Access to and use of psychotropic medicines in the South African public sector

Aim This paper reflects on the accessibility and use of psychotropic medicines in the resource-constrained South African public health sector. Method Current legislation, policies and processes supporting uninterrupted access to affordable psychotropic medicines of assured quality, safety and efficacy, by the South African population that is dependent on the public health sector, were reviewed and reflected on. Public-sector medicine procurement data obtained from the National Surveillance Centre were analysed, using defined daily dose per 100 000 uninsured population per day per province for the calendar years 2019─2023. Results The application of evidence-based medicine review processes has supported access to essential psychotropic medicines for a range of mental disorders at all service levels. The Standard Treatment Guidelines recommend that medicines be used in conjunction with psychosocial interventions, and provide guidance on monitoring of chronic treatment in people with severe mental illness at primary-care level. Access may be limited by prescriber restrictions: apart from anti-epileptic medicines, psychotropic medicines are listed as Schedule 5 or 6 and cannot be prescribed by Primary Health Care nurses or clinical associates. Provincial procurement data suggest that there is inequitable access to psychotropic medicines, with marked disparities in expenditure on psychotropic medicines between provinces. Conclusion Medicine accessibility may be constrained by affordability, supply-chain challenges, restrictive legislation, prescriber availability, and pragmatic implementation. However, patient-linked data are not routinely available, which prevents national monitoring of case-mix and medicine utilisation at the prescriber or patient level. Furthermore, apart from attempted suicide, national mental health indicators do not include person-centred outcomes, thus limiting capacity to evaluate the effectiveness of current care. Access to psychotropic medicines on the national Essential Medicines List for a range of mental disorders varies between provinces. While multiple factors may affect access, differing human resources for mental health and supply-chain issues should be examined. Outcome-based routine monitoring is recommended to inform quality improvement efforts.