Governance and power in mental health integration processes in South Africa

On the back of centuries of scholarship, mental illness remains a deeply political challenge in modern societies. Although much headway has been made in researching mental health service provision in low-to-middle income countries, a distinct gap exists in understanding the crucial roles of governance and power in care provision. Concerning integrated care, understanding the relations among state and non-state entities is paramount. This doctoral study sought to explore how power relations shape the governance of integrated mental health care in South Africa. More specifically, the purpose was to illuminate the dimensions and structure of integrated mental health care; to describe referral and collaborative ties in a service provider network; and to examine the relations between state and non-state mental health service providers. A pragmatic, theory driven case study was undertaken in Mangaung Metropolitan District, Free State province, South Africa, employing multiple methodologies. The macro contexts of integrated mental health care were explored by means of a framework analysis of health policy, while the case study employed social network analysis and semi-structured interviews with key stakeholders. The findings suggested that integrated mental health care is pursued in South Africa in two ways: 1) by integrating mental health care into primary healthcare, and 2) by fostering collaboration between state and non-state role players. The service delivery network exhibited fragmentation, low density, hospital-centrism and suggestions of significant professional power. Key points of state and non-state collaboration included housing and treatment adherence, though proportional interactions between state and non-state services were lower than interstate service collaboration. Governance-related fragmentation emerged in terms of state and non-state service providers, biomedical and social approaches to care, and departments of health and social development. Gaps in state stewardship included weak strategic leadership and poor information systems. Power emerged in both its mainstream and second stream conceptions, rooted in, for example, professional power, and through an apparent commodification of people living with mental illness. The ambiguities of mental illness were concluded to be an important undercurrent to the dynamics of power that play out in service provision processes. Key policy recommendations focused on improving the following: 1) availability of financial resources; 2) relationships between service providers; 3) overly myopic organisation of government departments; and 4) political relationships between state and non-state partners. Ultimately, the study lays a strong foundation for further research into the mechanisms of power in the governance of mental health care in South Africa.