The thesis is currently being prepared for the publication. The results of the thesis has been presented during International Mental Health Third Conference. King’s College London. Institute of Psychiatry. August 2006. When referencing or referring to the thesis please site as: Olga Golichenko, Wouter van de Graaf, Dr. Kingsley Oturu, Dr. Pim de Graaf. 2006. ROYAL TROPICAL INSTITUTE, Development Policy&Practice, the Netherlands. “Transition of Adult Mental Health Services in Ukraine (1991-2006)”. In the process of preparation for the publication. Transition of Adult Mental Health Services in Ukraine (1991-2006) Olga Golichenko Ukraine Master in International Health (MIH) Starting date: September, 2005 KIT (ROYAL TROPICAL INSTITUTE) Development Policy&Practice August 2006 i
Transcript
The thesis is currently being prepared for the publication. The results of the thesis has been presented during International Mental Health Third Conference. King’s College London. Institute of Psychiatry. August 2006.When referencing or referring to the thesis please site as:Olga Golichenko, Wouter van de Graaf, Dr. Kingsley Oturu, Dr. Pim de Graaf. 2006. ROYAL TROPICAL INSTITUTE, Development Policy&Practice, the Netherlands.“Transition of Adult Mental Health Services in Ukraine (1991-2006)”. In the process of preparation for the publication.
Transition of Adult Mental Health Services in Ukraine(1991-2006)
Olga GolichenkoUkraine
Master in International Health (MIH)Starting date: September, 2005
Table of contentsTable of contents.........................................................................................................................iAcknowledgements...................................................................................................................iiiAbstract.....................................................................................................................................ivList of abbreviations...................................................................................................................vIntroduction...............................................................................................................................viCHAPTER 1: Background Information of the Thesis...............................................................1
Country information...............................................................................................................1Health care system and budgeting..........................................................................................1Overview of epidemiology of mental disorders.....................................................................2Problem statement..................................................................................................................3Aim and objectives of the thesis............................................................................................3
CHAPTER 2: Methodology and Analytical Frameworks.........................................................4Methodology..........................................................................................................................4Theoretical frameworks.........................................................................................................5
Theories on mental health services delivery......................................................................5Framework of mental health services analysis...................................................................7Theories on transition.........................................................................................................7
Indicators of transition...........................................................................................................8CHAPTER 3: Overview of Mental Health Services in Ukraine..............................................10
Structure of mental health services delivery........................................................................10Individual level.................................................................................................................10Primary care services.......................................................................................................10Outpatient services...........................................................................................................10Inpatient services..............................................................................................................10Community care services.................................................................................................11
Problems of mental health services......................................................................................12Identification of elements of services to be included in transition......................................12
CHAPTER 4: Transition of Mental Health Services...............................................................20Periods of transition.............................................................................................................20
1991-2000 hospital level..................................................................................................201991-2000 community level............................................................................................222001-2006 hospital level..................................................................................................222001-2006 community level............................................................................................23
Factors of slow transition....................................................................................................24CHAPTER 5 : Discussion, Conclusions, Recommendations..................................................25
References................................................................................................................................29Appendix I. Map of Ukraine............................................................................................34Appendix II. Organizational Chart of Health Care System.............................................35Appendix III. Financial Flow Chart of Health Care System............................................36Appendix IV. Definitions.................................................................................................37Appendix V. Coding of Respondents...............................................................................38Appendix VI. Interview Guide.........................................................................................39Appendix VII. Structure of Email Communication with Experts....................................40Appendix VIII. Scheme of Mental Health Services.......................................................41
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Appendix IX. Matrix Model of Mental Health Services..................................................42Appendix X. Pathways to Mental Health Services..........................................................43Appendix XI. Comparison of the Periods of Transition of Mental Health Services.......44Appendix XII. Number of Mental Health Facilities 1991-2000......................................45Appendix XIII. Process of Transition of Mental Health Services in Ukraine.................46Appendix XIV. Process of Transition in Lithuania: Vasaros Hospital...........................47Appendix XV. Future Developments of Transition.........................................................50
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Acknowledgements
I would like to express special gratitude to Wouter van de Graaf for our intellectually stimulating discussions, mutual inspiration and his valuable inputs and contributions which were guiding and enriching my thesis. I also thank him for making me see the human factors behind the institutional structures of mental health services.
I would like to acknowledge my supervisor, Pim de Graaf, for his constant support and guidance. I am very grateful to him for making my thesis structured.
I am grateful to tropED and Erasmus Mundus for giving me the opportunity to undertake MSc in International Health degree. It was an enriching academic experience to study at Queen Margaret University College, Scotland; Department for International Health of Copenhagen University, Denmark; Royal Tropical Institute, Netherlands.
I am grateful to the people who support me in my academic work. My parents – Tetyana and Mykola Golichenko, my brother Ivan Golichenko. I would like to acknowledge my other relatives as well.
I would like to acknowledge the people whom I have met this year and who make my life pleasant and interesting when being outside from home.
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AbstractThis thesis aims at analyzing transition of mental health services in Ukraine from 1991 till 2006. The thesis is based on the literature review, interviews and e-mail communication with experts. Two periods and two processes of transition are analyzed in the thesis. The use of analytical frameworks make it possible to identify that the reasons for slow transition include: outdated curriculum at the university and lack of good active knowledge about mental health among professionals; lack of implementation of existing policies and legal frameworks; resistance to the process of transition by professionals on hospital level, particularly, in Kyiv; lack of strong and independent organizations of professionals; lack of the multidisciplinary teamwork; lack of the finances for the process of transition; intolerance of the public towards mental disorders; incoherence between two periods and two processes of transition of mental health services. Development of community care centers at health system level and a well-planned integration of mental health services into primary health care are recommendations for the development of the process of transition in Ukraine.
KEYWORDS:Mental health, mental health services, transition, Ukraine, psychiatry.
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List of abbreviations
CMHS – Community mental health servicesDALY – Disability adjusted life yearDSM - The diagnostic and statistical manual of mental disordersEU- European UnionFSU- former Soviet UnionGIP – Global Initiative on Psychiatry (formerly Geneve Initiative for Psychiatry)GP – General practitionerHCS – Health care systemIBPP – Institutional Building Partnership ProgramICD - International classification of diseasesICF - International classification of functioning, disability and healthIO – International organizationMD – Mental disorderMH – Mental healthMHS- Mental health servicesMHSM – Mental health systemMoF- Ministry of FinancesMoH – Ministry of HealthMSPL - Ministry of Social Policy and LaborNGO – Non-government organizationPHC – Primary health carePMD – People with mental disabilityTACIS- Technical assistance for the Commonwealth of Independent StatesUPA – Ukrainian Psychiatric Association
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There is no health without mental health.Helsinki, 1999
IntroductionAll structures of the society, which is in the process of transition from socialist to
post-socialist system, such as Ukraine, are changing, including health care system1 and mental health system2. Such changes include four key processes of MHSM: transition, de-institutionalization, institutionalization and mental health3 reform. They are often confused and thus need to be clarified.
Firstly, the author of the thesis defines transition as the process of change of the delivery of mental health services4 from one model of MHS to the other on the theoretical and practical levels. The word “transition” rather than “deinstitutionalization” is used in this thesis in order to capture the broad processes of changes within MHSM. Secondly, deinstitutionalization consists of three processes: the release of persons residing in psychiatric hospitals to alternative facilities in the community, the diversion of potential new admissions to alternative facilities and the development of special services for the care of a noninstitutionalized mentally ill population (Lamb and Bachrach 2001:1039). It implies not only an organizational/structural change but also and mainly a change of attitude towards mental disorders5, including the decrease of the discrimination. In the thesis I adopt Kreig’s definition of deinstitutionalization – a shift in the care of mentally ill persons and finances from long-term psychiatric hospitalization or social institutions to more independent living environments in a community based system (2001:1). The process of deinstitutionalization is not the final point of MH reform, but is a step towards the delivery of MHS of a better quality. Thirdly, institutionalization is the delivery of MHS in MH hospitals and institutions based on the hospital-like principles of the delivery of the services, for example social care houses. Fourthly, MH reform is the process of transition of MHS which is institutionalized, recognized and prioritized on the policy level.
In the first chapter, I present background information on the country, HCS, overview of epidemiology of MDs, problem statement, aim and objectives of the thesis. Methodology and analytical frameworks of the thesis are presented in the second chapter. In chapter three, analysis of MHS and main stakeholders involved in the field makes it possible to identify the reasons and needs for transition. The analysis of the transition of MHS is undertaken in chapter four. Conclusions on the reasons for the slow transition and recommendations on the development of the process of transition in Ukraine are drawn in the concluding chapter of the thesis.
1 Hereafter abbreviated as HCS.2 Hereafter abbreviated as MHSM.3 Hereafter abbreviated as MH.4 Hereafter abbreviated as MHS.5 Hereafter abbreviated as MDs.
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CHAPTER 1: Background Information of the Thesis
Country information Ukraine is a former Soviet Union low middle-income country with transitional
economy which is undergoing transformation from socialist to post-socialist society. It is situated in Eastern Europe (Appendix I). The country is divided into regions (oblast) and the regions are divided into districts (rayons). The cities of Sevastopol and Kyiv (capital) have oblast status. Historically Ukraine was divided into Western and Eastern Ukraine. This division is reflected in the contemporary Ukraine where Western Ukraine is more oriented towards Europe, whereas Eastern Ukraine is more oriented towards Russia.
Health care system and budgetingThe organizational structure and culture of HCS in Ukraine (Appendix II) has not
been significantly changed from the Soviet model (Lekhan et al. 2004:20). Primary care services, polyclinics, are officially the first entry point of HCS in Ukraine. General practitioners and nurses deliver basic health services and provide referrals to the specialized health care services there. By-passing primary health care services is habitual and results in the greater inefficiency of HCS.
Budgeting and planning systems are centralized. Today, “HCS is a complex multilayered system where responsibilities in the health care are fragmented among central government, 27 regional administrations, numerous administration bodies at municipal, district, township and village levels, as well as other ministries” (Lekhan et al. 2004:28). The procedures for budgetary planning and decision-making by national authorities are regulated by the resolution of the Cabinet of Ministers (Lekhan, Rudiy and Nolte 2004:26). Public health in Ukraine remains based on the traditional and largely obsolete functions of the state Sanitary and Epidemiological Service.. However, new public health functions are now being developed in response to HIV/AIDS (Lekhan 2004:61).
Ministry of Health6 is responsible for effective resource allocation for national activities. However, in practice, its influence is limited to the direct management of few specialized facilities because all regional MH programs are funded by the respective tiers of government from allocations provided by the Ministry of Finances7 or local governments (Appendix III). Therefore, the scope of work of MoH is limited to issuing guidance and norms (Lekhan et al. 2004:17) of resource allocation for activities. However, local governments have little “health care regulatory practice” (Lekhan et al. 2004:26).
MoH initiates the process national budget-setting for health care in the form of the draft budget which is afterwards submitted to MoF. The budget is based on the volume of work performed in the preceding year, the extent of cost recovery, epidemiological data indicative of changing needs in health services, institutional and financial restrictions set by the funding bodies for the next budgetary term as well as priorities in the health sector as determined by Cabinet of Ministers and MoH. The budget is then approved by the parliament that passes the law on the state budget (Lekhan 2004:97). “The budget allocations to hospitals remain largely based on their capacity. Budgets are strictly itemized according to line items. Given the chronic under-financing of HCS, the resources available are hardly sufficient to meet needs and are therefore mainly allocated to cover the expenditures in protected categories” (Lekhan 2004:100). Such a system is not stimulating for efficiency of the performance. MoF is responsible to the Cabinet of Ministers for drafting the state budget, and assigns budgets to the bodies responsible for health care facilities at each level of government, thus effectively determining the configuration of a system (Lekhan 2004:19). 6 Hereafter abbreviated as MoH.7 Hereafter abbreviated as MoF.
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“Within each Oblast, MHS are the responsibility of regional administrations. Additional related services are provided outside healthcare system and involve social service provision system and employment services. MoH develops legal and regulatory frameworks, strategies and policy guidance for the delivery of MHS. The Oblasts develop local strategies within these regulatory frameworks and delivery services to the population. MH resource allocation and provider payments administered at both Oblast and municipal level remain largely unchanged from Soviet times” (McDaid et al. 2006: 4).
The terms used in this thesis are defined in Appendix IV.
Overview of epidemiology of mental disordersThe overview provides general information on the factors which cause MDs in
Ukraine, epidemiology of MDs according DSM-IV8. DSM-IV classification does not provide full information about psychiatric disorders within the population and thus the last part of the section provides general statistics on psychiatric disorders based on the government of Ukraine data. Information on MH in Eastern Europe is usually restricted to data about hospital admissions and discharges, and about population suicide rates (Jenkins et al. 2001:18), thus it is a challenging task to provide epidemiology of MDs.
“After the breakup of the Soviet Union in 1991, life expectancy and standard of living declined and mortality increased, especially from cardiovascular disease, accidents, and other causes related to alcohol. Heavy alcohol consumption is a major public health problem that has deep roots in the social fabric of the culture. Violence against women in former Soviet Union countries is four to five times higher that in the USA. In addition, Ukrainian families carry the psychological burden of enormous intergenerational stress, such as the great famine-genocide of the 1930s and other premature and often violent deaths, disappearances, and incarcerations during the Stalin era, the Nazi occupation, and the period after World War II. Environmental pollution from industrial plants and from the Chornobyl nuclear power plant accident in 1986, a large number of industrial, mining and transport accidents, the high level of poverty and economic insecurity, an inadequate infrastructure and widespread corruption all contribute to what was recently described as the growing “anomie” in the Former Soviet Union” (Bromet et. al 2005:2).
Psychiatric disorder is common in the community (Bromet et al. 2005:8) in Ukraine. Prevalence estimates of alcoholism among men and recent depression among women were higher in Ukraine than in comparable European surveys. Close to one third of the population experienced at least one Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) disorder in their lifetime, 17,6% experienced an episode in the past year, and 10,6% of the population currently have a disorder. In men, the most common diagnoses were alcohol disorders (26,5% lifetime) and mood disorders (9,7 % lifetime); in women, they were mood disorders (20,8% lifetime) and anxiety disorders (7,9% lifetime).
According to the state statistics, at the beginning of 2005, more than 1200 thousands citizens of Ukraine required assistance of psychiatrist and more than 900 thousand required assistance of narcologist. The burden of MDs in Ukraine is high. During the last 12 years, from 1993, the prevalence of the officially registered cases of psychiatric disorders has increased in 1, 2 times from 222,3 to 248,2 for 100000 of the population. In the structure of the psychiatric pathology the 1,2 – 1,5 times increase in non-psychotic disorders, psychiatric disorder of the natural origin, schizophrenia and mental retardation is identified. Out of the total population of the registered cases of PMD, 69% are patients of the labor active age. The
8 The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the standard classification of mental disorders used by mental health professionals in the United States. It is different from International Classification of Diseases (ICD-10) widely used by the WHO. It also differs from International Classification of Functioning, Disability and Health (ICF), which complements ICD-10 classification by looking beyond mortality and disease. DSM-IV is the international classification according to which national-wide epidemiological study was carried out in Ukraine.
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overall DALY9 burden for Eastern Europe due to neuropsychiatric disorders is estimated as one of the highest in the world, at 17,2 per cent (Jenkins et al. 2001:16). The rate of suicide is 25-26 cases for 100 000 population. There is the annual increase in the number of people who receive disability status due to MDs (The Government of Ukraine 2006:1). Moreover, it is important to take into consideration a “hidden burden” of MH which is the result of humiliation, isolation, and social consequences such as unemployment, stigmatization and human rights violations (Weiss, Cohen and Eisenberg 2001:335), which are common phenomena of societies in transition.
Problem statementMHSM has undergone minor changes since Soviet time. However, there are new
needs, such as development of depression and alcoholism, in the population during the period of transition from socialist to post-socialist period. The core problem of MHSM is the lack of the progress in the change of MHS based on hospital model, with an emphasis on the biological approach, to MHS which take into consideration the psychological and social aspects of MH.
Due to the absence of modern approaches to MH care delivery, such as multi-disciplinary teamwork, case-management, rehabilitation programs, hospitalization leads to separation from society and thus to less chance of re-socialization. PMD receive only bio-medical assistance in the institutions and loose social and adaptive skills during the period of treatment. Thus there is a need to undertake the process of transition from hospital models of services. The process of transition has been started, however, it is very slow, compared to other countries, such as Lithuania. There is slow development of community services at HCS level, pilot projects on transition have been undertaken on the level of pilot projects and have not been multiplied at health system level.
Aim and objectives of the thesisThis thesis aims at analyzing transition of MHS in Ukraine. The main objective is to
analyze why the process of transition of MHS in Ukraine is happening slowly from 1991 to 2006. Specific objectives are the following:
1. to examine the need for transition of MHS using service delivery, service analysis matrix (Tansella and Thornicroft 1998) and theories on transition;
2. to analyze periods and processes of transition of MHS in Ukraine from 1991 till 2006;
3. to formulate conclusions on the reasons for slow transition; 4. to draw recommendations on the development of the process of transition of MHS in
Ukraine.This thesis is addresses to international and national stakeholders involved in the
process of transition of MHS in Ukraine and former Soviet Union10 countries.
9 Disability Adjusted Life Years.10 Hereafter abbreviated as FSU.
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CHAPTER 2: Methodology and Analytical Frameworks
Methodology The methods of the thesis consists of a literature review which focuses on studies, mainly in the domain of MHS in the region of Eastern and Central Europe. The searches for literature were performed in English, Russian and Ukrainian. Expert interviews and e-mail communication with experts were conducted after the author has experienced a lack of information on the topic in the existing literature.
A number of studies on MHS exist on the Kyrgyz Republic (Vasylchenko and Vasylchenko 2005), Moldova (InterMinds 2004), Armenia (Kampman 1998), Bulgaria (Grace-Biala 1998). However, these studies, except for few (McDaid et al. 2006), are aimed on general description, rather than analysis of the changes within the services. The focus on adult mental health is chosen because in itself it is a vast subject for research. This thesis concentrates on transition of adult MHS for people with mental disability (PMD)11. The thesis investigates services, predominantly in urban areas of Ukraine because the processes of transition of MHS are concentrated in urban areas.
Initially, a literature search of the Medline databases and GoogleScholar was conducted, using the keywords “MHS”, “structure/organization of MH services/community services”, “community psychiatry in Eastern Europe”, “utilization of MHS”, “MHS utilization indicators”, “MH system reform”, “psychiatrists and Eastern Europe”, “international MHS”, “MH in Ukraine”, “quality of MHS”, “psychiatry in Ukraine”, “MHSM reform”, “MHS and transition”, “deinstitutionalization and MHS”, “psychiatry and transition”, “transition and community care”, “MH reform”, “indicators of transition”. The references of the articles were reviewed and the interesting articles in them were analyzed as well. Further searches were made on the related articles of the important authors (Thornicroft, Tansella, Goldberg 1997) and authors (Evelyn Bromet, Thornicroft, Tansella) in Medline.
After this, the electronic library of the Free University was searched for the following journal titles: Social Psychiatry and Psychiatric Epidemiology, International Journal of Law and Psychiatry, International Journal of Mental Health, Social and Preventive Medicine, Harvard Review of Psychiatry. Picarta search engine was searched for the following key words: “Ukraine and MH”, “deinstitutionalization and community care”, “community care literature review”, “psychiatry in Ukraine”. The database of the Cochrane has been searched for the following keywords: “psychiatric beds”, “MHS”.
It is important to note that there were more results on the terms “psychiatry” in Russian and Ukrainian and “MH” in English literature search. Existing literature on MHS in Ukrainian and Russian concentrate on the study of psychiatric medical services and the questions of human rights abuse (Korotenko and Alykyna 202, Korotenko 2003).
Lastly, selected web pages (Interminds, Mental Health Europe, Open Society Institute Mental Health Initiative, European Observatory for Health Systems, WHO Mental Health Program, World Psychiatric Association, Kings College London, American International Health Alliance) were browsed for additional information.
E-mail communication was conducted with experts who have extensive experience of work in the field of MH in Ukraine. Interviews are conducted in the Netherlands. The interviews were recorded or written down and afterwards they were transcribed. Respondents are employees of international organization12, and hospitals or are independent experts in the field of MHS. They have extensive experience of work in Ukraine in the field of MHS as different periods of time. Profiles and coding of the respondents is described in Appendix V of the thesis. The questions of the interviews are presented in Appendix VI , structure of the e-mail communication is presented in Appendix VII.11 Mental disability is distinguished from learning disability (See Appendix IV).12 Hereafter abbreviated as IO.
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After the information from the literature, interviews and e-mail communication was collected, the process of triangulation was undertaken in order to eliminate the subjectivity of singular sources of information. This process was performed by identifying key controversial information of the research and comparing it from different sources.
The information for answering the objectives of the thesis was found in international literature and among international experts. As the result of this, the population of the respondents and literature has a certain bias towards respondents from IOs.
Theoretical frameworksAnalytical frameworks used in the thesis can be divided into three groups - theories on
MHS delivery, framework of MHS analysis and theories on the process of transition from one model of health service delivery to the other. The last part of the theoretical frameworks section consist of the indicators of transition developed by the author. Theories on MHS make it possible to understand what problems of MHS are and why the process of transition should be undertaken. Framework of MHS analysis is applied in order to understand which elements of MHS should undergo the process of transition. Theories on transition of services make it possible to identify why the process of transition is slow in Ukraine. This section is divided into three parts according to three groups of analytical frameworks.
Theories on mental health services deliveryTheories on MHS delivery consist of two frameworks. The first framework classifies
service delivery according to hospital, community and balanced care models (Thornicroft and Tansella 2002). Second framework classifies services according to five levels: individual level, primary care, inpatient, outpatient and community level. The second framework was developed by the author of the thesis based on WHO-AIMS research framework (2005). Both frameworks of service delivery are complementary to each other: whereas the first framework provides the general classification of service delivery, the second frameworks gives a more detailed picture of the service delivery and makes it possible to understand pathways to services and pattern of the use of services.
Hospital care modelIn the first framework, approach to hospital care model is critical. Despite the
importance of the hospital, there is remarkably little published research on the reconfiguration of hospital system, and most of what exists is from Canada or the United States (McKee 2004:6). A particular problem is the almost complete lack of evidence on the decrease of the capacities of hospitals from the previously Communist countries of central and eastern Europe and the countries of the former Soviet Union (McKee 2004:11). Hospitalizations, particularly involuntary, contribute to lowered self-esteem in PMD (Townsend and Rakfedlt in Peterson, Michael and Armstrong 2005:508). When hospitalized outside of the their home community, PMD have limited access to their typical social support. Yet, social support may be an important buffer in the experience of the disorder (Peterson et al. 2005).
Community Care Model “Community mental health services13 are those which provide a full range of effective
MH care to a defined population, and which is dedicated to treating and helping PMD, in proportion to their suffering or distress, in collaboration with other local agencies” (Thornicroft and Tansella 1999:12). CMHS include community-based rehabilitation services, hospital diversion programmes, mobile crisis teams, therapeutic and residential supervised services, home help and support services and community-based services for special
13Hereafter abbreviated as CMHS.
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populations (WHO 2003). Community-based services focus efforts on preventing severe episodes of disorders and the necessity for long-term hospital treatment (Mizuno 2005:95). Shahar and Davidson (2003) in Peterson et al. (2005:508) demonstrate that improved social functioning mitigates the effects of depression in the population. Adjustment to severe MD can be facilitated by the development of skills to improve social functioning (Birchwood et al. 1990 in Peterson et al. 2005:508-509). Corrigan (2002) in Peterson et al. (2005:509) suggested treatment partnerships that are embedded in the community are likely to foster empowerment in the presences of the disorder. Anthony (2003) in Peterson et al. (2005:509) conceptualized the recovery process in the treatment of people with serious MDs by emphasizing multi-modal intervention including social and work related skills as well as medication management. Davidson et al. (2001) in Peterson et al. (2005:509) suggested that PMD be encouraged to fully engage in society. They suggest that symptom presence should not preclude the engagement process and that it is important they be “let in” to experience social interaction and support at the same level as PMD. Community-based services provide the quality and continuity of care for the patients (Mizuno et al. 2005:95). Good community MH care model (Liegeois and Audenhove 2005:452) is not based purely on the community services, but is based on the combination of community and hospital services. Thus, whereas in theory there is a community-based model, in reality community –based model is a balanced care model.
Balanced Care ModelBalanced care approach aims to provide services which offer treatment and care with
the following characteristics: services which are close to home; interventions related to disabilities as well as symptoms; treatment and care according to the individual needs of the person; services which reflect the priorities of the service PMD themselves; services which are coordinated between MH professions and agencies; mobile rather than static services (Thornicroft and Tansella 2002). The aim of the process of transition in developed countries is the creation of balanced care service model based on the hospital and community care.
The evidence on the cost-effectiveness of community versus institutional care suggests that community based services do not reduce health-systems costs, but that the perceived quality of care and satisfaction with services by PMD is improved. A report prepared for the WHO Regional Office for Europe’s Health Evidence Network concluded that there are no persuasive arguments or data to support a hospital-only approach, nor is there any scientific evidence that community services alone can provide satisfactory comprehensive care (Thornicroft and Tansella 2003). Instead, it is argued that a “balanced” care approach is required where front-line services are based in the community, but that hospitals and other institutions can play an important role in providing services. Where required, hospital stays should be as brief as possible, with the services being provided community settings rather than in remote and isolated locations.
WHO-AIMS ModelWithin the second framework of MH delivery (WHO-AIMS 2005, Author of the
thesis) services on individual level include informal support and care services of PMD by family, friends and neighbors as well as consultations of traditional healers. Primary care MHS include MH outpatient facilities, day treatment facilities and community based psychiatric inpatient units on the outpatient level of services. Inpatient level services include MH hospitals as well as forensic and residential facilities. Services on the community level involve three models of service delivery: day care rehabilitation center, self-help group, community care center.
Framework of mental health services analysisThronicroft and Tansella (1998) matrix model of MHS framework (Appendix IX) is
applied in the analysis of MHS in Ukraine because it covers institutional as well as
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community aspects of the services on the level of the systems, professionals and PMD. This framework, rather than other frameworks, for example Walt and Gilson framework (1995), is used in the analysis because the current framework provides the focus on critical issues of MHS, such as epidemiology, needs assessment in the geographical and temporal dimensions. This framework is particularly important for understanding MHS in the process of transition from one model of MHS to the other.
Theories on transitionTheories on transition of services consist of analytical frameworks on the processes
of transition, particularly on the ways of the development of transition and its obstacles, and sources-impulses of the process of transition coming from society, state, institutions and IOs. Whereas the first two theories make it possible to analyze MHS as static processes, theories on transition of services make it possible to analyze the development of MHS as dynamic processes.
Analytical frameworks on the process of transition include analysis of the process of deinstitutionalization and MH care reform. A number of authors develop different schemes for the transition of care. McKee (2004:11) proposes the following way to reduce the hospital capacity and improve the quality of care. Firstly, intensive use of existing beds, many of which are empty for long periods should be introduced. Secondly, care protocols that reduce inappropriately long lengths of stay should be implemented. Thirdly, withdrawal of numerous ineffective treatment that have persisted from the Soviet period should be undertaken. Fourthly, a shift to ambulatory care for many common disorders should be made.
Jenkins et al. (2001:18) outline the framework for the shifts in approach to the care of PMD. They propose national component of a strategy, support infrastructure of a strategy, service components of a strategy in order to shift to the new model of MHS. The authors identify the following obstacles of transition: “lack of priorities to MH; lack of funding for community care; supply of medicine is variable; lack of clinical protocols for patient management; psychiatric training is brief and outdated compared to developed countries; MHS are not coordinated with the health and social sectors, or with the non-statutory services and NGOs; new community –based services run as demonstration projects are not sustainable if the donor pulls out , nor are there resource to roll out these services to the rest of the country; there is little system for monitoring MH needs, service use and outcomes; without community and user involvement, services may not gain community support or meet PMD needs” (Jenkins et al. 2001:18).
Theories on the sources-impulses of the process of transition make it possible to understand how the process of transition happens. The authors of these theories argue that the sources of the process of transition come from the structures of the government and institutions themselves. Scholars of society-centered theories argue that particular groups’ interests within the state define the process of service development and implementation. Pluralist theory suggests that the services are developed by particular powerful and influential interest groups whose needs and vision are based on selfish aspiration for ideological economic benefits (Polsby 1960, Dahl 1961). More particularly, the power elite’s interests are reflected in the policy agendas (Mills 1956, Domhoff 1990). This approach suggests that the groups of the society which have the most significant power and biggest amount of resources dictate and formulate state policies on services according to their own interest.
The state-centered approach suggests that the structure and agency of the state influences the development and implementation of policies on services. Moreover, the state is independent from the society and thus has its own interests and agendas (Skocpol 1985). State-centered approach suggests that the state is independent from the society and thus state policies are formulated according to particular interests of state officials rather than the needs of the population.
Neo-institutionalist scholars suggest that “folkways”, “patterns of behavior”, and “cognitive maps” of social institutions are crucial in determining patterns of the development
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of services (DiMaggio and Powell, 1991; Nee 1998). It is a particular nature of state institutions which defines the nature of policies on MHS. Kaufman (1998) argues that the development of policies follows the evolution of the “conception of individual” as perceived in society in general and within the state in particular. Thus, the quality of MHS cannot be improved unless the status of PMD is change in the society. Neo-institutionalist theory suggests that the process of policy formation is “highly dependent on the agenda-setting powers inherent in legislative rules” (DiMaggio and Powell, 1991:Introduction) and thus the process of policy formulation is dependent on the internal nature of the institutions in which the policies are developed.
The next group of authors regard IOs as the major sources of changes of the services. International relations theories, represented predominantly by international relations scholars, focus on the role of external politics, such as IOs’ involvement, in the formation of national policies on MHS. This group of authors regards IOs as the tool for the implementation of the models of services developed by powerful agents.
Neo-Realist theory suggests that international system, and the particular power position of the state in it, define the state’s opportunities and constraints (Krasner, 1983; Keohane, 1984; Haggard and Simmons, 1987). Using neo-Realist theory, Kichbush (2000) argues that institutional and ideological transformations within the WB and the WHO are the major determinants for the change of the concept of health policy at health system level, particularly in developing countries.
Constructivist scholars advocate that state values and attitudes are formed in the process of cooperation between international and domestic forces (Ruggie 1998; Wendt, 1999). Wendt (1999:372) suggests that states might be constituted by the international system and thus “the nature of states might be bound up conceptually with the structure of the international states system”. Using Dill (1994) and Altman (1994) theories, it is possible to argue that institutional and structural responses to MD are dependent and change according to the involvement of IOs in the process of transition of MHS.
Neo-liberal theory suggests that national social policy is increasingly determined by global economic competition and by the agenda of IOs (Deacon et al. 1997). As a result, the substance of social policy becomes increasingly transnational. Deacon et al. (1997:195) argue that the making of post-communist social policy has been very much the business of supranational and global actors. They suggest that in post-communist conditions of national stability and uncontested borders, the key international players are IOs, like the WHO, WB, IMF, ILO and European Union14. In post-communist conditions of complex political instability and contested borders the field is left much more open to international NGOs15
compared to developed countries, as argued by the authors (1997:195). These conclusions are very important because they shed light on the role of external forces in the development of MHS. The role of external forces in policy formation differs according to the local contexts where the tasks of IOs, formulated by external to IOs agents, are implemented.
Indicators of transitionIt is important to understand that the process of transition is a subjective development
unless objective indicators are proposed. For example, accepting the idea of human rights and dignity of PMD for professionals from the old system is already a significant transition, whereas for the other stakeholders, transition does not happen unless there are changes on the structural level. However, subjective indicators play an important role in the process of transition. Following the analysis of the above-mentioned theoretical frameworks and communication with experts the following indicators of transition are identified:
Decrease of the number of the hospital beds and the lack of fear from the director of psychiatric hospital from this.
14 Hereafter abbreviated as EU.15 Hereafter abbreviated as NGO.
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Number of services provided in the community by grassroots NGOs and their geographical location
Number and regional concentration of self-help groups Financing of the services, particularly of those delivered in the community, by the
social insurance or by separate budget line of the state budget Improvement of the status of psychiatric nurses Decrease in involvement and power of psychiatrist in the work of the team Number of multidisciplinary teams of professionals and their place of work Level of integration of the transition projects to the general structure of MHS Level of change in values and attitudes of professionals
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CHAPTER 3: Overview of Mental Health Services in Ukraine
Structure of mental health services delivery According to WHO-AIMS framework (2005) and analysis of the author of the thesis,
there are five levels of MHS in Ukraine: individual level, primary care, inpatient, outpatient and community level (Appendix VIII). However, only inpatient and outpatient services, based on the catchment areas, are recognized as a part of MHSM. Inpatient and outpatient services include: MH outpatient facilities, day treatment facilities, community based psychiatric inpatient units, mental hospitals, forensic and residential facilities. However, it is important to analyze elements of services in detail in order to understand the basis for the development of the process of transition.
Individual levelServices on individual level constitute a significant amount of support and care
services out of all the amount of services, however, they are hardly acknowledged in MHSM. The role of informal services is not recognized in the hospital, however, the importance of it is acknowledged in community services pilot projects based in the community and hospital. Informal carers are not appropriately involved in the process of formation of the policy of transition. So-called “relatives’ councils” exist in community centers, but relatives have little enthusiasm to participate in the activities of the council because of the lack of time resources. Moreover, many relatives of PMD come from disadvantaged backgrounds and, having lots of social, psychological and health problems themselves, can contribute little to the development of the model of transition which corresponds to their needs.
Primary care servicesPrimary care services, polyclinics, can do the referrals to the dispensaries. Little
preventive, supportive or curative MHS are provided on this level because of the lack of qualification among general practitioners and nurses in the field of MH. Primary health care services do not deliver any care to mentally ill. This level of services is regarded as the key level for the development of MH reform which is described in the Draft of the National program on MH and aims at integrating MHS into primary care level facilities.
Outpatient servicesOn the outpatient level of services, there are community based psychiatric inpatient
units are units with beds based outside psychiatric hospitals – dispensaries, as I3 explains. According to I6, dispensaries are mini hospitals and is the first point of entrance of PMD to MHSM. This structure is the part of the “revolving door” system in which individual can receive consultation and medication, however, still end up in MH hospital with a high frequency because of the lack of the social support in the community. Outpatients’ services are few. Expansion of outpatient services and day care is just starting in Ukraine (HiT summary: Ukraine, 2005:7). Outpatient mental institutions primarily provide sustaining biological treatment of PMD and monitor their mental condition (Yudin 2005).
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Inpatient servicesInpatient level services are mainly hospital based (almost 90% of estimated budget is
allocated to psychiatric hospitals). Similarly called, social protection homes, or internats, residential facilities or social care centers are the places where many former occupants of asylums end their days, having lost all contact with their families (Jenkins et al. 2001:15).
Community care servicesThere are three models of CMHS which exist in the form of pilot projects in the urban
areas of Ukraine. Community based services do not exist on health system level. As the result of this, the state provides little support for the development of the civil movement or maintenance of existing MHS. CMHS developed on MHSM have potential to improve the quality of the services. Firstly, they strengthen the rehabilitation services of the hospitals which are currently very weak. Secondly, they create the link between existing elements of MHS and social care services.
Rehabilitation center model is the example of the first type of CMHS. Center for Psycho-social rehabilitation of Pavlov Hospital, Kyiv is a typical model of the organization which proposes this type of services. The project was the first attempt in the former Soviet Union countries to initiate the process of transition from hospital to CMHS in early 1990s. It was undertaken in Kyiv and was based on the territory of Pavlov psychiatric hospital. The activities of the Center involve training for professionals, involvement of PMD and families in the therapeutic process, art therapy. The Center is open during the working days of the week during the day time. The particular thing is that, despite being the community level structure, it is situated in the hospital. This does not empower PMD to establish active social life and to integrate into society. Having excellent rehabilitation programs, such day care centers have little socialization and integration effect for PMD. Thus the services which this center provides have a strong therapeutic and supporting effect, however, they are very weak in socializing and integrating PMD in the community.
Self-help group16 is the second model of CMHS. According to author’s work experience in IBPP project (2003-2005), there are around 15 self-help groups in Ukraine based in the hospital and community. The particular thing is that this type of services exist on the regional levels. The services provided by self-help groups are rather limited because of the lack of funding, capacities and official registration of the groups. These groups provide informal mutual support services. They are the initiatives which can potentially lead to the development of CMHS.
Thirdly, there are community care centers. Community MH centers are specialized ambulatory17 services based in the community, staffed by psychiatrists, nurses and social workers. They aim at stopping people from going into hospitals, rehabilitating individuals after their stay in the hospital and integrating individuals to the society. Community Center “Friends Union”, Kyiv is a typical example of the organization which proposes this type of services. It was the first self-help group in Ukraine (Tymoshenko, Vasylchenko and Shneydina 2001:18) which later became community MH center based in the community. It was funded by Hamlet Trust from 2000 till 2005. It is drop-in centre for PMD. It has been operating for 6 years and offers rehabilitation, counseling, and support with training and employment issues. The services currently benefit over 150 PMD and PMD who have been staying in MH hospital and more than 70 family members or carers. It also involves the generous time and expertise of over 20 volunteers and health care professionals (including social workers, psychologists, psychiatrists and students). The activities of the center include: self-help meetings and workshops for PDM and their relatives and friends; training courses in communication skills aimed at building self-assurance; classes in practicalities like basic 16 Self-help group is an informal or formal organization of PMD or their relatives based in the hospital or community which aims at mutual support and development.17 Ambulatory services are health services provided to outpatients, or patients who are not admitted to hospital. Ambulatory Services are also provided to patients who receive services as part of community care program.
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nutrition and cooking, money management and logic; art, poetry and foreign languages classes; individual and group support and advice from professionals like lawyers, psychiatrists and psychologists; concerts, exhibitions and presentations; employment skills training like furniture repair and restoration, catering, horticulture and manual labor; development of social enterprise activities in which PMD are employed; co-operation between young PMD and young volunteers (Social Development Support Agency 2006). However, none of the pilot projects have managed to be replicated on a larger scale.
Although such centers have substantial rehabilitation and reintegration programs (Hatcher and Rasch 1980), they cannot be regarded as “community psychiatric services” (HiT summary: Ukraine, 2005:7) because of the lack of permanent sufficient funding and more significantly because of the social rather than psychiatric-oriented goals of such organizations. Moreover, most of community and rehabilitation centers are available for PMD only for periods of remission. A gap of co-operation, communication and experience sharing exists between hospital and community-based organizations. As a result of this, a number of PMD are able neither to stay in the hospital centers nor capable to adapt to the conditions of community centers and thus are left outside of both structures or have to shift from one structure to another in need of further social support.
Problems of mental health servicesAccording to I2, there is the split of the division of labor and lack of cooperation
between MoH and MLSP. There is lack of any other professionals in the field except of psychiatrists and a limited number of nurses. There is corruption around social care houses-based in mono employment villages and closed institutions. There is a lack of interest of government and population in the improvement of the services.
Psychiatric hospitals in many countries, particularly resource-poor setting, such as Ukraine, are usually in a bad state and thus are able to provide low quality of treatment and care (Lekhan, Rudiy, Nolte 2004:81). MHS in Ukraine are heavily institutional, with community care equated with outpatient or dispensary care, so that community – based care is practically non-existent at health system level, however a civil movement for the protection of PMD is developing. There are few community services in the form of pilot projects and no community services on MHSM level (Mental Health Atlas 2005:3), social work or occupational therapy, little concept of multidisciplinary team work, and no systematic framework for multiaxial assessment of each patient’s needs. There is no consecutive chain of services. There is little experience in intersectoral working, user groups are still rare, and services have a highly vertical structure. The presumption is that all MDs should be treated by a psychiatrist (Jenkins et al. 2001:17). There are some polyclinics and dispensaries which take care of ambulant psychiatric patients, but no other psychiatric institutions exist. Such a system can be called a “revolving door” system in which PMD have a high level of admissions to the hospital because of the late diagnosis and lack of support in the community. The approach is purely and exclusively medical. According to I3, in general, the emphasis of services is placed on treating the clinical aspects of psychiatric problems with no attention paid to the broader environmental and social consequences. The mentioned problems clearly demonstrate the need for transition. However, it is important to look more closely at MHSM in order to identify which elements of the services should be included in the transition.
Identification of elements of services to be included in transition
Country/regional levelA: Input phase:Expenditure on services
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MHS in Ukraine are financed through two sources: taxes and out-of-pocket payments. The market for private health insurance for MHS in the former Soviet Union is still small but is growing (Dixon, Mcdaid, Knapp and Curran 2006:175). Many of the countries of the former Soviet Union have introduced social health insurance, though its contribution to overall health expenditure remains limited (Dixon et al. 2006:176). High reliance on out-of-pocket payment, even in tax-dominated systems, will negatively influence equity of access to MHS (Dixon et al. 2006:177-178). In the former Soviet Union, entitlement to health services was a universal right, often embodied in the constitution. Thus, despite many of these countries shifting from state-funded health services to social health insurance during the 1990s, most were required to maintain provision of services for everyone regardless of contribution status. Due to the collapse in the formal labor market and the growth in the informal economy, these new systems generated very little revenue. Overstretched resources resulted in a reduced benefit coverage including MHS (Dixon et al. 2006:177). According to I2, there is a lack of investment to MHS at every level.
Role of the mediaThe media has a very vague understanding of mental disabilities and thus present the
materials on this topic in a rather unprofessional way. According to I2, there is poor presentation of MDs in the media.
Mental health lawSocial and legal protection of PMD is still on the basic level. The law “On Mental
Care” provides social and legal guarantees for PMD, was adopted in February 2000 and is hardly being implemented in Ukraine at the moment. The law has set out the legal and institutional basis for providing care based on the principles of human and civil rights. It determines the responsibilities of executive authorities and local governments as well as the legal and social rights of PMD, and regulates the rights and responsibilities of physicians and other workers involved in MH provision (Lekhan, Rudiy and Nolte 2004:81). There is concentration on psychiatry rather than MH on the legislative level. The law of Ukraine on Psychiatric aid was issued in 2000. The provision of outpatient psychiatric aid is mentioned in the law, however, it hardly resembles community health services. It states that “a person may voluntarily receive outpatient psychiatric aid in the form of psychiatric examination and treatment – consultation aid; such aid maybe also be provided coercively – in the form of coercive psychiatric examination and compulsory doctor’s supervision”. The concept of “care in the community” is not mentioned in the law. The legislation which was improved and adapted to international standards in 2002 is not implemented in practice.
Government directivesAccording to I3, there is no a policy or plan of MH in place. There is no MH
authority within MoH. The delivery, planning and financing of services depend mainly on regional level authorities as Ukraine is a federal State. National Policy on Mental Health has been drafted and now a public debate on it is about to get started.
According to I2, some new policy and legislation is on the way of being introduced. There is a commitment from the government to WHO to introduce policy and national plan for MH. The Concept of the State Targeted Complex Program for Development of Mental Health Program (the Government of Ukraine 2006) has been initiated and is undergoing public debate. Integration of MHS in primary care is presented in the Concept. Development of CMHS is not mentioned in the Concept.
I3 states that in the last year MH has been made a priority in the frames of the biennial collaboration between MoH and WHO. MoH has appointed a national working group and mandated it to develop policy. WHO is providing technical support to facilitate this process. In 2002 a new law was approved which is in line with international standards. These facts however have not had an impact on the way services are delivered.
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Special interest groups A stakeholder analysis is carried out in this section of the chapter. The section is
structured according to the following framework: stakeholder identification, stakeholder assessment, stakeholder diagnosis (Brugha and Varvasovszky 2000:242-243). Stakeholders or partners of MHS include: consumer groups, family groups, advocacy organizations and NGOs, professional societies, academic institutions and research institutes, policy makers, and IOs.
Consumer groupsPMD constitute this group of stakeholders. The participation of this group in the
transition of MHS is limited and is possible only through advocacy organizations and NGOs.
Family groupsInformal carers, such as relatives, friends and people from the close surrounding of
PMD represent this group of stakeholders. The participation of this group in transition is similar to the participation of consumer groups.
Advocacy organizations and NGOsIt is possible to identify two types of advocacy organizations and NGOs in the field of
MH in Ukraine: mainstream and grassroots organization. Mainstream NGOs are created by professional groups, particularly psychiatrists, in partnership of IOs on the ground of hospital. They are co-ordinated by professionals from the old system or those who are heavily influenced by the legacies of the past system and thus their approach to work is still medically oriented. Grassroots NGOs are created predominantly by professionals groups, other than psychiatrists, on the ground of the community and are supported by IOs. These types of NGOs are co-ordinated by professionals educated in the universities of Western Europe or USA or those who are open minded to the Western ideas. PMD and family groups have a more active participation in grassroots than in mainstream NGOs. These organization are implementing the development of services which take into consideration social and psychological dimensions of MH.
The following mainstream NGOs were created at the Ukrainian Psychiatric Association18 Board initiative (UPA 2006): the «Sphere» charitable publishing house, Social and Medical Rehabilitation Center, «Kastalia» charitable organization, Research Center for Social Policy, Ukrainian Mental Health Institute, «Public Health Initiatives», «Vita» mental patients relatives' association, The All-Ukrainian Public Organization of Disabled Persons with Mental Disorders, «Djerela» charitable society for help to disabled persons with intellectual impairment, Ukrainian psychiatric nurses association, International Medical Rehabilitation Center for the Victims of Wars and Totalitarian Regimes (MRC), «Ray of Light» public organization of aged psychiatrists, PMD NGO “Reflected Worlds”.
The majority of grassroots NGOs involved in MH are situated in Kyiv, according to I2. However, their number is decreasing in the past years due to the decrease of donors funding as Africa, Central Asia and Caucus are becoming the regions with greater needs than Ukraine. These organizations involve, firstly, NGO “Social Development Support Agency”, which runs the project Community Center for PMD “Friends Union”. Secondly, NGO “Support” which works in Chernigiv. Thirdly, “Vita” charitable foundation, Kyiv which aims at providing help, support and various services for PMD who are using or have been using MHS, methodological and informational support, and aid in the protection of social and economic rights of PMD (Hamlet Trust 2006). Fourthly, a number of self-help groups developed by Institutional Building Partnership Program (IBPP) in the project between NGO Social Development Support Agency and Hamlet Trust 2002-2004. They are organized on the basis of MH hospitals, advocacy NGOs and private psychiatric doctors.
.18 Hereafter abbreviated as UPA.
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Professional societiesNurses association was created by the initiative of UPA. Thus, it is not an independent
NGO. It is not implementing the project for the improvement of the status, working conditions and skills of psychiatric nurses. However, it is crucially important to have this organization for the development of the status of nurses in the country, current association have very little independence.
One of the main national stakeholders is UPA aimed to improve professional and allied knowledge of psychiatrists through special lectures and seminars as well as has been involved in the translations of foreign text-books and psychiatric instruments. From the very beginning the Ukrainian reformers took a balanced position and avoided confrontation with official individuals in national psychiatry. This has resulted in the fact that the authorities are involved in undertaking the reforms (Polubinskaya 2000:107). However, the lack of direct confrontation made the process very slow and not dynamic.
Directors of some psychiatric hospitals and chief psychiatrists from few regions are particularly influential individuals in this group.
Academic institutions and research institutesNational University of “Kyiv-Mohyla Academy” trains social workers. National
Medical institute teaches students according to outdated curriculum. There is no school of thought in MH which is able to stimulate changes in MHS. The stakeholders from this group do not have strong power positions in the field, however co-operation of other stakeholders with this group enables them to gain a lot of authority.
Policy makersMoH and the Ministry of Social Policy and Labor (MSPL) are the main policy makers
of MH. The discussions over the issue of budgets is the bone of contention in this group of stakeholders.
International organizationsOrganizations lacked experience in the field in early 90’s when they started to get
involved in the development of MHS in Ukraine. Global Initiative for Psychiatry19 which promotes more ethical and evidence-based practice, was the first international stakeholder which got involved in the field. GIP has launched the first project in 1990. It has supported the establishment of the Association of Reformers in Psychiatry in Eastern Europe in 1993 which has currently stopped its activities because of the lack of funding.. This organization has stimulated the creation and work of mainstream NGOs. The approach of the organization is to stimulate the transition of services on the level of hospital by the development of a chain of services which reaches out to the community and eventually becomes integrated into the community.
Hamlet Trust, from the UK, is the IO which supports organizations providing alternative services for PMD in Central and Eastern Europe and Central Asia. The activities of Hamlet Trust focus on self help and advocacy groups, and there are more than 50 community-based, consumer-led NGOs within its network. Hamlet's “pathways to policy” program enables local NGOs to work with other local MH stakeholders in order to have a greater influence on local MH policies, practices and procedures. This organization became involved in the field of CMHS on the NGO grassroots level in 2000.
The World Health Organization regional office for Europe coordinates MH activities and conducts research on the national scale, supports reform program and offers training programs. It is mostly involved on the level of policy making.
B: Process phase:Performance/activity indicators
19 Hereafter abbreviated as GIP.
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The hospitalization frequency of PMD in Ukraine is 480,9 persons per 100,000 in 2000, 13,7% of which are patients with schizophrenia (Korol et al. 2004:7).
C: Outcome phase:Suicide rates
Suicide is believed to have increased compared to previous years, and the average suicide rate, 24-32 per 100, 000 (depending on the source), ranks the top ten worldwide (Bromet 2005:2).
Standardized morbidity ratesGeneral characteristics of MDs is described in the introduction chapter of the thesis.
HomelessnessThe prevalence of MDs among homeless people is not known in Ukraine (Ryabchuk
2005: 59). However, there are several reasons which make it possible to argue that it is high. For example, a lot of PMD loose their apartments in Ukraine as a result of organized crime (Ryabchuk 2005: 5, Korotenko 2003).
Local level (catchment area)A: Input phase:Population needs assessment
Studies on population needs assessment are lacking in the region (Jenkins et al. 2001:17). According to I6, it is crucially important to undertake needs assessment studies among the population.
Population characteristicsThere is no gender difference in the overall prevalence rates of MDs. Age of onset
was primarily in the teens and early 20s. Age, education, and living in the Eastern region of Ukraine were significant risk factors across disorders, with respondents older than 50 years having the highest prevalence of mood disorder and the lowest prevalence of alcoholism and intermittent explosive disorder (Bromet 2005:1).
BudgetThere is no separate budget for MHS. This aspect of the budget is incorporated into
the general health care budget. MHS are funded from two budgets: MoH budget covers the majority of the medically oriented services and MSPL budget covers long-term care and social support of PMD. The budget of MHS in Ukraine is appointed from the regional health budget except for Kyiv MHS and a number of national hospitals.
StaffAccording to I2, there is the lack of appropriately trained staff to work in all kinds of
services. Human resources abound but certain categories are neglected: few psychologists and no social workers are included. Nurses get little training on MH or psychiatry and tend to have a little and passive role. Social workers have been introduced to the field of MH but it is not clear whether any of them are working in state MHS or any kind of state services outside Kiev.
Consumer participationThe level of consumer participation and their relatives is very low in Ukraine. The
perspectives of the clients, the informal and professionals carers, and the neighborhood residents are afforded insufficient attention and are only considered indirectly, if al all (Liegeois and Audenhove 2005:453). Values of PMD on which the services can be built (Liegeois and Audenhove 2005:453 - 454) are not taken into consideration by policy-makers.
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B: Process phase:Operational policies
Currently, there are no operational policies because there is no national program on MH. Operational policies will appear after the national plan is adopted and is implemented by the regional administrations.
Pathways to careThe pathways to care are quite unstructured (Appendix X). It is possible for PMD to
by-pass primary care facilities as well as there is limited chain of services which can support individual in the community and it exists only in the big cities. According to I2, the cooperation between social work, housing support and vocational rehabilitation services is very weak.
Case loadsCase loads are high because PMD are often admitted to the hospital because of the
lack of support in the community.
Contact rates Only a minority of respondents, who took part in the recent epidemiological study,
talked to a professional about their symptoms (Bromet et al. 2005:1). If extrapolated the results of this study as well as a number of international studies show that the contact with MHS is lower than the need for services among the population.
Targeting of special groupsThere is no targeting of particular groups, such as injecting drug users, people living
with HIV/AIDS because of the lack of connection of MHS with social care and HIV/AIDS services.
C: Outcome phase:Outcome studies at group level
There is no public MH indicator scheme20 that is applicable to middle-income countries (Saxena et al. 2006:496). As a result of this, the process of monitoring is based only on MH information systems21. This results in poor monitoring of MHS in Ukraine.
Secondary and tertiary preventionSecondary and tertiary prevention is happening on all levels of the services, however
the concept of prevention is poorly developed in MHSM.
Decrease of local stigmaAccording to I2, there is a high level of stigma and lack of expectation of what is
possible for people to achieve once they have been diagnosed.
Patient levelA: Input phase:Demands made by patients
20 Public mental health indicator scheme is a “systematic collection of brief proxy measure that represent summary information on variables that re potentially influence by or relevant to mental health systems, programs and services (Saxena et al. 2006: 488).21 Mental health information system has been defined as a “system for collecting, processing, analyzing and using information about mental health services and needs of the population” (WHO 2003 in Saxena et al. 2006: 489).
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PMD are excluded from the process of transition of services in Ukraine. They are not empowered for any voice in the process of decision-making about policy formation and implementation. Certain PMD-self-governed bodies such as “PMD’ councils” exist in community-based centers, but, having little control over budgets and lack of sufficient skills and knowledge, they can hardly be influential.
A number of patients has voiced the need for assistance in the process of property loss. There are no state services which deliver advices and practical assistance to PMD who need the explanation of legislation or help with legal work on the documents (Korotenko 2003:13). However, such services are provided by the NGO “UPA” on the permanent basis. According to I4, Ukrainian Association is one of the strongest organization in the region which is dealing with past and current abuses within MHS and addresses them in a very effective way.
B: Process phase:Quality of treatments
The quality of services is very low (HiT summary: Ukraine, 2005:7). Although most PMD do not talk to a professional about their symptoms, those who do
so turn to their general medical physicians. Unfortunately, these doctors have almost no training in MH (during their 2 years of internship, family doctors receive 3-5 days training) and thus are unable to accurately detect or provide adequate treatment for these problems. Moreover, Ukrainain Psychiatric Association22 survey of psychiatrists showed that accurate diagnosis under modern diagnostic systems and adequate MH treatment were sorely lacking (Bromet et a. 2005:8).
Not guided by the concerns about the quality of life of patients, MHS in Eastern Europe cater mainly to the needs of the staff and their organizational culture (Tomov 2001:24).
MedicationSome medical treatments are outdated or not evidence based. According to Uhlmann
description (2000:531), “psychotropic medication were inadequately used. Often neuroleptics were prescribed for nonpsychotic patients. Dosages wee often on the low side due to lack of drugs, and medications were frequently discontinued due to the lack of funds. Yet often several neuroleptics were given when one would suffice. The drug prescribed might depend greatly on what was available. Newer antidepressants were seldom obtainable, and laboratory monitoring was rare”.
Frequency and duration of treatmentPatients are often admitted to the hospital because of the lack of appropriate support in
the community. The duration of their stay is long compared to the West European duration because of the lack of incentives system in HCS in Ukraine.
Continuity of careThe structure and the path to the services demonstrate that there is a weak chain of
services. A system of MHS is a “revolving door system”, according to I4, I5, I6. According to I2, there is lack of options beyond hospitalization for the majority. Social services are not integrated with health services. Services for substance abuse and HIV/AIDS are separate from MHS. .
Income supportBenefits and pensions are set at levels just above poverty. There is no impetus to
return to work as well as there is no support from employment services.
Vocational services22 Hereafter abbreviated as UPA.
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There is a lack of employment opportunities for PMD, thus vocational services have more supportive than practical goals.
C: Outcome phase:Quality of life/accommodation
The lack of integration of MH and social services results in the lack of the accommodation services for PMD. There are several sheltered housing available for homeless people in Ukraine, however, there is no accommodation available exclusively for PMD.
Disability/work rehabilitationThere are several work rehabilitation facilities, however they are not widely
developed. There are few professionals in this field of rehabilitation.
Burden on care-giversAccording to I2, there is lack of support for families and carers. There have been no
studies on the burden on care-givers from the close circle of PMD. It is important to take into consideration the immediate circle of the individuals who are surrounding the patient because they provide efficient and cost-effective treatment which is not supported and encouraged by anyone.
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CHAPTER 4: Transition of Mental Health ServicesThis part of the thesis deals with the analysis of the transition in Ukraine from early
1990s till June 2006 in order to identify processes, periods and elements of transition. The particular interplay between IOs, state and civil society during this time resulted in the different patterns of transition at different periods of time at hospital and community levels. The interplay is made up of actions and reactions which are mutually directed to each other and cause changes in the stakeholders involved.
Periods of transitionIt is possible to identify two periods and two processes of transition: 1991-2001
hospital level, 1991-2000 community level, 2001-2006 hospital level, 2001-2006 community level, as described in Appendix XIII. Such classification is introduced in order to show the distinct difference in the dynamics of the transition during the two periods and two processes (Appendix XI). 1991 is chosen as the starting point for analysis of the process of transition because at this time Ukraine gained independence and IOs started to get involved in the projects of MHS.
1991-2000 hospital levelThe first period of transition is called transition on hospital level. During the first
period (early 90’s – 2000) the fields of transition included, firstly, development of day care rehabilitation center on the basis of Kyiv Pavlov hospital, and, secondly, training of psychiatric nurses and other professionals on the territory of the Pavlov hospital. At this period of time interventions were concentrated in the capital city of Ukraine. During this period of transition, the changes were starting to happen on the structural levels on the basis of the hospital. Center for Psycho-social rehabilitation of Pavlov Hospital, Kyiv, described in the previous chapter is the typical model of the process of transition from 1991 till 2000 on the hospital level, has been established. However, this attempt of transition was not integrated in the general work of the hospital but was more regarded as the supplementary element of the existing services.
According to Polubinskaya (2000:106), there have been a number of signs of the reform in MHSM at this moment of transition. Firstly, “the role of professionals’ organizations”, such as UPA, has increased and, secondly, “the development of psychiatric legislation”, such as the “Law on Psychiatric Support”, was adopted on 22 February 2000. A number of publications on the topic of MH care in Western Europe and USA in the local language became available (Voren and Whiteford 2000:64). This literature was widely read by the professionals in the field, however, the practices from the literature were not implemented into practice.
At this period of time, the process of transition was happening predominantly on the level of hospitals because, firstly, the level of development of NGOs was low, secondly, the development of the NGOs in the field of MH was monopolized by stakeholders from the hospital institutions. This process of transition did not get reflected in the significant decrease of the in-patient structures on MHSM level. Nevertheless, from 1991 till 1993 the number of hospitals and dispensaries have been decreasing (Appendix XII). The number of hospitals has been increasing in 1994 and has been falling till 1996. Since 1997 there is an increase in the number of the hospitals. The number of dispensaries as well as nursing homes are decreasing over the years.
Between 1991 and 2000, the general reduction in hospital beds has happened. According to Lekhan, Rudiy and Nolte (2004:81), the number of beds for PMD fell by 31% (from 70 7000 to 48 800). Furedi (2006:1) argues that a shift from traditional in patient facilities in the countries of Central and Eastern Europe towards out-patient and community
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services can be proved by a decreasing number of hospital beds. However, I disagree and argue that it is still possible to argue that there is the process of transition in Ukraine despite the lack of the decrease of the number of beds because of the following reasons. Firstly, the decrease of the number of beds does not give indications on the frequency, duration and patterns of use of beds. Secondly, it does not indicate individuals with what diagnoses are using beds. Thirdly, the decrease of the numbers of beds without any other types of indications does not make it possible to understand whether CMHS are being developed. For example, the reduction of beds in Ukraine was not paralleled by compensatory mechanisms such as expansion of outpatient services or day care hospitals. In contrast, the number of day care has fallen to 95 with an overall capacity of about 5000 beds (Lekhan, Rudiy, Nolte 2004:81).
The described elements of transition were stimulated from outside by IOs, such as GIP. LIEN project “Developing a fundament for a human MH care in Ukraine” has created the platform for the process of transition. International projects in the field of transition included the following. Firstly, a project on training of psychiatric nurses has been carried out by GIP and UPA. Secondly, a project on psychiatric services development was carried out in 1999–2001. Thirdly, the trainings for specialists in the field of MH on multi-disciplinary group work were conducted. Training modules on psycho-social rehabilitation programs in Ukraine (SILS modules) were developed with the support of Technical assistance for the Commonwealth of Independent States23.
Although emphasis was on transition of the hospital structures and stakeholders, according to I4, there was only a certain level to which these could accept changes. This limit was reached in 2000 during the discussion of the project on the development of crisis intervention unit in Pavlov hospital. The project (GIP 2000) had the following objectives:
1. to bring down with 10% the number of traditional hospitalizations in the hospitals, reducing the number of beds in the departments to date;
2. to substitute long-term traditional hospitalizations with short-term hospitalization to around three days till up to one week in a crisis unit, which is still to be set up;
3. to push back the average duration of patients’ stay in the hospital from 47 to 40 days;4. to introduce new methods of treatment, which were developed in the Western Europe,
including crisis intervention methodology and case management;5. to develop a new-fangled tradition of multidisciplinary co-operation and teamwork;6. to set up and develop necessary programmes for schooling and training to achieve
that.The negotiations on this project have failed because of a number of reasons, which
were present all the time during the process of cooperation between the stakeholders, but became most vivid at this moment of time. According to I7, there was bad communication, lack of trust and understanding among the stakeholders. During this period, the source of transition was predominantly external, brought by IOs. The changes in MHS at this period of transition were stimulated by IOs without the explicit need of national stakeholders. That is one of the reasons why they were not internalized by the existing system. The national forces were represented by the state, however neither institutions nor civil society have been ready for the changes. The end of the first period, first process of transition of services is characterized by the failure of the national and international stakeholders to get involved in the project of transition from hospital to community-based services in the form of crisis service development in the Pavlov hospital in Kyiv. This resulted in the decrease of the involvement of IOs in the process of transition on hospital level and the slowing down of the process of transition at health system level.
23 Hereafter abbreviated as TACIS.
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1991-2000 community levelDevelopment of the non-governmental sector in the field of MH, such as UPA (1991),
Kastalya (1994), Dzherelo 1994) and Vita (1997), has been started at this period of time. The particular feature of these organizations is that they were mainstream NGOs which were developed by top-down approach of IOs or the professionals from the hospital rather than have been developed based on the needs of individuals involved in the field in Ukraine. Nevertheless, these NGOs played a crucial role in the development of civil society initiatives in the field of MH..Stakeholders of the 1st period
From 1991 till 2000 the major stakeholders of the development of the process of transition of MHS were professional organizations, IOs and mainstream civil society organizations formed on the bases of the hospitals by the groups of psychiatrists. Academic institutions have been reinforcing the old-system concepts of MH by teaching nurses and psychiatrists old model of MHS. “Kyiv Mohyla Academy” School of Social Work had the first graduation of social workers in 1997 and, thus, has introduced new professionals to the field. However majority of them have been working in the NGOs rather than state facilities. Research institutes of MH are poorly developed at this period of time.
At this period of time the source of transition was the interplay between external and internal forces. IOs represented external forces, national forces were represented only by hospital structures. Neither institutions nor state officials were open for the change. The IO were providing impulses for the process of transition.
2001-2006 hospital levelAccording I2, the recent features are that the changes on the hospital level are taking
in the other places outside of Kyiv, such as Lviv in the Western part of Ukraine. However, there is little state support outside Kyiv. The tension between different stakeholders increases during the process of transition. The involvement of the state has two distinct features. Firstly, the government of Ukraine uses the term “out-of-hospital services” as synonym to CMHS. However these two concepts have very different meanings. Secondly, the priority of developing “out-of hospital services” has been voiced by the government, for example in The Concept of the State Targeted Complex Program for Development of Mental Health Program (2006), however, it has stayed on the rather declarative level.
The process of deinstitutionalization in Ukraine is still at the initial stage of policy formation and implementation. According to I3, there are only some isolated and weak initiatives and a just started process of policy development. According to I3, de-instituionalization is only the beginning for Ukraine at this stage. It is envisaged a long term process. Psychiatrists will have to play a leading role as they are holding the present system in their hands and PMD or relatives’ organizations appear weak and little represented. The political instability may undermine or delay the process. It should be happening on different levels such as care, role of professionals, appearance of the new actors such are relatives and clients, community councils, patients’ organizations. According to I2, currently there are no moves to close or re -organize social care houses as well as there are no moves beyond a small number of NGOs to create alternatives in the community. Reductions in hospital beds some years ago did not lead to increased community services – rather led to an increase in prison and internat populations and homeless people.
There are minor changes in the professional structure of MHS. In recent years, the nursing profession in FSU has consolidated its own reform, and many organizations of psychiatric nurses have been established in Ukraine. Professional psychiatric nursing can offer a perspective on MDs, which is independent of but complementary to psychiatry. These developments are potentially innovative in reducing the dependence on services which
22
consumers acquired within the authoritarian psychiatric model. However, professionals organizations are still weak and exist under the umbrella structure of the UPA.
2001-2006 community levelSecond period of development of MHS can be described as transition on community
level. The second period (2001-june 2006) is characterized by the introduction of the legislation and national policies in the field of MH as well as the development of the pilot community services outside of the hospital. At this period of time the initiatives started to be developed in the regions of Ukraine, however the majority of them are still concentrated in the capital city.
The beginning of the second period, second process of transition is characterized by the development of the first self-help group for PMD organized in the community. In 2002-2003 the EU funded project Institution Building Partnership program was carried out by the local NGO “Social Development Support Agency” and British fund Hamlet Trust. The project aimed at the development of the network of regional self-help groups in the field of MH. The groups were situated mostly outside of Kyiv. Currently, the process of transition is happening more on the grassroots rather than hospital level because of the high level of resistance of the old elites on the hospital level.
According to I2, the process of transition from hospital-based to community-based model is taking place in Ukraine on the level of the activities of a small number of NGOs. The lack of any policy framework or state interest suggest that the process of transition is not happening at health system level. It is more happening on the level of NGOs. This process is not taking place at health system level. Because of this a number of literature and experts conclude on the lack of the process of transition in Ukraine (I2). I disagree with such statements. The transition is taking place, however, it is more taking places in the form of pilot projects in the big hospitals of the cities, such as Kyiv and Gytomyr. However, cases on this scale can be considered as the elements of the process of transition so that the process of transition can be understood and be developed.
According to I3, the process of transition from hospital-based to community-based model at health system level at this stage is only being discussed among main stakeholders within the policy process. There are some experiences being implemented: Zhytomir Hospital, rehabilitation center at Kiev’s hospital, Friends’ Union in Kiev (self help group) and at Hospital N. 2 in Kiev. The process of transition is happening because there is a group of professionals in the country that pushes for a change to take place. WHO has also raised the need for the development of transition at MoH.
A number of projects implemented in cooperation with IOs in the field of MHS has been carried out. Firstly, WHO-AIMS (2005) study on the assessment of MHSM in Ukraine is currently being carried out. Secondly, a project on Community Psychiatry (2000-2003) has been implemented by five NGOs, including UPA. GIP was a leader of the project. Basis model for effective psychiatric rehabilitation services was developed. TACIS/Lien has sponsored the project. As a result of this project, the first self-help group was organized in Ukraine (Vasylchenko 2001). Outpatient care development in Ukraine (2000–2002) project was funded by TACIS and resulted in establishing a rehabilitation day centre, involving PMD and their families in MH care on daily basis. Currently, GIP does not undertake projects in Ukraine in the field of MH.
A number of attempts of transition have been undertaken. Community Center “Friends Union”, Kyiv described in the previous chapter, is a typical example of transition of the model from the second period of time. Ukraine is one of the first countries in the region of Central and Eastern Europe where the process of transition from hospital to community based care models of services has been started by IOs, such as GIP24. A number of projects of transition has been implemented in the big hospitals in Ukraine in co-operation with IOs,
24 Former name Geneva Initiative on Psychiatry.
23
however this has not lead to any changes in the models of service delivery at health system level. As the result of these attempts, community based services exist on the level of pilot projects and are often established by reform-minded professionals, but inter-linkages with existing services are virtually absent.
It is important to analyze, why the process of the transition is taking place in Ukraine. According to I2, it is happening because of the few interested people are pushing it forward and because there is an impact of WHO, however, the nature of this impact is not clear to the respondent.
Stakeholders of 2nd periodThe process of transition from one model to another has started in 1991 and has
developed in a different paste and pattern at two periods of transition. However, it is not yet possible to observe the development of the comprehensive process of transition in Ukraine as it was happening in a number of countries, such as Lithuania, during the process of deinstitutionalization. The reason for it is the lack of actual co-operation between hospital and community and thus there are two “pieces” of transition happening on the level of community and hospital, which hardly overlap. Currently, the process of transition on community level is more intense than on the hospital level. There are a number of reasons for the lack of cooperation. Firstly, the NGOs became able to attract significant resources of international donors. The stakeholders have changed at different periods of transition. The process of transition brought changes the power positions of the stakeholders.
At this period of time the source of transition was the interplay between external and internal forces. IOs represented external forces, national forces were represented only by civil society organizations. The impulses of transition at this period of time was coming from NGOs and have been supported to IOs.
Factors of slow transitionThere are a number of factors which influence the slow transition of the services.
Firstly, it is the persistent resistance of the old elites of psychiatrists who are in power to the changes. Secondly, lack of recognition of the need for transition by the government. Thirdly, the particular nature of the process of transition. The major obstacles for the implementation of the transition include: limited political will; strong resistance of professionals; weaknesses of organizations of PMD and relatives; lack of certain professional profiles; most of the available budget being allocated to mental hospitals; separation of social and health services; lack of a notion of community based MH; stigma.
The development of the transition in Ukraine in early 90s’ has served as the model for developing he projects of transition in other countries, for example Lithuania. The case of successful transition at the Vasaros hospital in Lithuania is presented in Appendix XIV.
The main objective of the thesis is to analyze why the process of transition of MHS in Ukraine is happening slowly from 1991 to 2006. One of the results of the thesis is the framework of indicators of transition. It is important to apply these indicators to the process of transition in Ukraine in order to re-examine the nature of transition in Ukraine vis-à-vis these indicators. Decrease of the number of the hospital beds is happening very slowly and is not consistent from one year to the other. There is a big fear from the directors of psychiatric hospital to loose patients and decrease numbers of beds in the hospital. Number of services provided in the community by grassroots NGOs is very small and is in the form of pilot projects. These services, except for a number of self-help groups, are predominantly concentrated in Kyiv or other big cities. Financing of CMHS is carried out by IOs. The status of psychiatric nurses is very low in Ukraine with little changes during last 15 years. Decrease in involvement and power of psychiatrist in the work of the team working in the field of MH is not happening. Multidisciplinary teams of professionals and their place of work are virtually non-existent except for several project experiments carried out by IO. Level of integration of the transition projects to the general structure of MHS is very low. Level of change in values and attitudes of professionals is happening very slowly is not progressing after certain level of changes. The application of the indicators of transition to the process of transition in Ukraine proves the problem of MHS – slow transition of services from hospital-based model of services and the need for the process of transition to happen on MHS level.
My findings have the following implications for the research on the process of transition in the countries of Eastern Europe, particularly Ukraine. Firstly, it makes possible to understand the particular nature of transition of MHS in the countries of former Soviet Union. Secondly, it contributes to the development of analytical rather than descriptive studies of MHS in the region. Thirdly, it makes it possible to identify the reasons for the lack of change in MHSM in the region. Last but not least, the results of my analysis can be valuable for understanding the process of transition of MHS in the countries of the former Soviet Union where the level of transition is lower than in Ukraine, particularly in Russia, Belarus and countries of Caucas and Central Asia.
Conclusions
Epidemiology of mental disordersEpidemiology has only recently taken root as a methodology in FSU. Consequently,
available statistics on MDs and alcoholism in FSU comes primarily from treatment samples that have both known and unknown biases (Bromet 2005: 2). Secondly, different stakeholders identify the morbidity according to different systems of classification, thus it is difficult to compare the existing statistics. However, there is the general agreement in the literature that the rates of morbidity are higher in Ukraine than in the West European region. Last but not least, it is possible to conclude that not all MDs, particularly those spread in Ukraine, require hospital based care. Actually, most of them require community based care, which integrates medical and social support. Old services can response little to the new types of MH needs of the population caused by the process of transition from socialist to post-socialist period.
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Analytical frameworksExisting analytical frameworks on MHS and process of transition suggest that
transition of MHS is the result of the interplay of internal and external factors which originate from internal and external sources on the levels of the society, state, institutions and IOs. It is important to identify the source of transition in order to understand the particular form of these changes and the process of its development in the country. When analyzing the process of transition in the country, it is important to use theoretical frameworks which make it possible to identify, firstly, why is it necessary to undertake transition, secondly, in which elements and level of services transition should take place, thirdly, how the process of transition takes place.
Structure of mental health services deliveryThere have been no changes from 1991 till 2006 in the structure of MHS delivery on
MHSM level, however, there are some changes on the grassroots level, in the form of pilot community care services projects.
Periods of transitionThe lack of the progress in the change of MH service delivery to the system of service
delivery which takes into consideration the psychological and social dimensions of MH is happening because there are two processes of transition taking place: on community level, at the fist period of transition, and hospital level, at the second period of transition, and the link between two levels of transition is very weak. Such nature of transition prevents the comprehensive development of transition.
Reasons for slow transitionBased on the existing literature, it is possible to draw conclusions on the reasons of
the slow transition of MHS in Ukraine. The major reasons for the slow development of the process of transition include a number of the management and ideological problems on the levels of service planning, delivery and monitoring.
Firstly, there is the outdated curriculum at the university and lack of good active knowledge about the developments in MH among the professionals. Secondly, there is the lack of implementation of existing policies and legal frameworks. Thirdly, there is lack of desire among national stakeholders who are in power to accept the changes. Pluralist theories makes it possible to understand that this happens because a group of old-minded stakeholders have monopolized the power centers in the hospitals structures as well as have monopolized many structures in the community which are able to become locus for the process of transition. Fourthly, there is the lack of strong and independent organizations of a number of professionals, such as psychiatric nurses, social workers. Fifthly, there is the lack of the multidisciplinary teamwork. Sixthly, there is the lack of the finances for the process of transition. Thus, a number of economic barriers to MHS transition exist (Knapp et al. 2006). Seventhly, there is the lack of the public tolerance towards the issues of MDs.
All these reasons have resulted in the situation where the process of transition could not have happened on community and hospital levels at the same time and this have lead to the slowing down of the process of transition.
There are a number of lessons learnt from Lithuanian experience for transition in Ukraine (Appendix XIV). PMD should be prioritized and “targeted” (Shepherd 2002:91) during the development of CMHS so that they will not be underserved. The extent to which services can be shifted from institutions to the community is context specific. It is difficult to implement Western model of transition from hospital based to community based models in FSU countries. The process of transition is only possible when a number of favorable conditions exist.
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Recommendations
Community Mental Health ServicesPublic debate among professionals and PMD on the definition and expectations on
CMHS and the process of transition should be initiated and be carried out. This can be done in the form of Green paper (2005) on MH (2005) and Red paper (Santegoeds and Tekeer: 2006) response to the Green paper which has recently been carried out in EU countries. CMHS should be introduced to the Concept of the State Targeted Complex Program for Development of Mental Health Program (the Government of Ukraine 2006). The ground for the implementation of the services should be prepared and the initial steps in the form of the pilot projects should be undertaken. For the transition to develop, resources should be redirected from hospital to community.
CMHS are capable of decreasing the level of stigmatization of PMD in society. It is worth investing in self-help groups as the entry point for development of CMHS because they are efficient and cheap way of services delivery. The informal support of relatives and friends of PMD should be recognized and supported. The development of CMHS should be localized in other areas of the country rather than Kyiv in order to avoid resistance of the current power group of old-minded psychiatrists.
Journalists need to be trained in the topic of MH in order to decrease the level of stigmatization and develop a different attitude of the population to PMD by providing a more clear and objective information about MH in media.
Human Resource Development
General practitioners25 should receive more training in the field of MH as they are the main agents whom PMD address on primary care level. It is important to upgrade the status and recognize the expertise of nurses in the field of MH. Young reform-oriented professionals should be introduced into the field.
Development of Mental Health Services
There are two possibilities for the development of the process of transition in Ukraine (Appendix XV). However, these developments can be implemented only if a comprehensive process of transition on hospital and community levels take place.
Firstly, integration MHS to primary care level services can take place. This should include the integration of education on MH to the curriculum of MH nurses and GPs. An increase in the role of local GPs as gatekeepers to MHSM should be developed (Amaddeo et al. 2001:500) so that PMD do not bypass primary care services. This form of transition is recognized on the policy level and is outlined in the Concept of the State Targeted Complex Program for Development of Mental Health Program in Ukraine (the Government of Ukraine 2006). However, this kind of transition will not be able to support PMD in the community and thus will lead to high levels of readmissions to the hospitals. However, it will be able to prevent some MDs in the population. Secondly, the development of CMHS should be initiated. This services can be initiated on the bases of psychiatric hospitals and with the time should be moved to the community. It is important that both of the models of transition are developed at the same time so that the comprehensive chain of services can be created. Thus, the services for substance abuse should be integrated with the services for MDs. Experiences of transition of MHS in similar countries, for example Lithuania, should be studied, contextualized and be adopted in Ukraine.
The author of the thesis argues for the development of transition on the basis of the psychiatric hospitals as well as on the basis of primary care facilities. Despite the fact that the transition based on hospital model have already been initiated and has failed, the second
25 Hereafter abbreviated as GP.
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attempt should be undertaken because of the number of reasons. Firstly, psychiatric hospitals are the core elements of MHS. Secondly, the first attempts of transition on hospital level have been implemented in early 1990’s and thus currently there might be more favorable conditions for implementation of transition. Moreover, it is crucially important to increase the role of PMD and their relatives in the process of transition so that the transition corresponds to the needs of individuals who are situated on the receiving end of the services. This can be done by developing and adopting the concept of PMD involvement. In short, the process of transition should be initiated in the hospital in the form CMHS and gradually should be moved to the community and be undertaken simultaneously to the development of transition in PHC. Day care rehabilitation centers on the territory of the hospitals can be temporary institutions of transition, which after a period of time should be moved to the community. Self-help groups should play a significant complementary role. The chain of MHS should be created. However, it is important to remember that the process of transition is not the final objective, but is rather the process which can make it possible to reach the model of balanced care MHS.
Disseminating Results of the ThesisResults of the thesis will be presented in the form of poster presentation on the Third
International Mental Health conference in the Institute of Psychiatry, King College London in August 2006 as well as will be sent to the European Coalition for Community Living. The thesis will be developed further on and will be published in one of international journals on MHS.
Further researchA number of issues on MHS in Ukraine are not explored and thus need further
investigation. Firstly, it is important to identify the particular nature of the stigma which exists in Ukraine and find the appropriate way of tackling them. Secondly, a number of indicators necessary to describe MHS according to Thornicroft and Tansella framework need to be investigated in the further research, such as special inquiries for services, fixed expenditures, patterns of service use, better access to services, individual needs assessment, demands made by families, symptom reduction, satisfaction with services. Thirdly, the burden born by patients’ families and other unpaid caregivers should be studied. Last but not least, there are no formally published MH economic studies from the countries of Eastern Europe except for a small number of cost-effectiveness and cost of illness analysis which have only been presented at scientific meetings (Shah 2000:61). Thus, it is difficult to analyze the economic aspect of the process of transition in Ukraine, which in fact is a very strong political argument in the debate for or against the process of transition. More studies of cost-effectiveness and cost of illness should be carried out.
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Appendix I. Map of Ukraine
Retrieved May 25, 2006 (http://travel.kyiv.org/map/).
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Appendix II. Organizational Chart of Health Care System
Lekhan, V., Rudiy, V., Nolte, E. 2004. WHO on behalf of European Observatory on Health Systems and Policies. Health Care Systems in Transition Ukraine. Retrieved December 10, 2005 (http://www.euro.who.int/Document/E84927.pdf). P.18.
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Appendix III. Financial Flow Chart of Health Care System
Lekhan, V., Rudiy, V., Nolte, E. 2004. WHO on behalf of European Observatory on Health Systems and Policies. Health Care Systems in Transition Ukraine. Retrieved December 10, 2005 (http://www.euro.who.int/Document/E84927.pdf). P.99.
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Appendix IV. Definitions
Community –based care means that the large majority of patients requiring MH care should have the possibility of being treated at community level. MH should not only be local and accessible, but should also be able to address the multiple needs of individuals. It should ultimately aim at empowerment and use efficient treatment techniques which enable PMD to enhance their self help skills, incorporating the informal family social environment as well as formal support mechanisms. Community based care (unlike hospital-based care) is able to identify resources and create healthy alliances that would otherwise remain hidden and inactivated (World Health Report 2001).
Social care are services related to long-term inpatient care plus community care services, such as day care centers and social services for the chronically ill, the elderly and other groups with special needs such as the mentally ill, mentally handicapped and the physically handicapped (European Observatory on Health Care Systems 2001). The borderline between health care and social care varies from country to country, especially regarding social services which involve a significant, but not dominant health care component such as, for example, long-term care for dependent older people. (Glossary of European Observatory on Health Systems and Policies 2006).
Mental disorders are different from other conditions such as intellectual disability. The term "MDs" is used when an individual’s mental condition significantly interferes with the performance of major life activities such as thinking, communicating, learning, and sleeping. Individuals can experience MDs over many years. The type, intensity, and duration of symptoms vary broadly from person to person. Symptoms can come and go and do not always follow a regular pattern, sometimes making it difficult to predict when symptoms and functioning will worsen. MDs are typically treated through some combination of hospital care, medication, psychotherapy, and social support. Unfortunately, the inappropriate use of some of these treatments, such as long-term hospitalization, is still common (Open Society Institute 2006).
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Appendix V. Coding of Respondents
International I1 – WHO Acting Regional Adviser for Mental Health (Interview).I2 – International Expert Working in Mental Health and Social Care (email communication).I3–Mental Health Officer World Health Organization Regional Office for Europe (email communication).I4 –Global Initiative Project Manager with experience of working in Ukraine (interview).I5 –Global Initiative Project Manager with experience of working in Ukraine (interview).I6 –Global Initiative Project Manager with experience of working in Ukraine (interview).I7-Psychiatrist from the Netherlands with experience of working in Ukraine and Lithuania (interview).
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Appendix VI. Interview Guide0 Epedimiology
1. Is there the increase of the morbidity of people with mental disabilities in the region, particularly Ukraine? What are the patterns of the increase? Where is it possible to obtain the statistics?
I Mental health services:1. What are the main elements of the structure of mental health services in Ukraine?2. What are the changes in mental health services over the past years? 3. What are the turning points in the development of mental health services in Ukraine?4. What are the indicators of the changes?5. What are the differences of mental health services in Ukraine compared to the
services in other countries of the region? 6. What are the major problems of mental health services?7. Who are the major stakeholders?8. Is there clinical protocols for patient management?9. Why GIP is not working in general psychiatry in the last 5 years in Ukraine?
II Deinstitutionalization1. Is there the process of deinstitutionalization of mental health services?2. How do you define deinstitutionalization?3. What are the particular features/indicators of it? 4. On which stage is the process of deinstitutionalization in Ukraine?
III Models of mental health services1. What are the advantages and disadvantages of hospital model, community model and
balanced care model in the context of Ukraine?
IV Transition2. Is the process of transition from hospital-based to community-based or balanced care
models taking place in Ukraine? 3. Is there the need for the process of transition?4. How is it happening? 5. Why the process of the transition is taking place in Ukraine?6. What are the major obstacles for it?7. The experience of which countries are useful for understanding the process of
transition in Ukraine? 8. What are the indicators that the transition is taking place?9. How is the process of transition taking place? Is it the same as deinstitutionalization?
V Community mental health services1. What are space and resources for the development CMHS in Ukraine?2. What is your definition of CMHS?3. At which level of mental health care system the community services can be
developed?a) Mental health outpatient facilities.b) Day treatment facilities.c) Community based psychiatric inpatient units. d) Mental hospitals.e) Forensic and residential facilities.4. Which model of CMHS can be developed? 5. How is this model different from the Western models?
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Appendix VII. Structure of Email Communication with Experts
Thank you for spending your time on answering the questions. The respondents will be coded so your name will not appear in the research. Please answer the questions bellow as fully as
possible. You may use the language which is mostly convenient for you (Russian, Ukrainian, English).
Return the answered questions to [email protected] in the nearest time possible (preferably before June 25th)
0 Epedimiology2. Is there the increase of the morbidity of people with mental disabilities in the region,
particularly Ukraine? What are the patterns of the increase? Where is it possible to obtain the statistics?
I Mental health services:10. What are the main elements of the structure of mental health services in Ukraine?11. What are the changes in mental health services over the past years? 12. What are the turning points in the development of mental health services in Ukraine?13. What are the differences of mental health services in Ukraine compared to the services in
other countries of the region? 14. What are the major problems of mental health services?
II Deinstitutionalization5. Is there the process of deinstitutionalization of mental health services?6. How do you define deinstitutionalization?7. What are the particular features of it in the context of Ukraine?8. On which stage is the process of deinstitutionalization in Ukraine?
III Models of mental health services10. What are the advantages and disadvantages of hospital model, community model, balanced
care model (26) approaches in the context of Ukraine?
IV Transition11. Is the process of transition from hospital-based to community-based model taking place in
Ukraine? 12. How is it happening? 13. Why the process of the transition is taking place in Ukraine?14. What are the major obstacles for it?15. The experience of which countries are useful for understanding the process of transition in
Ukraine?
V Community mental health services6. Is there space and resources for the development of CMHS in Ukraine?7. What is your definition of CMHS?8. At which level of mental health care system the CMHS can be developed?f) Mental health outpatient facilities.g) Day treatment facilities.h) Community based psychiatric inpatient units. i) Mental hospitals.j) Forensic and residential facilities.9. Which model of CMHS can be developed in Ukraine? 10. How is this model different from the Western models?
26 Balanced care approach aims to provide services which offer treatment and care with the following characteristics: 1. Services which are close to home; 2. Interventions related to disabilities as well as symptoms; 3. Treatment and care according to the individual needs of the person; 4. Services which reflect the priorities of the service users themselves; 5. Services which are coordinated between mental health professions and agencies; 5. Mobile rather than static services (Thornicroft and Tansella 2002).
Lekhan, V., Rudiy, V., Nolte, E. 2004. WHO on behalf of European Observatory on Health Systems and Policies. Health Care Systems in Transition Ukraine. Retrieved December 10, 2005 (http://www.euro.who.int/Document/E84927.pdf). Pp. 74, 80.
27 It is not possible to provide statistics on the number of mental health facilities in the second period of transition (2001-2006) described in the coming sections of the chapter because of the lack of the published statistics at this period of time.
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Appendix XIII. Process of Transition of Mental Health Services in Ukraine1991-2000 2001-2006
HOSPITAL LEVEL
Legislation level
Cooperation
Rehabilitation Center on the territory of the hospital – the model of transition
HOSPITAL LEVEL
Policy Level
?Not developing but blocking the process of
transition on community level
Cooperation
COMMUNITY LEVEL
Cooperation
Not developed
?
COMMUNITY LEVEL
Cooperation
Grassroots initiatives in the form of pilot projects in the urban areas
Community mental health centers– the
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model of transition
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Appendix XIV. Process of Transition in Lithuania: Vasaros Hospital
Currently, other countries of the region, for example Lithuania (Puras et al. 2005, Puras, Povilaitis, Povilaitiene 2002), are on a much more advanced level of transition than Ukraine. Thus, it is important to analyze the case of transition of MHS in Lithuania in order to draw lessons for the development of the transition in Ukraine.
The case of Lithuania is similar to Ukraine because of a number of reasons. Firstly, similarly to Ukraine, a system of in-patient social care institutions still prevails in Lithuania (Juodkaite 2004-2005:5). The majority of the budget for MH is allocated for hospitals. Secondly, level of acceptance of PMD in both countries is low and the level of stigmatization within and outside of HCS is high (Juodkaite 2004-2005:6, 8). Last but not least, both countries share the elements of the same Soviet MHSM structure, for example social care homes. However, there are a number of differences between two cases: the capacity of civil society sector in Lithuania is higher than in Ukraine, thus it is easier to scale up CMHS there; geographically Lithuania is geographically smaller than Ukraine, thus, it can be possible to implement transition in a smaller country faster than in a large country.
The process of transition in Vasaros hospital is described according to the indicators of transition which were identified in the second chapter of the thesis. The project on transition of MHS in the capital of the country, Vilnius, was launched in 2003 and targeted the restructuring of the municipal MH hospital on Vasaros street, situated in the center of the city. A young energetic hospital director decided to invest time in upgrading the hospital and opened it to reforms. A young mayor understood the need to improve the quality of health care services in the city (Tomov, Voren, Keukens and Puras to be published) and has created political platform for the introduction of the changes. According to I4, hospital administration had the agreement with city administration to sell the part of the territory to the city. The new houses were built on this territory and the profit of this venture were directed to the improvement of facilities of the hospital, as the result of this, the integration of the hospital in the community has happened from the side of the hospital. As a result of these conditions, the Dutch Ministry of Foreign Affairs agreed to finance the implementation of the plan.
The task of the project is to develop the chain of a coherent services based on the needs of PMD (MATRA project:2002). The first component of the project is training in the field of health care management, professional training in multi-disciplinary teamwork and case-management, developing of the nursing section and library. Development of the department of registration, examination and crisis intervention is the second component of the project. A department of psycho-social rehabilitation is developed as a day care program and constitutes the third element of the project. Implementation of assertive community treatment team is the fourth element of the project. Next component of the project is the development of specialized services, such as eating disorders services. User involvement and patient advocacy are the next elements of the project. Development of a university department of social psychiatry at Vasaros is another component of the project. Task force on reformed MH funding is set up. Last but not least, development of psycho-geriatric department in the hospital is undertaken (MATRA project:2002). As a result of this, three new modules of specialist psychiatric care are introduced: crisis intervention, assertive community treatment and specialized services for eating disorders. The model of transition is based on the hospital-based model of transition, similar to the one which has been developed in Ukraine during the first period and first process of transition. However, it is more successful than the Ukrainian process of transition.
Firstly, the number of beds is decreasing in the hospital. In spite of this, according to I7, the director of the hospital is not panicking that the hospital’s budget will decrease but accepts these changes as a positive phenomenon. Secondly, crisis intervention multidisciplinary team is working and is starting to provide services in the community as social insurance schemes are being developed. The role of psychiatrists is decreasing in the new hospital structures as old psychiatrists retire. Multidisciplinary teamwork is introduced in which psychiatric nurses start to play an important role.
The source of transition is the interplay between external and internal forces. External sources were represented by IOs, internal forces were represented by the society, state and
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institutions, which makes it possible for the transition to happen. According to the first audit (MATRA project 2004:2), the project stimulates the participation of all relevant stakeholders –“users and relatives, MH professionals, the university, the municipality – in the reform of MH care in Vilnus and in Lithuania as a whole”.
To conclude, conditions, which made it possible for transition in the case of Lithuania to take place requite rapidly, are the following. On the external level, international stakeholders themselves were more experienced than in the case of Ukraine and were to support the development of a “bottom up approach” (MATRA project 2004:2). On the internal level, transition project in Lithuania was undertaken later than the crisis intervention services project in Ukraine, MH institutions and professionals were more open for the changes. There are young professionals in the hospital who are, firstly, open for changes, secondly, possess linguistic and managerial skills to develop, implement and monitor the project. The project corresponds to the needs of the national stakeholders and stakeholders are actively involved in the project. The city authorities co-finance the transition project. Currently, social health insurance scheme is being developed and will make it possible for the crisis intervention service to develop and expand its services in the community. There is the co-operation between the project and University of Vilnus which creates a good ground for the research activities. The project areas are integrated in the general work of the hospital. Last but not least, the general cooperation and communication between two partners is established and stimulates the appropriate transfer of expertise (MATRA project 2004:2).
The scheme of the process of transition can be presented in the following way:
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Process of Transition of Mental Health Services in Lithuania2003-2006
HOSPITAL LEVEL
Legislation level
Policy level
COMMUNITY LEVEL
Social insurance scheme
Cooperation
52
53
Appendix XV. Future Developments of Transition1991-2000 2001-2006 Future developments
Hospital level
Hospital
NGOs developed by hospital strucures
Rehabilitation Center on the territory of the hospital – the
model of transition
Not developing but blocking the state funding
for the process of transition on community level
Integration of mental health services in primary care services (policlinics)
Not developed
Community level
Grassroots initiatives in the form of pilot projects in the urban areas
