Speaking notes for Minister of Health, Dr Manto Tshabalala-Msimang at the Forensic Mental Health Seminar/Workshop, Birchwood Hotel, Benoni

Programme Director
Honourable Judge of the High Court
Honourable members of the Judiciary
Invited guests
Officials from provincial and national departments
Ladies and gentlemen

Good morning!

It is a great honour for me to welcome you to this important meeting. I particularly wish to express appreciation for your response to our invitation to attend this meeting. I also want to express my appreciation of the positive response we got from all departments that were requested to nominate persons to the task team that organized this event.

This demonstrates that we appreciate the intersectoral nature of the challenges we face and that our approach to address our challenges should include development of sustainable and integrated solutions.

Recently the Department of Health held a meeting where we revisited our approach to primary healthcare. Among other things, this meeting reminded us about the need to continuously engage and consult with other government departments and sectors outside health to ensure that factors outside the control of health that have an impact on the health of the nation as well as the systems for health delivery are addressed.

Our gathering here today reaffirms our commitment to honour the promises that we made to the people we serve. It also reaffirms our belief that as a country we shall do everything in our power and everything possible within the means afforded to us to contribute towards universal realisation and achievement of justice for all.

The choices that we have made as a nation and the value system espoused and encapsulated by our Constitution compels us to constantly engage each other, evaluate what we are doing so that we can improve the systems and services required by our communities.

Our Constitution founded our democratic state and common citizenship on the values of human dignity, the achievement of equality and the advancement of human rights and freedoms.

These values call upon all of us gathered here to constantly revisit our mandates and contributions towards building a caring and humane society for all that leave in our country.

We have a particular and special challenge to ensure that these fundamental rights enshrined in our Constitution also benefit those that due to mental illness cannot represent themselves or benefit from these rights at their own volition.

The diversity of issues affecting those affected by mental illness is not being fully appreciated by society due to the stigma associated with mental illness and the concomitant discrimination that is fuelled by the inclination by society to discriminate those that may be different from us.

This depicts itself in many aspects of our lives as well as the services, behaviour and attitudes we display towards the people that are perceived to be different, whether by gender, race colour, creed, religion, class, etc.

The current situation means that people with mental illnesses are at best ignored and at worst actively discriminated against. Studies by the World Health Organisation (WHO) show that of all persons with disabilities, those with a mental illnesses face the highest degree of stigmatisation, unfair discrimination, violation of their human rights, exploitation, abuse and the greatest barriers to accessibility of opportunities.

Awaiting trial prisoners that have a mental illness and prisoners who develop a mental illness while serving their sentences may be the most vulnerable due to the stigma, discrimination, human rights violations and barriers to treatment as experienced by people who suffer from mental illness in general.

It was in this line that the Department of Health proposed that all the key stakeholders that are involved in rendering services to awaiting trial prisoners that require a forensic psychiatric evaluation, state patients, mental ill prisoners and victims of crime and violence come together and focus on what we can do to transform these services in order to give effect to the constitutional values. It is imperative that from time to time we revisit the policies, so that we can identify what is working, preserve what is working, review and find solutions for what is not working.

I would like to make a few observations and remarks, which may help, set a tone for the work that you will be doing in the two days.

The biggest focus should be around the implementation of the legislation and policies that we have adopted. Most of the interventions require inputs from different sectors and spheres of government. The way we are departmentalised brings about many challenges. At present it is very difficult to create the necessary linkages that we require for the provision of holistic and integrated services.

Systems in the different spheres of government as well as between departments are not aligned. This has a major impact on service delivery. This often results in many tensions, blaming and counter accusations between departments. I hope that you will emerge from the two days with practical proposals that will benefit our communities. These proposals must seek to develop a sustainable system that addresses all policy gaps and create the necessary linkages and acknowledge the diversity of the challenges we have in the different sectors.

The contextual framework for this seminar/workshop is underpinned by the Criminal Procedure Act, the Mental Healthcare Act, Services Charter for Victims of crime and violence, Domestic Act, Maintenance Act, the Sexual Offences Act and many more, which enforce certain procedures to be followed in forensic psychiatric evaluations of awaiting trial prisoners, victims of crime and in the care, treatment and rehabilitation of state patients and mentally ill prisoners.

This meeting must also identify areas where we can integrate and link our mandates for the improvement of services to our citizens.

Within the health sector, many strides have been made to improve health services, but there are many areas that still need our attention.

The evaluation of awaiting trial prisoners requires specialised training of health professionals to be able to appreciate the legal context to which the information they provide applies. The current conditions globally impacting on human resources have a huge impact on training, recruiting and retention of specialised professionals. In this regard it remains prudent to pool resources and provide specialised services such as forensic psychiatry in certain designated healthcare points, while we focus on building capacity.

The Department of Health has designated such facilities in terms of the Mental Healthcare Act No 17 of 2002. There are 15 health establishments designated to care for state patients and mental ill prisoners. Ten of these have the capacity to conduct the 30 days court observations due to the security requirements.

As we implement the National Human Resources Strategy we will continue to pay close attention to the training of the professionals required to render these services.

Also as part of the hospital revitalisation programme we have prioritised the revitalisation of psychiatric hospitals. This will also address the security requirements that were raised by the South African Police Services (SAPS) regarding the facilities designated to conduct the 30 days court observations.

International as well as local research shows an increase in the prevalence of mental disorders. There might be a real increase or perhaps an improvement in reporting of cases also as a result of recent interest in conducting research in this area that was previously neglected worldwide.

Some studies indicate that mental illnesses are among the leading causes of disabilities worldwide and are more common than cancer, diabetes or heart diseases. It is reported that one in every four person will be affected by a mental disorder at some stage in life. Only a small minority of people who suffer from mental or behavioural disorders receive treatment. Individuals with mental illnesses struggle in silence. This is in part due to the victimisation of people with mental illnesses, stigma and discrimination; poor access to healthcare; increasing cost of medication etc.

If the figures are correct, we should experience a steady increase in the number of individuals affected by mental disorders entering the criminal Justice System. From our own records there are about 5 671 state patients on the national departmental database. The number of state patients recommended for transfer from detention centres to health establishments between the months of January to June in 2008 is 220. There were 91 cases referred to us between January to June 2007.

The system must ensure that people who commit minor offences do not clog up the Criminal Justice System as well as forensic psychiatric services designated to conduct the 30 days court observations. This will help reduce the unnecessary backlogs for observations. We have also proposed to the Department of Justice and Constitutional Development that the issue of panel observation be reviewed. With the current human resources challenges we are unable to have three professionals to evaluate one case at a time.

While awaiting observation, if it appears that the person requires treatment, that person must be referred to an appropriate facility for care, treatment and rehabilitation. If this is not done we would then be contravening our own laws.

If a person who is referred by the court of law to a health establishment is terms of section 79 is found to be mentally ill to the degree that he is a danger to himself or herself or others, treatment must be commenced immediately even before the report is submitted to a court of law.

State patients awaiting admission to a designated health facility must be held in an appropriate detention centre that can provide the necessary treatment and care. Mentally ill prisoners must be evaluated and treated accordingly.

This meeting must also deliberate on ways that we can improve the referral pathways; from the time a court decides to refer an awaiting trial prisoner for forensic psychiatric observation until a report is concluded. The systems at the referring court, South African Police, Detention Centres and health need to be aligned to ensure that unnecessary delays are done away with.

The Department of Health is able to process requests of transfer of state patients and mental ill prisoners within 72 hours of receipt of the necessary documentation. But these often arrive many months from the date that the case was concluded. This is of major concern.

Partly due to limited capacity and poor co-ordination of services at local level, some state patients that were put on rehabilitation programmes are lost within the system, in some cases they reappear having re-offended. Systems that deal with state patients that abscond need to be strengthened and should be prioritised. Similarly, we need to strengthen and improve the communication and systems to manage the applications for discharge of state patients who have successfully been rehabilitated.

I am raising these specific issues as they are of major concern to us. They also have received public and media attention lately.
Each one of us in this meeting should use this opportunity to raise issues and propose ways that can improve services that we render to our communities. We need to be mindful of our unique challenges as a country.

This meeting is also coincidentally taking place during July, which is dedicated towards raising public awareness on mental health issues. Throughout this month we are embarking on activities aimed at raising public awareness of the real burden of mental disorders and their costs to human, social and economic realities. Public awareness will also help dismantle some of the barriers, particularly of stigma, discrimination and inadequate services, which prevent many people in our country from receiving the treatment they need and deserve.

I also think it is important to share with you two separate interesting matters on mental health which were recently dealt with by the High Court.

Regarding the "Court order on decisions of the Review Board: Mental Healthcare/Minister of Health and Director of Public Prosecutions," the High Court of South Africa: KwaZulu-Natal Provincial Division, the Honourable Judges concluded that the relevant sections of the Mental Healthcare Act dealing with functions and roles and the Mental Health Review Boards were constitutional. It was their view that the legislature had fully complied with its constitutional obligations as well as criteria laid down in international conventions. They suggested one improvement which we are already considering and have engaged the Legal Aid Board relating to the appointment of a curator-ad-litem to serve on each board whose sole responsibility would be to represent the interests of users whose cases are before the board.

Regarding the matter between the State vs Aaron Mokwena and the State vs Albert Phaswane we welcome the judgement on the Constitution issues relating to the position of children involved in criminal trials either as complainant witnesses or victims of violent crimes, or witnesses in criminal trials. Children require special protection and any laws that provide for this protection should be repealed. In this context we hope the judgement will help protect children from psychological trauma and re-victimisation from the court process.

I would like thank you all for your shared commitment to this important meeting, and wish you a successful and productive seminar/workshop.

Thank you.

Issued by: Department of Health
14 July 2008