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Overcoming barriers to the greater deinstitutionalisation of mental health care in Russia. David McDaid LSE Health & Social Care & European Observatory on Health Systems and Policies, London School of Economics [email protected]. Mental Health Reform. - PowerPoint PPT Presentation
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Overcoming barriers to the greater deinstitutionalisation of mental health care in Russia
David McDaid
LSE Health & Social Care & European Observatory on Health Systems and Policies, London School of Economics
Mental Health Reform
3 year DFID funded technical assistance programme led by Prof Rachel Jenkins at Institute of Psychiatry
Multi-disciplinary team of UK and Russia based researchers and policy makers
Focus on Sverdlovsk Region but with dialogue at Federal level
Multi-disciplinary team
• Institute of Psychiatry: Rachel Jenkins, Stuart Lancashire, Samantha Green, Jonathan Watkins, David Goldberg, Nick Purchase
• LSE: David McDaid,• Imperial College: Rifat Atun, Yevgeniy
Samyshkin,• Kastanja Consulting: Jo Lucas• Swansea University: Peter Huxley• Sverdlovsk MoH: Angelina Potasheva,
Zinaida Bobylova• Sverdlovsk MoSP: Alexey Nikiforov,• AMH Project, Ekaterinburg: Valery Gafurov
Severdlovsk Oblast
Sverdlovsk Region
Size of France
4.8 million population
Yekaterinburg 1.29 million
Above average economic development
$57 per annum per capita on health care
2.6% (112,000) registered with mental
disorders
Aims
To identify how health and non-health system factors impact on mental health provision in one region of Russia
In particular to explore issues around the balance of care
Identify barriers and potential solutions to help facilitate greater use of community services/ promote reintegration
Methods Interviews with a range of key stakeholders
using semi-structured questionnaire
Identified through preparatory work and discussions with Regional MoH and MoSP
Meetings with other representatives of MoH, MoSP, Employment Services etc as local links built
Triangulation of qualitative data with analysis of routine documents and statistics and lit review
Mental Health SystemVertical programme with earmarked
funding
Delivered mainly in parallel to general health care services
Responsibility of Oblast Ministry of Health and municipalities (raions). Federal Ministry develops legal/regulatory frameworks & policy guidance
Important role for Ministry of Social Protection
Federal Employment Service
Mental Health SystemFunding based on historical norms
Difficult to identify funding – crude estimate $9 on inpatient care
Care highly institution focused
Nationwide 279 psychiatric hospitals; 110 inpatient depts in 171 psychiatric dispensaries; 161,00 beds in hospitals; 125,000 social care homes (internats)
Federal Policy 2003-2008: emphasised downsizing hospitals; more integration with general health services; day care/outpatient services
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50
100
150
200
250
1970 1980 1990 2000 2010
ArmeniaAzerbaijanEstoniaGeorgiaLatviaLithuaniaPolandRussian FederationUkraine
Psychiatric hospital beds per 100000
Stakeholder perceptionsConsensus that system under funded!
Fragmented budget for region/municipalities
Recognition need to develop more community based services
Perception illegal to deliver services through primary care
Recognition that funds might be transferred elsewhere – social protection, employment
But…cautious about co-ordination & co-operation across sectors
Resource ScarcityOnly 12% of municipalities had some
day care facilities
40% of all bed capacity in two hospitals
Workforce issues – e.g. limited availability of social workers; many posts unfilled
Absence of contemporary training materials / multi-disciplinary teams
Limited civil society resources
Narrow approach to care/rehabilitation
Narrow model: focus on medical treatment
Underestimate psychological /environmental factor impact on disorders & outcomes
Therapeutic pessimism – recovery unlikely – protective institutional care required
Hierarchical decision making – limited role for non-psychiatrists
Structural barriersHospital funding: dependent on
maintaining high rate of occupancy
Funding based on historical norms rather than population needs
Regulations stipulate periods of hospitalisation
Local communities dependent on institutions for employment
Administrative barriers can make it difficult to pool/shift resources between sectors
Role of MSECsMedico-social and educational assessment
committees play critical role
Determine whether an individual qualifies for disability benefits
Should produce plan for occupational and social rehabilitation
But ..lack of multi-disciplinary participation in MSECs…places for non-medics vacant
If assigned highest level of disability benefit; legally and practically v difficult to obtain employment
System Pathways
Technical Assistance Actions
Communicating legal position re role of primary care / community social work
Facilitate development of inter-sectoral committees (ISCs) at region/municipal level
Employment Services – participate in ISCs/share job vacancies with mh staff
Training programmes for GPs/ social workers :helped influence development of retraining course for nurses as social workers in Russia
Training/technical support for NGOs
Policy dialogue at Regional and Federal Level
People with psychosis obtaining employment
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10
20
30
40
50
60
Num
bers
2001 2002 2003 2004 2005
Hospital 29Nizhny-TagilPervouralsk
Clients with multi-axial care plans
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10
20
30
40
50
60
Num
bers
2001 2002 2003 2004 2005
Hospital 29Nizhny-TagilPervouralsk
Trends in beds per 10,000 population
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2
4
6
8
10
12
14
2001 2002 2003 2004 2005 2006
Bed
s p
er 1
00,0
00 p
op
Hospital 29
Nizhny-Tagil
Pervouralsk
Sverdlovsk Oblast
Russian Federation
Conclusions Multiple barriers require multiple solutions
Takes time – look for innovative ways around bureaucracy to facilitate flexible use of resources
Cultural factors: limited role for primary care sector/ mental health – low priority
Role of rehabilitation critical needs to be in place alongside any medical support
Rebalancing of care requires additional investment:
Housing stock; Support for Families; Employment; Access to cash benefits
Policy climate provides opportunities for change
Further info Jenkins R, Lancashire S, McDaid D et al. Mental
health reform in Russia: an integrated approach to achieve social inclusion and recovery. Bulletin of the World Health Organization, 2007, 85(11): in press
McDaid D, Samyshkin Y, Jenkins R, Potasheva AP, Nikiforov AI, Atun RA. Health system factors impacting on delivery of mental health services in Russia: multi-methods study. Health Policy 2006; 79 (2-3): 144-152
WHO Collaborating Centre for Research and Training in Mental Health and Section of Mental Health Policy http://www.iop.kcl.ac.uk/departments/?locator=430