Lessons From Italy On Mental Health Care

This article first appeared in the Pretoria News on April 12, 2018.
In the 1970s Italy was in financial difficulty. The boom years of the 1950’s and 60’s had quickly given way to stagnation and then two financial crises in 1974 and 1976.
Inadvertently, the timing was perfect for Dr Franco Basiglia, a psychiatrist appalled at the treatment of mental health patients in institutions. He proposed that Italy abandon treating mental health patients in ‘lunatic asylums’, condemning the blurred lines between punishment and treatment which saw patients shackled, isolated and ignored. Instead, patients should be returned to their families, looked after by those closest to them, with support and treatment provided by the state.
The government, keen to cut costs passed Law 180, which approved the closure of the country’s mental health hospitals. Implemented over time, new applications were refused, patients returned, and doctors reassigned.
The reading material online celebrates the introduction of the community-care model with heralded as Italy the first country in Europe to move away from the chaos and confusion that made asylums like London’s Bedlam notorious.
But under the media headlines of success is a story of mayhem. The Italian government, in closing its hospitals, failed to provide families with support. Social workers, occupational therapists, out-patient centres, psychiatrists and psychologists – all failed to materialise. People battling with an array of illnesses from schizophrenia to severe depression wound up on the streets and in the prison system. The good intentions to unblur the lines between treatment and punishment was backfiring with severe consequences.
Sound familiar?
Italy of the 1970’s is South Africa’s Gauteng Province in 2018, when hospitalised support for mental health patients was stripped under the banner of a progressive care in the community model that failed because it had never been set up. There are so many parallels to what is now titled the “Life Esidimeni Tragedy”  – the lack of support to NGOs and families, having to care for relatives with complex illnesses, the silence from the State to provide an immediate response when issues were raised, the increasingly shrill clamour of the public voice calling for urgent action, as patients suffered. We now know 144 people died, and 62 are still missing, unaccounted for.
So how did Italy transform its mental health story from headlines of ruin to reformation?
Communities, fed up with the government’s disinterest in resolving the issue, banded together to form mental health co-operatives and later social enterprises, small organisations that began to provide the care that was so deeply needed. These organisations mushroomed across the country, by 40% a year from the 1970s, as citizens co-ordinated to take action as the economy worsened and the government struggled to respond.  They set up clinics, out-patient centres, visits, carer services, and carer support. And they charged for it, ensuring an income stream that enabled the model to expand swiftly. Today Italy has over 70,000 social enterprises and co-operatives, and their success in addressing the mental health crisis is what quietly sits behind the country’s reputation as a leader in health reform.
This is the spirit of social enterprise. People banding together to tackle deeply complex issues in environments of deep political and economic constraint. It is social entrepreneurs who take the plunge, tackling the societal issues that are ignored by everyone else. They recognise first that long-term change is led, not by governments, but by communities, with clear goals on what can be achieved and a commitment to work together.
As funding to NGOs continues to be cut, it is imperative that we look to new ways to ensure our society does not suffer. Our shock at the Life Esidimeni tragedy is not enough – we need to convert this to action, banding together to set up social enterprises with clear goals that work to strengthen our society. The great difference between social enterprise and charity is that they are built around an income model that brings earned income into the organisation. This reduces their dependencies on grants and singular government contracts, ensuring organisational longevity. Our best social enterprises are hybrid models – both for profits and not for profits, combining the best of values and business models: Avril Elizabeth Home funds its work looking after disabled children by renting the Roseacres Hospital to the Life group.  Hospice extends its funding through its network of charity shops.
It took Italy ten long and difficult years to build an alternative system that would provide better support to its mental health patients and their families, and for the revolutionary model proposed by Dr Basiglia to be heralded. That the model worked is thanks to community activism and social entrepreneurship. What we learn from Italy, a country that also has its share of political and economic instability, is that reformation comes from banding together and working towards those changes we want to see in our society.
Krige is the co-author of Disruptors: Social entrepreneurs reinventing business and society. She is Chief Technical Adviser to the International Labour Organisation on the Social Economy Policy, and formerly led the Network for Social Entreprenurs at the Gordon Institute of Business Science. This is written in her personal capacity. She is part of the Nation Builder collaborative network. www.proudnationbuilder.co.za