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

1. Overcoming barriers to the greater deinstitutionalisation of mental health care in Russia David McDaid LSE Health & Social Care & European Observatory on Health Systems and Policies, London School of Economics d.mcdaid@lse.ac.uk

2. Mental Health Reform • 3 year DFID funded technical assistance programme led by Prof Rachel Jenkins at Institute of Psychiatry • Multi-disciplinary team of UK and Russia based researchers and policy makers • Focus on Sverdlovsk Region but with dialogue at Federal level

3. Multi-disciplinary team • Institute of Psychiatry: Rachel Jenkins, Stuart Lancashire, Samantha Green, Jonathan Watkins, David Goldberg, Nick Purchase • LSE: David McDaid, • Imperial College: Rifat Atun, Yevgeniy Samyshkin, • Kastanja Consulting: Jo Lucas • Swansea University: Peter Huxley • Sverdlovsk MoH: Angelina Potasheva, Zinaida Bobylova • Sverdlovsk MoSP: Alexey Nikiforov, • AMH Project, Ekaterinburg: Valery Gafurov

4. Severdlovsk Oblast

5. Sverdlovsk Region Size of France 4.8 million population Yekaterinburg 1.29 million Above average economic development $57 per annum per capita on health care 2.6% (112,000) registered with mental disorders

6. Aims • To identify how health and non-health system factors impact on mental health provision in one region of Russia • In particular to explore issues around the balance of care • Identify barriers and potential solutions to help facilitate greater use of community services/ promote reintegration

7. Methods • Interviews with a range of key stakeholders using semi-structured questionnaire • Identified through preparatory work and discussions with Regional MoH and MoSP • Meetings with other representatives of MoH, MoSP, Employment Services etc as local links built • Triangulation of qualitative data with analysis of routine documents and statistics and lit review

8. Mental Health System • Vertical programme with earmarked funding • Delivered mainly in parallel to general health care services • Responsibility of Oblast Ministry of Health and municipalities (raions). Federal Ministry develops legal/regulatory frameworks & policy guidance • Important role for Ministry of Social Protection • Federal Employment Service

9. Mental Health System • Funding based on historical norms • Difficult to identify funding – crude estimate $9 on inpatient care • Care highly institution focused • Nationwide 279 psychiatric hospitals; 110 inpatient depts in 171 psychiatric dispensaries; 161,00 beds in hospitals; 125,000 social care homes (internats) • Federal Policy 2003-2008: emphasised downsizing hospitals; more integration with general health services; day care/outpatient services

11. Stakeholder perceptions • Consensus that system under funded! • Fragmented budget for region/municipalities • Recognition need to develop more community based services • Perception illegal to deliver services through primary care • Recognition that funds might be transferred elsewhere – social protection, employment • But…cautious about co-ordination & co-operation across sectors

12. Resource Scarcity • Only 12% of municipalities had some day care facilities • 40% of all bed capacity in two hospitals • Workforce issues – e.g. limited availability of social workers; many posts unfilled • Absence of contemporary training materials / multi-disciplinary teams • Limited civil society resources

13. Narrow approach to care/rehabilitation • Narrow model: focus on medical treatment • Underestimate psychological /environmental factor impact on disorders & outcomes • Therapeutic pessimism – recovery unlikely – protective institutional care required • Hierarchical decision making – limited role for non-psychiatrists

14. Structural barriers • Hospital funding: dependent on maintaining high rate of occupancy • Funding based on historical norms rather than population needs • Regulations stipulate periods of hospitalisation • Local communities dependent on institutions for employment • Administrative barriers can make it difficult to pool/shift resources between sectors

15. Role of MSECs • Medico-social and educational assessment committees play critical role • Determine whether an individual qualifies for disability benefits • Should produce plan for occupational and social rehabilitation • But ..lack of multi-disciplinary participation in MSECs…places for non-medics vacant • If assigned highest level of disability benefit; legally and practically v difficult to obtain employment

16. System Pathways

17. Technical Assistance Actions • Communicating legal position re role of primary care / community social work • Facilitate development of inter-sectoral committees (ISCs) at region/municipal level • Employment Services – participate in ISCs/share job vacancies with mh staff • Training programmes for GPs/ social workers :helped influence development of retraining course for nurses as social workers in Russia • Training/technical support for NGOs • Policy dialogue at Regional and Federal Level

18. People with psychosis obtaining employment

19. Clients with multi-axial care plans

20. Trends in beds per 10,000 population

21. Conclusions • Multiple barriers require multiple solutions • Takes time – look for innovative ways around bureaucracy to facilitate flexible use of resources • Cultural factors: limited role for primary care sector/ mental health – low priority • Role of rehabilitation critical needs to be in place alongside any medical support • Rebalancing of care requires additional investment: • Housing stock; Support for Families; Employment; Access to cash benefits • Policy climate provides opportunities for change

22. Further info • Jenkins R, Lancashire S, McDaid D et al. Mental health reform in Russia: an integrated approach to achieve social inclusion and recovery. Bulletin of the World Health Organization, 2007, 85(11): in press • McDaid D, Samyshkin Y, Jenkins R, Potasheva AP, Nikiforov AI, Atun RA. Health system factors impacting on delivery of mental health services in Russia: multi-methods study. Health Policy 2006; 79 (2-3): 144-152 • WHO Collaborating Centre for Research and Training in Mental Health and Section of Mental Health Policy http://www.iop.kcl.ac.uk/departments/?locator=430