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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 d.mcdaid@lse.ac.uk. Mental Health Reform.

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Overcoming barriers to the greater deinstitutionalisation of mental health care in russia

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

d.mcdaid@lse.ac.uk


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


Severdlovsk oblast

Severdlovsk Oblast


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


Overcoming barriers to the greater deinstitutionalisation of mental health care in russia

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


System pathways

System Pathways


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


People with psychosis obtaining employment

People with psychosis obtaining employment


Clients with multi axial care plans

Clients with multi-axial care plans


Trends in beds per 10 000 population

Trends in beds per 10,000 population


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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