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Background: Mental health problems represent the greatest global burden of disease among children and adolescents. There is, however, lack of policy development and implementation for child and adolescent mental health (CAMH), particularly in low- and middle-income countries (LMICs) where children and adolescents represent up to 50% of populations. South Africa, an upper-middle income country is often regarded as advanced in health and social policy-making and implementation in comparison to other LMICs. It is, however, not clear whether this is the case for CAMH. The national child and adolescent mental health policy framework of 2003 was developed to guide the establishment of CAMH policies provincially, using a primary care and intersectoral approach. This policy provided a framework for the nine South African provinces to develop policies and implementation plans, but it is not known whether this has happened. The study sought to examine the history and current state of CAMH policy development and implementation, and to perform a systematic analysis of all available CAMH service-related policies. Methods: A comprehensive search was performed to identify all provincial mental health and comprehensive general health policies across South African provinces. The Walt and Gilson policy triangle framework (1994) was used for analysis. Results: No South African province had a CAMH policy or identifiable implementation plans to support the national CAMH policy. Provincial comprehensive general health policies addressed CAMH issues only partially and were developed mainly to address the challenges with HIV/AIDS, TB, maternal and child mortality and adherence to the millennium development goals. The process of policy development was typically a consultative process with internal and external stakeholders. There was no evidence that CAMH professionals and/or users were included in the policy development process. Conclusions: In spite of South Africa’s upper-middle income status, the absence of any publically-available provincial CAMH policy documents was concerning, but in keeping with findings from other LMICs. Our results reinforce the neglect of CAMH even at policy level in spite of the burden of CAMH disorders. There is an urgent need to develop and implement CAMH policies in South Africa and other LMICs. Further research will be required to identify and explore the barriers to policy development and implementation, and to service development and scale-up in CAMH.
In order to identify all publically-available policy documents related to CAMH two search strategies were used. Firstly, web-based searches were performed of the national and all provincial departments of health websites. Searches were conducted in June 2016 and September 2016. All potentially relevant information was downloaded for analysis. Search terms included “child”, “adolescent”, “mental health”, “policy development”, “policy implementation”, “integrated school health services”, “intellectual disability”, “CAMH policy”, and “health policy”. We searched for the latest version of the provincial stand-alone mental health and CAMH policies, and for broad, inclusive or comprehensive general health documents. In parallel with the web-based search, a stakeholder-based search strategy was used. Key staff at the national department of health, academics involved in mental health policy, and senior clinicians in CAMH were contacted to obtain the names and contact details of responsible individuals and policy stakeholders at national or provincial level. All identified policy stakeholders were contacted telephonically and by email by the first author (SM) to obtain the most recent policy-related documents. The Walt and Gilson “policy triangle model” [24] was used as framework for extraction and analysis of identified policy documents. Walt and Gilson’s “triangle model” is a useful model for analysing a variety of health issues including mental health issues. It focuses on the content of policy, range of actors, context and processes and the interaction between these elements in policy making and policy implementation. The model provides a framework for understanding the process of health policy reform and to plan for effective implementation [24]. The model can be used retrospectively and prospectively. Figure 2 shows the policy triangle model as adapted from Walt and Gilson [24]. The Walt & Gilson (1994) policy triangle model All obtained provincial documents were read, and data extracted focusing on the content, the context, the process of policy development as well as the actors involved in developing the policy. No formal interviews were conducted to obtain further information, beyond the contacts made to access the documents.
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