A situation analysis of clinical psychology services in South Africa’s public rural primary care settings

Abstract

The goal of our study was to provide a situation analysis of clinical psychology services in South Africa’s public rural primary healthcare sector. In this setting, the treatment gap between human resources for and the burden of disease for mental illness is as high as 85%. The majority of South Africa’s mental health specialists – clinical psychologists and psychiatrists – practice in the country’s urban and peri-urban private sector. At the advent of South Africa’s democracy, public clinical psychological services were negligible, and the country is still facing challenges in providing human resources. The study was based on the analysis of both primary and secondary data. Primary data were collected by interviewing the heads of 160 public hospitals classified as rural by the Department of Health, while secondary data comprised a literature review. The number of clinical psychologists working in the public sector indicated a substantial growth over the last 20 years, while the number employed and/or doing out-reach to public rural primary healthcare areas shows a shortfall. Clinical psychology’s numbers, however, compare favourably to that of other mental health specialists in public rural primary healthcare settings. Since the National Mental Health Summit of 2012, strategies have been implemented to improve access to mental health care. In clinical psychology’s case relating to human resources, these strategies have showed encouraging results with a substantial amount of participating institutions reporting that clinical psychologists form a part of their proposed future staff establishment.

Keywords

Clinical psychology mental health primary health care rural South Africa

South African (SA) psychology has undergone crucial transformations over the last two decades. At the dawn of its Democracy in 1994, SA psychology was at a cross-road with regard to relevance, credibility, legitimacy, and applicability within its demographically diverse society (Rock & Hamber, 1994). By the early 1980s, SA psychologists had become increasingly concerned with the applicability of psychological theory and practice with a general plea for greater relevance through inclusively meeting the mental health (MH) needs of the country (Hayes, 1993). While the discipline of psychology has had difficulties establishing its relevance within SA’s health professions, it was its historic alignment with the narrow racial politics of the Apartheid regime (Whittaker, 1993) that saw a divide within the discipline, weakening its already uncertain position.

The establishment of the independent, non-racial Psychological Society of South Africa (PsySSA), shortly before the inauguration of SA’s democratic government, unified SA psychology by replacing the previously politically aligned professional body. It was PsySSA, together with the Health Professions Council of South Africa’s (HPCSA) Professional Board for Psychology, who was charged with guiding the profession of psychology to a societally applicable position within SA’s health context (Cooper & Nicholas, 2012).

By 1994, there was no coherent plan of how PsySSA and the Professional Board would go about consolidating psychology within the country’s health context, but it was clear that psychologists needed to be profiled as professionals who could offer effective MH services to a diverse, inclusive population (Rock & Hamber, 1994). The wake of the country’s apartheid political system left SA with social inequality and a disproportionate distribution of resources. At this time, the majority of psychologists were practising in the private sector and providing services to an exclusive population (Pillay & Petersen, 1996). Due to a myriad of psychosocial difficulties caused by poverty and inequality, people living in lower social-economic areas have been found to have a higher vulnerability to develop common MH disorders (Patel & Kleinman, 2003; Skeen, Lund, Kleintjes, Flisher, & Consortium, 2010). The negligible provision of psychological services in the public sector, the sector responsible for the MH needs of people who could not afford private health care, was therefore a comment not only on the apartheid policy’s unequal distribution of resources, but also on the profession of psychology’s seeming complacency with this system (Freeman, 1993).

SA’s new democratic government’s health policy had a focus on inclusivity. The White Paper for the Transformation of the Health System (DoH, 1997b) and the National Health Policy Guidelines for improved MH in South Africa (DoH, 1997a) endorsed MH treatment at primary healthcare (PHC) level. This policy’s aim was to promote health, including MH, for all South Africans. By 1994 it was evident that the profession of psychology, whose services were largely limited to SA’s urban communities, needed to address serious challenges of relevancy and accessibility if it were to contribute meaningfully in promoting MH for all South Africans. PsySSA and the Professional Board set out on the task of lobbying for a more relevant SA psychology capable of providing psychological services in keeping with the governments’ policy (Rock & Hamber, 1994). A more relevant psychology would have needed to address the needs of a country in which an excess 70% of the population was dependent on the public health system, and almost half of the population was living in rural settings, dependent on the PHC system (Council for Medical Schemes, 2014). The establishment of human resources for psychology within the public health sector, especially in historically underserved PHC areas, was therefore seen as a priority. Clinical psychologists were regarded as the appropriate professionals to provide human resources in the public sector’s medical settings as it is the registration category of psychologist charged with the primary clinical task of assessing, diagnosing, and treating relatively serious forms of psychopathology (Forum, 1993). Even though this goal has been set forth two decades ago, significant data gaps remain with regard to the situation of clinical psychology services in SA’s public, rural settings.

The goal of this study was to investigate the gains made over the last two decades towards establishing a more relevant clinical psychology in SA by providing a situation analysis of its human resources and services within the public rural primary healthcare (PRPHC) setting.

Method

Participants

A total of 98% of SA’s PRPHC facilities (160) participated in the situation analysis. Clinical managers, chief executive officers (CEOs), and nursing service managers (NSMs) were included as participants as these professionals are regarded as best positioned within SA’s Department of Health (DoH) structures to provide information about the clinical psychology services and resources at their respective institutions. The primary data for this study were collected from 138 (86.3%) health facility managers in charge of overseeing the medical and allied health professionals’ clinical duties (Clinical managers), 20 (12.5%) CEOs, and 2 (1.3%) health facility managers in charge of overseeing nursing and other paramedical professionals’ clinical duties (NSMs).

Instruments

The participants were interviewed using a structured questionnaire. This questionnaire was developed with the aim of gathering information about the clinical psychology services and human resources at participating institutions. The construction of this questionnaire was preceded by a literature review on the DoH’s strategic planning for the distribution of MH resources (DoH, 2013), and the World Health Organization’s (WHO) recommendations on situation analysis audit tools (WHO, 2015b). Participants were asked questions such as ‘Do you have clinical psychologists employed at your health facility? Does your facility receive out-reach clinical psychology services? Does your facility envision employing more clinical psychologists? Are clinical psychologists a part of your facility’s confirmed future staff establishment plan?’ In cases where the participants were unavailable for the telephonic interview, an electronic copy of the telephonic interview schedule was e-mailed to them to complete using the FluidSurveys online domain.

Procedure

Secondary data gathering

The situation analysis was based on analysis of both primary and secondary data. The secondary data collection and analysis involved a desk review. Local and international journals and books were reviewed with the aid of electronic academic search engines including PubMed, Medline, and Science-Direct. Our search strategy was based on validated methodologies (Ranson, Chopra, Atkins, Dal Poz, & Bennett, 2010; Wilczynski, Haynes, & Hedges, 2006) to obtain the literature on ‘mental health’, ‘human resources’, and ‘health services’ in ‘low –and middle income countries (LAMICs)’. These terms were combined with free-text and index-text relating to the different professionals working in MH. The local sources included studies, reports, and policies by government departments such as the DoH, the HPCSA, PsySSA, the Health Systems Trust (HST) as well as the census and national household survey data from StatsSA. International MH human resources data were acquired from WHO’s 2014 Mental Health Atlas, the 2004 WHO Global Burden of Disease Report, and the 2005 WHO Assessment Instrument for Health Systems (AIMS).

To avoid publication bias, the desk review also extended to grey literature such as conference proceedings, websites of appropriate organizations such as the WHO and DoH, as well as unpublished academic works. Reference lists of key articles were read which guided the inclusion of unpublished articles, and assisted in identifying key authors on the subject. Key authors were contacted personally to ensure the inclusion of all relevant unpublished works. The analysis of the secondary data preceded and informed the primary data collection procedure.

Primary data gathering

The primary data were collected by auditing the clinical psychology human resources and services in PRPHC settings. Secondary data perusal revealed that eight out of SA’s nine provinces (the only exclusion being Gauteng) have institutions categorized as ‘rural’ in PRPHC settings. Existing data refinement coincided with the primary data collection. Existing data purging and refinement was deemed necessary as the only secondary data available on rural public hospitals’ classification (DoH, 2004) were outdated. Since 2004, there have been numerous provincial DoH legislature changes, provincial boundary changes, provincial name changes, and hospital name changes. New hospitals were built and others changed in function to become specialized hospitals or Community Health Centres (CHCs). As there were no updated national or provincial reports available to identify a novel list of rural hospitals, each provincial DoH’s information management director was contacted to provide an updated list of hospitals regarded as rural, including the approximate population that it serves, using the 2004 DoH circular as the standard.

All participating provinces officially confirmed that the DoH’s Human Resource Management Circular of 2004 was used as the basis to define their hospitals as ‘rural’. Minor changes were made to the list of hospitals included in the audit after consultation with the various provincial DoHs, bringing the total from 175 to 163.

After the lists of rural hospitals/CHCs for each province were finalized, the various provinces’ district managers were contacted via telephone and e-mail to request them to provide the researchers with the names and contact details of CEOs and clinical managers in the identified hospitals.

Hospital CEOs were e-mailed and telephoned to inform them about the pending research at their institutions and to request them to discuss this audit, as well as the nature of the study with their hospital’s clinical managers. The clinical managers were then also telephoned and e-mailed to request their participation in the audit. The participating clinical managers and/or CEOs were interviewed using a simple telephonic structured interview regarding the clinical psychology services and human resources at their hospital. The duration of this situation analysis’ data collection was 25 months.

Every effort was made to minimize non-response bias by collecting the maximum amount of primary data from the selected sample of hospitals. Triangulating data collection methods were practised: where clinical managers’/CEOs’ telephonic contact proved to be unsuccessful, the district managers were contacted again to request an alternative contact method for these professionals. These clinical managers/CEOs were then contacted again telephonically; if this attempt proved to be unsuccessful again, an electronic version of the telephonic questionnaire, using the FluidSurveys online platform, was forwarded to them to complete. Four e-mail reminders were sent to clinical managers/CEOs receiving the electronic questionnaires. If no response was obtained after the reminders, it was assumed that the clinical manager/CEO exercised his/her right to choose not to participate in the study. In the few cases where health facilities did not have a clinical manager or CEO on-site, the facility’s nursing services manager participated in the audit.

Ethical considerations

Ethics approval for the study (BE 416/13) was obtained from the Biomedical Research Ethics Committee (BREC) of the University of KwaZulu-Natal (UKZN). After obtaining ethics approval for the study, each participating province was sent a request to conduct research at their institutions and the data gathering started only after this permission was granted. Participant confidentiality was guaranteed in the sense that their names were only disclosed to the researchers, while they were informed that participation was voluntary and that there would be no adverse outcomes if they should choose not to participate. The names of the clinical managers/CEOs with their responses to the structured interviews as well as the lists of clinical psychologists have been stored safely (encrypted on hard disc drives).

Data analysis

The structured telephonic interviews were digitally recorded, transcribed verbatim, stored, and encrypted. After the collected data were collated by the researchers, lists of clinical psychology services and resources were compiled per hospital and per province making use of FluidSurveys’ Statistical Package: StatWing. The statistics were then transferred to Microsoft Excel’s Spreadsheet function and analysed using IBM’s SPSS for Windows. The results of the analysis are presented as tables in the ‘Results’ section.

Results

Clinical psychology human resources

The analysis of the secondary data revealed that by 2014, there were 2786 clinical psychologists registered in SA with 1213 practising in the public sector at a rate of 2.6 per 100,000 population (Day & Gray, 2014). The number of clinical psychologists practising in the public sector per year is presented in Table 1.

Table 1.

Clinical psychologists employed in the public sector per province since 2000 (Personnel and Salary Information System (PERSAL), 2015).

Year	Province									Total
Year	EC	FS	GP	KZN	LIM	MPU	NC	NW	WC	Total
2000	23	11	97	35	5	2	1	10	54	238
2001	25	10	107	38	14	1	2	12	49	259
2002	25	12	114	36	14	1	2	10	52	267
2003	27	17	112	50	34	7	3	18	48	317
2005	37	29	122	67	35	17	7	27	58	399
2006	36	26	132	66	40	15	5	25	60	405
2007	45	29	135	65	41	13	3	17	71	419
2008	43	25	161	67	43	11	4	14	65	433
2009	52	32	166	67	42	14	6	17	75	471
2010	56	32	176	68	50	18	9	15	74	498
2011	66	29	183	71	69	19	8	25	75	545
2012	75	33	186	84	90	19	8	28	85	608
2013	62	37	212	109	91	19	11	37	85	1131
2014	62	36	232	115	101	35	17	48	86	1213

EC: Eastern Cape; NC: Northern Cape; WC: Western Cape; LIM: Limpopo; MPU: Mpumalanga; NW: North West; KZN: Kwazulu-Natal; FS: Free State; GP: Gauteng Province.

The audit revealed that PRPHC facilities, as well as their satellite clinics and affiliated CHCs serve a combined population of approximately 17,143,872 people. These health centres had a total of 81 full-time clinical psychologists employed at a rate of 0.47 per 100,000 population. A total of 50 (31.2%) of the facilities received sessional or so-called out-reach clinical psychological services. The human resources and out-reach services for clinical psychology in PRPHC settings with the corresponding population size and rate per 100,000 population per province are represented in Table 2.

Table 2.

PRPHC population sizes, health facilities, clinical psychology human resources, and rates per 100,000 population per province.

Province	Rural population reliant on PRPHC health facilities^a		Clinical psychologists
Province	Population	Facilities (N)	N	Rate	Out-reach: visits per month
EC	3,333,810	31	0	0	2
FS	465,925	7	8	1.07	2
KZN	4,581,901	34	11	0.24	16
LIM	4,105,933	36	41	1.0	17
MPU	1,621,686	17	11	0.68	3
NC	173,248	10	0	0	4
NW	2,063,721	14	5	0.24	2
WC	797,648	11	5	1.0	6
Total	17,143,872	160	81	0.47	52

EC: Eastern Cape; FS: Free State; KZN: Kwazulu-Natal; LIM: Limpopo; MPU: Mpumalanga; NC: Northern Cape; NW: North West; WC: Western Cape; PRPHC: public rural primary health care.

The rural population for each province represents the population making use of the public health sector and was obtained by calculating the hospitals included in the audit, as well as their satellite clinics and Community Health Centre’s (CHC) population.

Of the facilities included in this audit, 58 (36.3%) reported that employing more clinical psychologists is a part of their confirmed future staff establishment plan (Table 3). While this statistic does not necessarily reflect a commitment to prioritise clinical psychology services at these institutions, it does reveal a theoretical plan that includes clinical psychologists as a part of its future human resources.

Table 3.

Clinical psychology posts confirmed on PRPHC facilities’ future staff establishment plan.

	EC		FS		KZN		LIM		MPU		NC		NW		WC		Total
	N	%	N	%	N	%	N	%	N	%	N	%	N	%	N	%	N	%
Clinical psychologist	8	25.8	0	0	22	64.7	15	41.7	4	23.5	2	20	5	35.7	2	18.2	58	36.3

EC: Eastern Cape; FS: Free State; KZN: Kwazulu-Natal; LIM: Limpopo; MPU: Mpumalanga; NC: Northern Cape; NW: North West; WC: Western Cape; PRPHC: public rural primary health care.

Human resource production

The output of all categories of psychologists and registered councillors trained per year is presented in Table 4. Over the last two decades, 2264 clinical psychologists were trained in SA, the highest of all psychologists’ categories (HPCSA, 2015b). According to the HPCSA (2015a), there were 27 newly registered clinical psychologists during 1995, while during 2013, 159 new clinical psychologists registered with the health profession’s governing body. Between 2001 and 2014, on average 130 new clinical psychologists were registered per year (HPCSA, 2015b). Registered counsellors, a mid-level practitioner with 4 years of university training and 6 months of practical training, was introduced in 2004 as new category of MH professional to help address SA’s MH human resource crisis (HPCSA, 2015b).

Table 4.

Psychologists and registered counsellors qualifying per year from 1995 to 2014 (HPCSA, 2015b).

Category	Year																				Total
Category	1995	1996	1997	1998	1999	2000	2001	2002	2003	2004	2005	2006	2007	2008	2009	2010	2011	2012	2013	2014	Total
Clinical psychologists	27	42	71	104	97	106	155	157	132	135	101	130	126	107	134	98	118	133	159	132	2264
Counselling psychologists	25	23	32	53	55	56	82	92	88	92	89	76	80	55	66	50	61	46	55	55	1231
Educational psychologists	23	16	38	46	68	63	93	98	64	79	79	64	59	57	59	39	60	73	53	69	1200
Industrial psychologists	46	30	44	61	68	75	102	126	126	115	110	89	104	103	93	90	85	105	104	106	1782
Research psychologists	13	11	18	30	20	25	30	29	35	27	21	18	31	26	28	23	27	27	34	37	510
Registered counsellors										129	130	135	148	158	219	281	383	314	328	174	2399

HPCSA: Health Professions Council of South Africa.

Discussion

Public sector human resources

The ratio of clinical psychologists per 100,000 population practising in SA’s public sector is well above par when compared to other LAMICs (0.02–0.04), and superior even to upper middle income countries (MICs) (1.47) (WHO, 2015a). Over the last two decades, there has been a dramatic increase in clinical psychologists employed in the public system (Table 1), the sector responsible for more than 44 million South Africans’ health care (Council for Medical Schemes, 2014). In this regard, SA’s clinical psychology has made great strides to offer a more inclusive service, especially if taken into account that its human resources were virtually non-existent in the country’s public sector at the advent of its democracy (Rock & Hamber, 1994). With regard to MH specialists practising in the public sector, clinical psychology’s human resources (2.6 per 100,000 population) are better represented than psychiatrists, who are practising here at a rate of less than 0.05 per 100,000 population (WHO, 2015a). Recent local studies suggest this ratio to be close to 0.03 per 100,000 people in PRPHC settings (De Kock, 2016).

Rural public health sector

The authors are not aware of data from other LAMIC’s rural areas that are comparable to this study in terms of scope or coverage. While impossible to ascertain SA’s PRPHC clinical psychology services’ position compared to that of other LAMIC’s PRPHC areas, the ratio of 0.47 clinical psychologists per 100,000 rural population is well below the international standards set for quality of care (WHO, 2011). This ratio, even though below par, is still superior to the coverage of clinical psychological services in other LAMIC’s (0.02–0.14 per 100,000 population average) entire populations (Morris, Lora, McBain, & Saxena, 2012).

The Human Resources for Health South Africa (HRHSA) report of 2012 indicated that 43.7% of SA’s population live in rural areas which suggests that this study elucidates the fact that a substantial amount of SA’s population still do not have appropriate access to clinical psychology services. These findings are in line with WHO (2004, 2012) estimates that the treatment gap between human resources and mental illness is as high as 85% in LAMICs, and even higher in the rural areas. This study indicates that the EC and NC provinces are in the direst situation regarding clinical psychology services with no full-time employed clinical psychologists in PRPHC areas, while the WC, LIM, and FS provinces are the best served. LIM’s rural clinical psychology workforce comprises almost half of the country’s clinical psychologists practising in PRPHC settings. This finding is not surprising as 90% of this province’s population is living in areas classified as rural (Kok & Collinson, 2006).

Human resource production

The training of clinical psychologists has increased drastically over the last two decades (see Table 3). Psychology is the third most popular course enrolled for by undergraduate and postgraduate South African university students. A total of 14 out of 17 South African universities offer graduate training in clinical psychology leading to professional registration (Cooper & Nicholas, 2012; HPCSA, 2014). Clinical psychology is furthermore within the profession of psychology the most representative category of psychologist (see Table 4). Clinical psychology as a profession, it would seem, is in a favourable position to supply more human resources in an effort to alleviate SA’s MH burden and treatment gap.

This study suggests that there are, albeit theoretical, efforts from the DoH to decrease the MH treatment gap in SA’s PRPHC areas by employing more clinical psychologists. A total of 58 health centres indicated that clinical psychologists are already part of their future staff establishment plan (Table 3). If these future staff establishment plans come into action, it would place the ratio of clinical psychologists to the proportion of the population making use of PRPHC facilities at approximately 0.83:100,000. A further human resource increase can be expected as the national DoH’s MH strategic plan for 2013–2020 (DoH, 2013) proposes strategies that include the training of future psychologists and registered counsellors, albeit partly, at district level’s designated National Health Insurance (NHI) pilot sites. The roll-out of these MH professionals into the PHC areas would necessitate clinical psychologists to be employed as both supervisors and clinicians (Tlou, 2013).

This study provides the first published national indication of clinical psychology services in SA’s rural public healthcare settings. Future comprehensive inquiries on this subject should note some of the limitations of this review: with this audit’s duration taking in excess of 2 years, it should be noted that the list of facilities included may not be exhaustive, and that some facilities may have been added or removed by provincial departments since the start of the study. However, with 98% of the facilities deemed to represent rural health facilities in SA participating in this audit, the results can be interpreted as representative. Furthermore, the calculation of the rural population sizes making use of the public health sector per province was done conservatively. SA’s rural population, its poorest population, may well be more dependent on the public health sector than what is suggested in this article (HRHSA, 2012; Lehohla, 2013a, 2013b).

Conclusion

Since the advent of democracy in SA, there has been a call for a more relevant, applicable psychology in this country. The theme of the International Congress of Psychology (ICP), held for the first time on African soil in Cape Town during July 2012 was ‘Psychology Serving Humanity’, alluding to a novel, context specific re-organization of the profession, in touch with the needs of the population that it serves. The SA National Mental Health Summit of April 2012 concluded that a movement towards community based MH care should be made. This process would start with the re-engineering of the PHC system, to fully integrate MH services (Motsoaledi, 2012). This re-engineering would, among other strategies, include task shifting which is the delegating of tasks from one cadre of health professional to another (new or existing) cadre with either less training or narrowly specialized training (WHO, 2008). When compared to other MH specialists’ availability, output, and distribution in the public health sector, it appears that clinical psychology is well-suited to provide specialist human resources in this re-engineering process. The relevance and applicability of a profession is, however, not measured purely by its human resources’ distribution. This article does not address the applicability of a psychotherapy and assessment based eurocentric clinical psychology training curriculum in SA’s rural areas. Even before SA’s democracy, various authors have critiqued this training approach (Hayes, 1993) with its perceived narrow scope of practice (Van der Westhuysen & Plug, 1987), especially when clinical psychologists are practising in medical settings (Rock & Hamber, 1994). Perhaps now that the basic need for establishing clinical psychology human resources in the public sector has been met, it is an opportune time to re-examine the profession’s clinical alignment with the needs of its population. The time has come for clinical psychology to actively lobby to be included as leaders in the PHC re-organization, as applicable MH specialists, in touch with the MH needs of the community that it serves. It is imperative that clinical psychology is equipped to meet these needs by re-evaluating its professional training and scope of practice in order to successfully engage, not only in its clinical work at PHC level, but also in task shifting in an effort to alleviate medical workforce shortages.

While establishing a relevant psychology in SA is a multifactorial concept, the major challenge posed to the profession at the advent of this country’s democracy was to provide inclusive psychological services, meeting its society’s needs (Whittaker, 1993). Various gains towards meeting this challenge have been made with a remarkable rise in clinical psychological services in the public sector. However, to establish a truly applicable psychology, serving humanity by inclusively addressing the country’s MH needs, a greater focus on integrating these services into the PHC system’s rural areas is needed.

Footnotes

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

Cooper

Nicholas

(2012). An overview of South African psychology. International Journal of Psychology, 47, 89–101.

Council for Medical Schemes. (2014). Public sector dependent population. In Medical schemes 2013–14: Council for Medical Schemes annual report 2013/14. Pretoria, South Africa: Council for Medical Schemes. Retrieved from http://us-cdn.creamermedia.co.za/assets/articles/attachments/51352_councilmeidalshcemesreport.pdf

Day

Gray

(2014). Health and related indicators. In Padarath

A. E.

English

(Eds.), South African health review 2013/14 (pp. 201–345). Durban, South Africa: SA Health Systems Trust.

De Kock

J. H.

(2016). Alleviating the mental health crisis in South Africa’s rural primary care areas through task shifting: Non-medical prescribers and the case of clinical psychology (Unpublished doctoral dissertation). University of KwaZulu-Natal, Durban, South Africa.

Department of Health. (1997a). National health policy guidelines for improved mental health in South Africa. Pretoria, South Africa: National Department of Health (Directorate for Mental Health and Substance Abuse).

Department of Health. (1997b). White paper for the transformation of the health system in South Africa. Government Gazette, 382(17910). Retrieved from http://www.gov.za/sites/www.gov.za/files/17910_gen667_0.pdf

Department of Health. (2004). Human resource management circular 87 of 2004. Pretoria, South Africa: National Department of Health.

Department of Health. (2013). National mental health policy framework and strategic plan 2013–2020. Pretoria, South Africa: National Department of Health.

Forum. (1993, September 2–4). Summary report from the working group on relevance. Paper presented at the Forum on the Role and Function of Psychology in the New South Africa, Johannesburg, South Africa.

10.

Freeman

(1993, September 2–4). Provision of psychological services in the new South Africa. Paper presented at the Forum on the Role and Function of Psychology in a New South Africa, Johannesburg, South Africa.

11.

Hayes

(1993, September 2–4). Finding space for critical thought. Paper presented at the Forum on the Role and Function of Psychology in the New South Africa, Johannesburg, South Africa.

12.

Health Professions Council of South Africa. (2014). List of accredited Universities in South Africa. Pretoria, South Africa: Author.

13.

Health Professions Council of South Africa. (2015a). Output of clinical psychologists per year. Pretoria, South Africa: Author.

14.

Health Professions Council of South Africa. (2015b). Output of psychologists per year. Pretoria, South Africa: Author.

15.

Human Resources for Health South Africa. (2012). Human Resources for Health South Africa: HRH strategy for the health sector: 2012/13–2016/17. Johannesburg, South Africa. Retrieved from http://www.gov.za/sites/www.gov.za/files/hrh_strategy_0.pdf

16.

Kok

Collinson

(2006). Migration and urbanisation in South Africa: Statistics South Africa. Pretoria, South Africa: Statistics South Africa, pp. 1–35

17.

Lehohla

(2013a). Census 2011 census in brief. Pretoria, South Africa: Statistics South Africa, pp. 105.

18.

Lehohla

(2013b). Use of health facilities and levels of selected health conditions in South Africa: Findings from the General Household Survey, 2011. Pretoria, South Africa: Statistics South Africa.

19.

Morris

Lora

McBain

Saxena

(2012). Global mental health resources and services: A WHO survey of 184 countries. Public Health Rev, 34, 1–19.

20.

Motsoaledi

A. P.

(2012). Speaking notes for the minister of health: Dr A P Motsoaledi at the national mental health summit. Gauteng, South Africa: Ministry of Health, Republic of South Africa: Retrieved from http://www.polity.org.za/article/sa-motsoaledi-address-by-the-minister-of-heallth-at-the-national-mental-health-summit-johannesburg-12042012-2012-04-12

21.

Patel

Kleinman

(2003). Poverty and common mental disorders in developing countries. Bulletin of the World Health Organization, 81, 609–615.

22.

Pillay

Petersen

(1996). Current practice patterns of clinical and counselling psychologists and their attitudes to transforming mental health polices in South Africa. South African Journal of Psychology, 26, 76–80.

23.

Personnel and Salary Information System (PERSAL) (2015). Number of psychologists. National Treasury – Vulindlela. Retrieved from http://www.vulindlela.gov.za

24.

Ranson

M. K.

Chopra

Atkins

Dal Poz

M. R.

Bennett

(2010). Priorities for research into human resources for health in low-and middle-income countries. Bulletin of the World Health Organization, 88, 435–443.

25.

Rock

Hamber

(1994). Psychology in a future South Africa: The need for a National Psychology Development Programme. Retrieved from http://www.csvr.org.za/index.php/publications/1759-psychology-in-a-future-south-africa-the-need-for-a-national-psychology-development-programme.html

26.

Skeen

Lund

Kleintjes

Flisher

Consortium

M. R. P.

(2010). Meeting the millennium development goals in Sub-Saharan Africa: What about mental health? International Review of Psychiatry, 22, 624–631.

27.

Tlou

(2013). Psychology, mental health and the National Health Insurance system. PSYTalk, 2, 1–2.

28.

Van der Westhuysen

T. W. B.

Plug

(1987). The training of South African psychologists: Summary of finding of the PASA Council for Training. South African Journal of Psychology, 17, 165–169.

29.

Whittaker

(1993, September 2–4). Psychology and mental health care in a de-racialised South Africa. Paper presented at the Forum on the Role and Function of Psychology in a New South Africa, Johannesburg, South Africa.

30.

Wilczynski

N. L.

Haynes

R. B.

Hedges

(2006). Optimal search strategies for identifying mental health content in MEDLINE: An analytic survey. Annals of General Psychiatry, 5, 4.

31.

World Health Organization. (2004). Access and use of psychotropic medicines. WHO Drug Information, 18, 244–244.

32.

World Health Organization. (2008). Task shifting: Rational redistribution of tasks among health workforce teams: Global recommendations and guidelines (Report Task Shifting, Retrieved from AWN database). Geneva: Author.

33.

World Health Organization. (2012). WHO launches the World Health Statistics 2012. Euro Surveillance: Bulletin Européen Sur Les Maladies Transmissibles = European Communicable Disease Bulletin, 17, 20175.

34.

World Health Organization. (2015a). Mental Health Atlas 2014. Geneva: Author.

35.

World Health Organization. (2015b). Situation analysis and priority setting. National health policies, strategies and plans. Retrieved 24 February 2015, 2015, from http://www.who.int/nationalpolicies/processes/priorities/en/