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The finance and delivery of mental health services in Central Europe University of California, Berkeley and Charles University, Prague Country presentationCzech Republic(economic interests and political power or evidence-based and informed- policy?) Petr Hava 21/5/2007
1.Structure of mental health delivery system Organizational change of outpatient services in 90s DECENTRALIZATION AUTONOMY CONTRACTING Lower level of coordination and integration No human resources management, spontaneous (“free market”) development
2. What are the key organizations in the mental health delivery system? Health services • Primary health care • Outpatient psychiatrist • Clinical psychologist • Day treatment community center • Assertive community team • Crisis services • Homecare team • Inpatient psychiatric ward (psychiatric dept. of a general hospital) • Follow-up medical inpatient care Facilities and social programs • Club house (center of daily activities) • Vocational and employment support • Assisted living • Self-help groups Primary care model was Implemented in 70s and 80s In the Czech republic we can speak about: “Medium resource model” of mental care
3. How are mental health services financed Source: Table adapted from Dlouhý (2004)
4. What reforms have been made or attempted in the past 5 years? • Concept of psychiatry (2001),the similar conceptions has been formulated for other medical specialties • Important event, the establishment of NGO: Center for the Mental Health Care Development (1995 - ) • SYMPATHEA (2005-2007) patient oriented supports • Promotion and development of VIDA centers (2001-2003) / patient advocation • Association of community mental health services (1999-2007) • Mainstreaming Mental Disability Policy (2005-2006) • Czech Mental Health Policy(Open Society Fund) (2003-2004), published 2005 • Current situation • Ways to realization • Healthy cities, Healthy schools (90s – 00s) • New Act on social services (2006), new opportunities social and for social and health services coordination • National psychiatric program 2007 [Only one page!, proclamative letter to MOH, formulated by the Czech psychiatric association, not connected to Czech Mental Health Policy 2005 documents] Very good, structured basic approach, there is still need for more complex and EB
Czech Mental Health Policy (Open Society Fund) (2003-2004), published 2005
5. What are the major obstacles to reform? • Critical need for political and professional leadership to give priority focus to integrating different perspectives and disciplines into a coherent and agreed conceptualization (knowledge management) • Agenda setting process • The approaches of many actors are not enough evidence-based, health status is not recognized by politicians as an important investment factor and policy priority • Human rights are not accepted by all national and regional policy makers as important principal approach (MOH! E.g.) • National, regional and local politicians are not informed, simplification and “market” ideology often prevail • Serious deficits in research of health services and related social topics, clinical research completely prevails [esp. pharmaceutical`s trials] • Medical paradigm prevails, health promotion paradigm needs to be reviewed • Battles for financial sources, reactive proclamations, simple lobbying • Failing national policy makers, especially at MOH, • Interests, political power dominating in policy making • Fragility of existing health promotion infrastructure, particular the funding mechanism, limitations of the current and predominant value base for health promotion • Social context: • prevailing orientation on free market concepts • Democracy and ethical deficits • Burden vs. budget
Obstacles to reform Actors in different communities Politicians Government Media Patients Medical Psychiatric Social Sociology Public policy Economics Research Social sciences Medical sciences Public health Statistics Utilization expenditures Visions strategies Agenda setting Social problems Social consequences Political programs Government Influential persons Policy making Policy implementation Implementation support Outcomes Cooperation Knowledge management
6. What are the major mental health or behavioral problems (personal view of the author, only examples, partly EB) Treatment vs. primary prevention Risk population groups • Homeless • Unemployed, poor • Families, schools, children Violence(at work, at schools, public services, elderly abuse) – growing warning signals Substance abuse: Drug, alcohol, tobacco (growing prevalence in children age group) Growing incapacity to work due to mental illness (real or misused for temporarily unemployed??]
Tobacco consumption growth 1994-1998Czech Republic [prevalence in %] Age 15-16 Age 13-14 Age 11-12 boys girls
7. What research resource exist? • Academic research institutions (e.g.) • Prager Psychiatric Center • Medical Schools • Faculty of Social Science, Charles University Prague • Faculty of Natural Science, Charles University • Faculty of Human Sciences, Charles University • Economic University Prague • Masaryk University Brno • Research Institute of Work and Social Affairs • Czech Academy of Science, Institute of Sociology • Senior researchers/research programs • not yet written • Data available to researchers • Czech Health Statistics Institute (health services utilization) • Czech Statistical Office (demography) • Ministry of Health (public health insurance) • Public Health Insurance Funds (utilization data) • State Institute of Pharmaceuticals Control
8. Research priorities • Health Services Research • Utilization, variances, prescription behavior • Access to services (homeless and other population groups), services networks, patient pathways, patient factors. stigma • Community services, organizational changes • Outcomes (QALY), performance, quality, standards, human resources management • Epidemiology, needs assessment, burden of disease (DALY) • Mental Health Economics • National Health and Social Accounts (production functions of different providers), Financing, performance payment, cost analysis, social consequences • National and International Mental Health Policy Analysis(agenda setting, policy making and implementation) • Drug policy, Tobacco policy, Action plans • Mental Health Promotion • Health and Social services coordination, complex services (e.g.homeless – housing, health services access, work market reintegration, social inclusion)
Our own Czech experienceHomeless and their determinants of health • Employment and HS access variables are highly significant. • We can speculate that the perceived injustice of the society toward homeless as seen from the point of view of homeless person is exemplified in the refusal of the adequate health care and employment. • After a bad experience with the system many homeless people may simply stop trying to interact with institutions and people representing the system.
Example of policy implications • Variables HS access, Employment and Education can be influenced by policies aiming to improve access to health, job opportunities and level of education for homeless people. • Authorities can implement programs in the areas of health care access and job opportunities relatively fast, while improving the education level is a longer-term proposition.
Literature • Review of Health Promotion and Infrastructures in the Czech Republic. WHO Regional Office for Europe 2004 • Czech HIT 2005 (www.observatory.dk) • Czech Mental Health Policy. Open Society Fund 2005 • Concept of psychiatry (2001) • Center for the Mental Health Care Development (www.cmhcd.cz) • Dlouhý, M. (2004). Mental Health Care System and Mental Health Expenditures in the Czech Republic. Journal of Mental Health Policy and Economics, 7(4), 159–165.