Costs, Benefits and Potential Replicability/Transferability
In 2011, it was calculated that it cost PMHP R185 (US$22.50) to provide maternal mental health services to one woman for one year. This included as many counselling sessions as she needed, the counsellor’s liaison work with psychiatric services and social support agencies, and postnatal followup care. This can be compared to the average rate of private-sector psychotherapy which is R700 (US$85.00) per hour for one individual counselling session alone (PsySSA 2012). Although PMHP’s mental health services were initiated with volunteers providing counselling, it became clear, as uptake increased, that a project coordinator and funding for basic costs were necessary for the smooth running and sustainability of the service. PMHP covers these costs through a variety of sources, namely philanthropic foundations locally and internationally, the Department of Social Development Western Cape, individual donors, the corporate sector and research funding agencies. PMHP’s operations were formalised when it relocated into the University of Cape Town. This relocation was significant, affording the project considerable support from the institution for operational overheads and the infrastructure to access funding from donor organisations, as well as providing the project with access to expertise for the evaluation and further development of the intervention
In terms of the effects of the projects, a preliminary evaluation of the followup calls made by counsellors in 2011 (n = 276) indicated that 90% of clients reported that their primary problems had improved, 71% reported they were coping at follow-up, 74.6% reported positive mood, 95% reported successful bonding with their baby and 93% of women viewed counselling sessions positively (Field et al. 2014). Furthermore, a study conducted between January 2010 and December 2011 which investigated the use of PMHP services at one of its facilities found that, of the women who attended counselling, the majority came for two sessions or more, and most of these women did not default any counselling appointments, suggesting that the women found the service satisfactory (Baron et al. 2014). Interestingly, the study found that women with more children were more likely to default several counselling appointments compared to women with no children, suggesting that childcare responsibilities make it potentially more difficult to attend health care appointments.
In addition, an external qualitative evaluation found that staff benefited from improved capability to identify and assist with mental health problems (Chesselet 2005). Rather than adding a burden to their workload, staff reported a sense of relief that systems have been developed to meet previously ignored need. Furthermore, the study found that the uptake of training and associated enthusiasm amongst staff was further enhanced when participative methodologies were used. The staff reported that this gave them a sense of empowerment to address their own and clients’ psychological distress.
Ultimately, these findings suggest high levels of acceptability for, and significant benefits of, the PMHP services which can be provided at a relatively low cost and delivered in considerably busy, low-resource facilities. However, if the model were considered for application elsewhere, certain key issues would need to be carefully considered. For example, PMHP sites are all situated in urban areas, where the availability of resources and the quality of health care are considerably better in comparison to rural areas. Furthermore, given the high antenatal attendance in South Africa, women’s first antenatal visit provides a suitable and effective opportunity to initiate contact and screen pregnant women for mental distress. In situations where women do not attend health facilities regularly in the perinatal period, careful thought would need to be given to what would be the optimal environment to reach, screen and provide mental health care to women. In addition, the use of telephone calls as the primary mode of follow-up is feasible in South Africa, where there is high mobile phone ownership, text messaging services are relatively cheap and ‘please call me’ messages can be sent free of charge. Although a similar pattern is true in other African countries (UNDP 2012), this may not be the case in all low-resource settings, where alternative means of follow-up and continuous care, factors inherent in the model’s success, would need to be considered.