Overcoming barriers to the greater deinstitutionalisation of mental health care in Russia
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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.

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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
Mental Health Reform mental health care in Russia

  • 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
Multi-disciplinary team mental health care in Russia

  • 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
Severdlovsk Oblast mental health care in Russia


Sverdlovsk region
Sverdlovsk Region mental health care in Russia

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 mental health care in Russia

  • 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
Methods mental health care in Russia

  • 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 system
Mental Health System mental health care in Russia

  • Vertical 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 system1
Mental Health System mental health care in Russia

  • Funding 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


Stakeholder perceptions
Stakeholder perceptions mental health care in Russia

  • Consensus 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 scarcity
Resource Scarcity mental health care in Russia

  • Only 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 approach to care/rehabilitation mental health care in Russia

  • 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 barriers
Structural barriers mental health care in Russia

  • Hospital 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 msecs
Role of MSECs mental health care in Russia

  • Medico-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
System Pathways mental health care in Russia


Technical assistance actions
Technical Assistance Actions mental health care in Russia

  • 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
People with psychosis obtaining employment mental health care in Russia


Clients with multi axial care plans
Clients with multi-axial care plans mental health care in Russia


Trends in beds per 10 000 population
Trends in beds per 10,000 population mental health care in Russia


Conclusions
Conclusions mental health care in Russia

  • 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
Further info mental health care in Russia

  • 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


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