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

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

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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

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60

Num

bers

2001 2002 2003 2004 2005

Hospital 29Nizhny-TagilPervouralsk

Trends in beds per 10,000 population

0

2

4

6

8

10

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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