W o r k O r g a n iz a tio n , D emocratization and Health. Amityville: Baywood Publishing Company. K R A M E R , M . e t a l. (in p r e s s ) . T h e epidem iological basis for primary health care. In B. Cooper (ed) Proceedings o f the W orld Psychiatric Association Section on Epidemiology. L A C H M A N , P I . & ZW A R E N ST E IN , M. (199). Child health and health care. South A frican M edical Journal 77:4676-470.
CONCLUSION
LOUW, J. (1988). Professionalism as a moral concern. P sychology in Society 9:66-80.
This paper has attempted to review the literature on the need for primary health care. It has tried to outline some o f the issues related to the development o f primary mental health in both developed and developing countries as both areas are represented within South Africa.
NAVARRO, V. (1 9 7 4 ). The underdevelopment o f health or the health of underdevelopment. International Journal o f Health Services. 4:5-27.
It is the contention of these reviewers that while the value o f primary mental health care is undeniable, it will not be achieved unless there are accompanying structural changes making possible the i nternal ization o f di fferent forms of output values such as those suggested by Karasek (1991).
REFERENCES B EIGEL, A. (1983). C om m unity Mental H ealth C are in D ev elo p in g C ountries. A m e ric a n J o u r n a l o f P sy c h ia try 14 0 : 1491-1492. BUH RM AN N, M.V. (1983). Com m unity H e a lth and tr a d itio n a l h e a le rs . Psychotherapedia, 30:15-18. FREEMAN, M. (1989). Mental Health Care in C risis in South A frica. P aper No. 16. Johannesburg: Center for the Study of Health Policy. G A S K , L ., M c G R A T H , G . ( 1 9 8 9 ) . P s y c h o th e ra p y an d G e n e ra l P ra c tic e . British Journal o f Psychiatry 154:445-453. GOLDM AN, II.II. (1982). Integrating health and mental health services: H istorical o b stacles and o p p o rtu n ities. American Journal o f Psychiatry 139:616-620.
ORM EL, J. et al. (1989). Measuring Change w ith the G eneral H eealth Q uestionnaire (GHQ). Social Psychiatry and Psychiatric Epidemiology. 24:227-232. SALM ON, J.W . (1985). Organizing medical care for profit. In J. McKinlay (ed) The P o litic a l E c o n o m y o f H ealth. London Tavistock. SARTORIUS, N. (1988). Mental Health in Primary Health Care. International Journal o f M ental Health. 17:5-12. S C H U R M A N , R.A . et al. (1985). W hen D octors Listen: C ounselling Patterns of N o n -P sy c h ia trist P h y sicians. American Journal o f Psychiatry 142:934-938. W ALT G. AND VAUGHAN, P. (1982). The Primary Health Care Approach: How did it evolve? Tropica!D octor. 12:145-147.
Y.G. Pillay (MS, Natal; Registered Clinical Psychologist); Currently a doctoral student at John Hopkins University, U.SA. H. Subedar (B-Soc.Sc., Natal.) Department o f Nursing,
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REVIEW
PRIMARY MENTAL HEALTH CARE: INDICATIONS AND OBSTACLES Y.G. Pillay and H. Subedar INTRODUCTION
Abstract This essay critically examines literature that has suggested the need for primary mental health care. In exploring this literature the issue o f context as a crucial variable is stressed. Context refers to both the geographic area (South Africa, urban/rural) and the particular type o f health service in use. The basic point is that the designation o f the prim ary p ractitio n er is co n tex t d ep en d en t, be h e /h er the general practitioner in the United States, the psychiatric nurse in rural South Africa-or the public health nurse in an urban context which stresses primary prevention. In articulating a response to the topic it is useful to ask the following questions: (a) what is primary mental health care? ^ ^ b ) who should practice it and where? what types o f patients would benefit from it? (d) what constraints exist which make the practice of mental health care difficult?
A BRIEF REVIEW OF TIIE HISTORICAL DEVELOPM ENT OF THE CONCEPT ‘PRIMARY HEALTH CARE’ Given that there is a thrust to re-incorporate mental health care into prim ary care, it is p e rtin e n t to tra c e b rie fly th e h is to ric a l developm ent o f primary health care within which primary mental health should be situated. We argue that the attempt is a re-incorporation b e c a u s e th e u se o f p s y c h o t h e r a p e u t ic techniques in the arm am entarium o f indigenous healers has been well documented (Buhrmann, 1983). Walt and Vaughan (1982) suggest that there were five basic issues which provided the thrust for the developm ent o f primary health care culminating in the Declaration o f Alma Ata in 1978. The first was the realization in the 1960’s that economic growth was not being equitably distributed and that with growing polarization of the social classes in society, the rich were getting richer and the poor poorer. The number of people with wealth was diminishing, the number of poor w as increasing and there was concomitant realization that the poor had very limited or no access to health care despite increasing technological sophistication in the provision o f such care. The second issue w as concern about the rapid growth of the w orld’s population associated
Curationis. Vol. 15, No. 2, 1992
This paper considers indications and obstacles for the development o f primary mental health care practice in both d e v e lo p e d and under-developed countries. Both are considered as this represents the South African reality. While a significant body o f literature has documented the need fo r primary mental health care, the obstacles (e s p e c ia lly in term s o f the commodification o f health) to its fruition are seldom addressed
Uittreksel Hierdie referaat beskou indikatore en struikelblokke vir die ontwikkeling van primêre geestesgesondheidsorg in o n tw ik k eld e-so w el as onder ontwikkelde lande. Ueide hierdie w ord verteen w oordig binne die Suid-Afrikaanse realiteit. Alhoewel ‘n a a n d u id en d e h o eve elh e id literatuur die behoefte aan primêre geestesgesondheidsorg dokumenteer, word die struikelblokke (spesijiek i.t.v . d ie g eb ru ik sw a a rd e van geson dh eid) selde tot die voile verwerkliking aangespreek.
with concern about competition for a finite amount of natural resources. While this is a real concern, it can also be demonstrated that, at least to some extent, the problem is compounded by the distribution of resources. For instance, in som e countries the real issue is land distribution and not a population explosion (Navarro, 1974). This distinction is crucial as it has obvious im plications for interv en tio n s such as the d e c is io n to in v e s t f in a n c e a n d h e a lth labour-powcr in family planning (use o f the term ‘population control’ illustrates the point well) as opposed to advocating land reform. The third issue was general disillusionmentwith mechanistic solutions to health problems and the realizatio n that, d e sp ite tcchnoligical advances in health care, the health o f the
populace was not significantly better. Although it can be argued that the tide has turned since the early 1980s, technical solutions especially in the 1960s and 1970s were viewed as being limited and the need for a holistic approach to health including social, economic, educational and political domains w as advocated. The need for community based health which incorporated all the above dim ensions w as advanced by workers such as King (W att & Vaughan, 1982). The well-publicised Chinese experiment with com m unity participation and the ‘barefoot doctor’ and its success in delivering health care to the people w as the fourth impetus to the developm ent of the notion o f primary health care. It is necessary, however, to contextualise th is e x p e rim e n t in term s o f the political economy that gave rise to it and not to view it as yet another technical innovation. The Cuban experience and the massive reduction in infant mortality rates in a relatively short period of time also added to the appeal o f primary health care. International adoption o f the concept came with the W orld Health O rganization’s decision in 1975 to strive for provision o f basic health services for all by year 2000 and the subsequent adoption by the international community of the Declaration o f Alma Ata in 1978 outlining the need for primary health care as the important methodology for reaching the goal Health for All by year 2000.
PRIM ARY MENTAL HEALTH CARE (a) T h e Need fo r P rim a ry M ental H ealth C a r e : T h eo re tic a l C on sideration In defining health the Declaration of Alma Ata stated that it w as the state of complete physical, mental and social w ell-being of a person. Also d o cu m en ted w as the fact that health w as influenced by factors beyond the control of the health sector, such as social and economic considerations. Given the contention that at least in some countries one important issue is the need for land reform, it appears necessary to add the p o litical sec to r to this list. The Declaration includes the spirit o f this suggestion in its assertion that people have the right to participate, both individually and collectively, in planning and im plementation o f health care (and, it may be argued, by extension, to all other facets o f civic life). The Declaration, by including mental health as an essential com ponent o f health, provides rationale for the existence o f ‘primary mental
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health care’ as a legitimate concern and area of study. Goldman (1982) suggests other factors that provided the impetus for primary mental health care which are to some extent, parochial to the U.S.A. He argues that with the creation of public assistance by means o f Medicare and Medicaid, more money w as avai lable for mental health care in general health settings. Secondly, the psychopharmacological revolution made it possible for large numbers o f mentally ill people to be treated w hilst in the community with m aintenance therapy provided by prim ary mental health practitioners. Thirdly, the rise of the community mental health movement helped to partly de-m edicalize and de-stigm atize, m e n ta l d i s o r d e r s a n d p r o b a b ly m o re im portantly "...succeeded in m oving mental health concerns into public consciousness" (Goldman, 1982, 619). The need to prioritize mental health in the provision of primary health also is suggested by Sartorius(1988) w ho argued that mental illness is important because it causes suffering to the individual, the family and the community; it has s o c ia l/e c o n o m ic c o n s e q u e n c e s su c h as d e c re a s e d p ro d u c tiv ity ; in c r e a s in g life expectancy gives rise to increases in the rates of mental disorders (eg. depression and dementia in the elderly); increases in the level o f stress and the fragmentation o f the family and other traditional support systems imply the need for alternative support mechanisms and that mental health expertise can help to hum anize the delivery of health care. The nature of primary mental health may be derived from the need for mental health services that are accessible primary care level. This need has been demonstrated by numerous studies of patients presenting to prim ary health care practitioners, in both post-industrialized and partially industrialized countries, with overt manifestations o f mental disorders as well as important covert or masked mani festations such as somatization". (b)The Need fo r P rim a ry M en tal H ealth C are: E m pirical Evidence In d ev elo p e d c o u n trie s, fo r ex am p le the U.S.A. and Britain and certain sectors o f the South A frican population the regular primary health practitioner is the general practitioner, family practitioner or internist (Lachm an and Zwarenstein, 1990). K ram er et al. (in press) found that for the two year period January 1 9 8 0 to D e c e m b e r 1 9 8 1 , 4 5 .3 % o f all physician office v isits w ere to e ith er the g e n e r a l p r a c t i t i o n e r o r th e i n t e r n i s t , in c re a sin g to 56 .4 % w h en o n e in c lu d e s p ed iatrician s. T his figure b eco m es even more relevant when it is realized that general practitioners in B ritain are the main providers for 95% o f the population with psychiatric morbidity (G ask and M cG rath, 1989). The picture is further com plicated by the fin d in g th a t tre a tm e n t ra te s fo r m en tal disorders w ere very low. K ram er et al. (in press) found treatm ent rates o f 7% w hile B eigel (1983) suggested a figure o f 15% which w hile significantly greater than that found by K ram er et al., is still unacceptably low. T his suggests that a very small minority o f those w ho needed treatm ent w ere receiving
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it. Reasons for this are com plex but limited access to care, estimated by Kramer et al. to be over 37 million or 16% of the U.S. population, must be contributory, especially if the assertion that this group represents those most vulnerable to mental illness is valid. Prevalence rates for mental disorders appear to depend in part on the sensitivity o f the sc re e n in g in stru m en t used. O rm el et al (1 9 9 0 ) fo u n d th a t p re v a le n c e ra te s o f psychological disorders in patients presenting in general practice in the N etherlands, varied fro m 4 6 % w h e n th e G e n e r a l H e a lth Q uestionnaire (G H Q ) w as used to 15% when the P resent State E xam ination (PSE ) w as used. G eneral practitioners seem ed able to identify about 56% o f the cases positively identified by the GHQ. V arious studies o f patients presenting to primary care providers in p ost-industrialized countries found that " ...o v e r a th ird o f c o n s e c u tiv e g e n e ra l p ra c titio n n e r a tte n d e rs sh o w s u b s ta n tia l l e v e l s o f m e n ta l d i s t r e s s a n d th a t ap p ro xim ately 15-25% can be assigned a sp e c ific d ia g n o sis in the d e p ressio n and anxiety spectra..." (Ormel et al., 1990, 909). The W orld Health O rganization (W H O ) in their seven country study, tried to study the is s u e in p a r t i a l l y d e v e lo p e d a n d under-developed countries. H arding et al (1980) reported that the W HO C ollaborative Study on Strategies for E xtending M ental Health C are (o f four o f the countries studied ie. C olom bia, India, P hilippines and Sudan) found that prevalence rates for consecutively presenting adults ranged from 10.6% in the S u d an ese sam p le to 17.7% in the Indian s a m p le . T h e y a ls o fo u n d , c o n tr a ry to expectation as well as priority set by the W orld Health O rganization ie. to target the anticipated large num ber o f psychotics, that o f all the patients found to have som e form o f p sy ch o lo g ical d istu rb an ce , a p p ro x im ately 86% o f them w ere diagnosed as having som e form o f n eu ro sis. An eq u ally im p o rtan t finding w as the percentage o f m entally ill p a t i e n t s w h o p r e s e n te d w ith s o m a ti c com plaints w hich w ere m issed consistently as indicators o f mental illness by the primary health care w orker. T he em p irical ev id e n c e p resen te d above covers developed, partially developed and under-developed countries. T his begs the issue as far as South A frica is concerned, given that it includes both a developed society a n d o n e th a t c a n b e d e s c r i b e d a s under-developed. Data that w ould assist the d escrip tio n o f the p ro b lem and p lan n in g responses are largely unavailable. W e have to rely on estim ates that are based on som e of the research conducted by the W orld Health O rganization. Freeman (1989) suggests that, b a s e d on a 15% p re v a le n c e o f m e n ta l disorders, approxim ately 5 million people in So u th A frica have som e form o f m ental d is o r d e r w ith 3 3 0 ,0 0 0 b e in g s e v e r e ly incapacitated. He also suggests that mental health resources arc inadequate to cope with the num bers o f people requiring help. T his supports the need for prim ary mental health services to be provided by a broad range o f health care practitioners including general practitioners, nurses, paraprofessionals and
indigenous healers w ho are integrated into the health care system. (c) F orm o f P rim a ry M en tal H ealth C are W hile there is considerable agreement about the need for primary mental health care there is less agreem ent about the form that it should ta k e , s u g g e s t i n g th a t th e r e is so m e d isag reem en t ab o u t the nature o f primary mental health skills necessary. This issue is sum m arized adequately by G ask and McGrath (1 9 8 9 ). T h e c o n tro v e rsy larg ely centres around the issue o f theoretical orientation (eg. the applicability o f psychodynam ic theory as opposed to a problem-focused approach) and the related issu e o f w h o sh o u ld practice primary mental health care. T h e f ir s t is s u e fo c u s e s o n th e ty p e o f intervention primary health care practitioners sh o u ld be ex pected to provide. It is the contention of this paper, supported in part by Schurm an et al (1 985), th at prim ary care practitioners, be they village workers, nurses or general practitioners should not be expected to provide the type o f diagnostic or therapeutic intervention w hich specialist mental health practitioners provide. N evertheless, primary care practitioners should be trained to make a d e q u a te firs t level d ia g n o se s o f m ental disorders, make appropriete referrals where possible and possess a therapeutic attitude that perm eates their practice and helps humanize the practice o f health care. D e s p ite c o n tr o v e r s y a b o u t th e o r e tic a l orientation, there is some agreem ent about a few issues. The im portance o f a therapeutic attitude has been articulated (Schurman et al., 1985; G ask and M cGrath, 1989). This can be a fairly n e b u lo u s c o n c e p t but is seen as c o n s i s t i n g o f a t le a s t th e f o llo w in g c o m p o n e n ts :- a d e q u a te lis te n in g sk ills , attention to both verbal and non-verbal cues and an em pathetic attitude. In terms o f im proving the diagnostic ability of primary health care workers, the use o f such standardized scales as the GHQ, PSE and the S h o rt R eporting Q u estio n n aire (SR Q ) can in c re a se the p e rc e n ta g e o f p a tie n ts w ith p sy c h o lo g ic a l p ro b lem s id entified by the prim ary care practitioner. M any o f these instrum ents such as the PSE,GHQ and SRQ have been standardized for use in developing countries. W hat is more difficult to achieve is the change in attitude o f primary health care practitioners to mental disorders. The historical relationship betw een m edicine and psychiatry has been docum ented by, am ongst others, G oldman (1982). I Ie suggests that these two branches of health care only recently have begun to talk the sam e language, with the m edicalization of mental disorders facilitated by advances in b iological psy ch iatry . The view o f these reviewers is at odds with Goldman w ho appears to consider this necessarily advantageous. It is possible that as psychiatry becom es subsumed by technology, psychiatry may becom e as mechanistic as the rest o f medicine rather than becom ing humanised.
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(d) Some obstacles to the development of Primary Mental Health Care These authors are not optim istic about the p o s s ib ility o f m a k in g h e a lth c a re le ss mechanistic and more humanistic. This pessimism rests on the nature o f the health c a re d e liv e ry sy ste m in m o st c o u n trie s, including South Africa. The treatment o f health as a commodity on which an exchange value is placed and the degree o f professionalization o f the health care providers, tw o related issues, are advanced as reasons for such pessimism. In terms of the commodification o f health and ill-health, the form o f the output of services rendered by health practitioners is expected to be som e physical entity such as drugs or surgery. This parallels all other com m odities on which an exchange value has been placed, resulting in what M arxcalleda m aterialisteconom icsystem (Karasek, 1991). This type of econom icsystem , w here the commodity being sold or bought must be physically packaged and transferred from the producer to the consum er, creates obvious difficulty for the sale and purchase o f mental health, with its nebulous and intangible quality. The possible exception is the sale o f drugs but not even this is entirely true given the nature of mental disorders - unlike physically-damaged tissue, mental illness cannot be demonstrated in a form consistent with the expectations o f a material isticsociety. the provision of mental health services (and ^ A e a l t h generally) is to be widely available and ^ ^ is e d , the need arises for an alternate form of economy within which the provision o f health services may be more adequately provided and used. Karasek has suggested the need for a new form o f output value which is related to the use o f skill: "In the New Value production ...the producer provides the kind o f output that can facilitate the developm ent o f new skills or capabilities in the user" (Karasek 1991, 170). Such suggestion postulates the replacement o f exchange value with a form of output transfer that does not alienate the producer (in terms o f loss o f control over his skills) and involves the c r e a tio n o f n ew s k i l l s in th e u s e r . De-mystification o f knowledge and skills is implied as one cannot help create new skills without sharing the essence of that which is being transferred. It is this that provides the link between the issues o f forms o f output value and professionalization. The nature of professionalism is alluded to by Louw (1988) w ho argues that professionals are la rg e ly s e lf-d ire c tin g in th a t th ey have significant autonom y over the content and practice of their area o f expertise. Goulder (1979) supports and extends this thesis by p r o p o s in g th a t th e e litis m in h e r e n t in p r o f e s s i o n a lis m u n d e r m in e s p u b lic d e c is io n -m a k in g as it b e c o m e s th e only legitimate authority. The ‘legitimate’ authority which G ouldner discusses is in part bestowed by su c h a c tiv itie s as a c c re d ita tio n an d m em bership o f professional organizations. These activities serve to regulate and ‘privatize’ knowledge in the hands o f a few w ho thereby acquire enorm ous power in terms o f the use value and exchange value which they are able to generate from the commodity over which
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they have developed hegemonic control. These p r o f e s s io n a l b o d ie s th e r e f o r e p la y a gate-keeping role, making it difficult for true skill-sharing to occcur. It may be argued too, that the narrowly based professional health field m akes real collaboration between the various members o f the health team difficult. There is yet another aspect to the delivery of health care that requires consideration and w hich is related to the former two and this is the e ffe c t o f w h a t S a lm o n (1 9 8 5 ) c a lls the industrialization o f health. Hereby reference is made to the wholesale take-over o f hospitals by multinational and transnational corporations whose primary interest is to extract the largest possible p rofit m argins. Such strategy is exem plified by the privatization o f health s e rv ic e s in S o u th A fric a by th e c u rre n t government. This would mean that only the barest minimum, in terms of short-term costs, of health care will be provided and then only to those w ho can afford to pay. The role o f health care workers in this situation will be limited as decision making will be made by administrators on the basis o f profit margins. Additionally, the use o f cost/benefit ratios, which cannot take into c o n s id e r a tio n in ta n g ib le s su c h as ‘th e th e ra p e u tic a ttitu d e ’, c o u ld ru le out any incentives for health care systems to provide a labour force sensitive to the mental health care needs o f their patients.
G OU LD NER, A.W . (1979). The future of intellectuals and the rise o f the New Class. New York: Continuum. HARDING, et. al. (1980). Mental disorder in p rim ary h ealth care: a study o f their frequency and diagnosis in four developing c o u n tr ie s . P s y c h o lo g ic a l M e d ic in e 10:231-241. K A R A S E K , R. ( 1 9 9 1 ) . T h e P o litic a l I m p li c a ti o n s o f P s y c h o s o c ia l W o rk Redesign: A Model of the Psychosocial Class Structure. In J.V. Johnson and G. Johansson (eds.) The Psychosocial Work E n v ir o n m e n t: W o r k O r g a n iz a tio n , D emocratization and Health. Amityville: Baywood Publishing Company. K R A M E R , M . e t a l. (in p r e s s ) . T h e epidem iological basis for primary health care. In B. Cooper (ed) Proceedings o f the W orld Psychiatric Association Section on Epidemiology. L A C H M A N , P I . & ZW A R E N ST E IN , M. (199). Child health and health care. South A frican M edical Journal 77:4676-470.
CONCLUSION
LOUW, J. (1988). Professionalism as a moral concern. P sychology in Society 9:66-80.
This paper has attempted to review the literature on the need for primary health care. It has tried to outline some o f the issues related to the development o f primary mental health in both developed and developing countries as both areas are represented within South Africa.
NAVARRO, V. (1 9 7 4 ). The underdevelopment o f health or the health of underdevelopment. International Journal o f Health Services. 4:5-27.
It is the contention of these reviewers that while the value o f primary mental health care is undeniable, it will not be achieved unless there are accompanying structural changes making possible the i nternal ization o f di fferent forms of output values such as those suggested by Karasek (1991).
REFERENCES B EIGEL, A. (1983). C om m unity Mental H ealth C are in D ev elo p in g C ountries. A m e ric a n J o u r n a l o f P sy c h ia try 14 0 : 1491-1492. BUH RM AN N, M.V. (1983). Com m unity H e a lth and tr a d itio n a l h e a le rs . Psychotherapedia, 30:15-18. FREEMAN, M. (1989). Mental Health Care in C risis in South A frica. P aper No. 16. Johannesburg: Center for the Study of Health Policy. G A S K , L ., M c G R A T H , G . ( 1 9 8 9 ) . P s y c h o th e ra p y an d G e n e ra l P ra c tic e . British Journal o f Psychiatry 154:445-453. GOLDM AN, II.II. (1982). Integrating health and mental health services: H istorical o b stacles and o p p o rtu n ities. American Journal o f Psychiatry 139:616-620.
ORM EL, J. et al. (1989). Measuring Change w ith the G eneral H eealth Q uestionnaire (GHQ). Social Psychiatry and Psychiatric Epidemiology. 24:227-232. SALM ON, J.W . (1985). Organizing medical care for profit. In J. McKinlay (ed) The P o litic a l E c o n o m y o f H ealth. London Tavistock. SARTORIUS, N. (1988). Mental Health in Primary Health Care. International Journal o f M ental Health. 17:5-12. S C H U R M A N , R.A . et al. (1985). W hen D octors Listen: C ounselling Patterns of N o n -P sy c h ia trist P h y sicians. American Journal o f Psychiatry 142:934-938. W ALT G. AND VAUGHAN, P. (1982). The Primary Health Care Approach: How did it evolve? Tropica!D octor. 12:145-147.
Y.G. Pillay (MS, Natal; Registered Clinical Psychologist); Currently a doctoral student at John Hopkins University, U.SA. H. Subedar (B-Soc.Sc., Natal.) Department o f Nursing,
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