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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
  • 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
  • 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
sverdlovsk region
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

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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
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 system
Mental Health System
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
technical assistance actions
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
conclusions
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
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
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