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Health system factors impacting on delivery of mental health services in Russia: Multi-methods study
Health Policy 79 (2006) 144–152
Health system factors impacting on delivery of mental health services in Russia: Multi-methods study David McDaid a,b,∗ , Yvevgeniy Aleksievich Samyshkin c , Rachel Jenkins d , Angelina Potasheva e , Alexey Nikiforov f , Rifat Ali Atun c a
LSE Health and Social Care, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, United Kingdom b European Observatory on Health Systems and Policies, London School of Economics and Political Science, Houghton Street, London, United Kingdom c Centre for Health Management, Tanaka Business School, Imperial College, London, United Kingdom d WHO Collaborating Centre, Institute of Psychiatry, King’s College, London, United Kingdom e Chief Psychiatrist, Sverdlovsk Oblast Psychiatric Service, Ekaterinburg, Russian Federation f Deputy Minister for Social Protection, Sverdlovsk Oblast Ministry of Social Protection, Ekaterinburg, Russian Federation
Abstract Objective: To evaluate how the regulatory environment and health system organisation, financing and provider payment systems influence the delivery of mental health services in the Sverdlovsk region of the Russian Federation. Methods: A multi-methods study was conducted including analysis of routine data and key informant interviews supplemented by analysis of published literature, legal and regulatory documents, ministerial orders and reports. Results: Mental health care services are still largely provided in hospitals, although the need for more community-based and rehabilitation services is widely recognised. Resource allocation and provider payment systems remain largely unchanged from Soviet times and favour large inpatient institutions, creating incentives for hospitals to maintain a large number of beds and staff. Community-based social services and human resources remain limited, especially in the areas of social work, housing support and vocational rehabilitation, but co-operation across sectors at local level is growing. Conclusion: In Russia, the pace of reform in the mental health system will be helped if financial resource allocation mechanisms and provider payment systems are also reformed, so that resources follow individuals regardless of where they are treated. Such major health system shifts can only be achieved through changes at the Federal level and require major political will. Additional transitional funding is also required to help develop the necessary alternative community-based services. The nature of mental health disorders mean that this is not a problem faced within the health system alone, greater attention needs to be placed also on how to maximise the cross sector benefits especially with the social protection and employment sectors. © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Mental health policy; Health and social systems; Russian Federation; Healthcare organisation and financing
∗
Corresponding author. Tel.: +44 207 955 6381. E-mail address: [email protected] (D. McDaid).
0168-8510/$ – see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.healthpol.2005.12.014
D. McDaid et al. / Health Policy 79 (2006) 144–152
1. Introduction Russia’s health care system, established in 1918 with the aim of ensuring universal access to free health services, is characterised by centralised planning and administration, government financing and public provision of services [1]. There are several vertical programmes and related infrastructures for priority diseases including tuberculosis, mental disorders, sexually transmitted infections, diabetes, vaccine preventable diseases, substance abuse, cancer and HIV/AIDS. The health system as a whole and the vertical programmes in particular are dominated by inpatient care delivered through an extensive network of general and specialised hospitals. In 2001, there were 9.1 beds per 1000 population, compared to figures of 2.4 and 4.1 for the UK and European Union, respectively [2]. Although an extensive primary care network, comprising polyclinics, ambulatory care centres and feldsher stations1 exists, the role of primary care has focused on referral rather than “gate keeping” and patient management. Since the break up of the Soviet Union in 1991, Russia has experienced profound political, economic and social changes with increased unemployment and an expansion in the informal and criminal economies. Although economic stability and resumption of growth has been achieved, this has only benefited a segment of society with uneven income distribution, widened inequalities and increased poverty all adversely impacting on population health with reduced life expectancy, increased morbidity and an explosion of communicable diseases, placing the health system under great pressure [3–8]. In response, Russia has introduced structural and financing reforms to the health system. The responsibility for financing and delivering general health care was devolved to the regions. A mixed financing model has replaced the Semashko model, which was funded from general taxes. Financing now comes from four sources: federal taxes, in the form of budget transfers; compulsory medical insurance collected at regional level; formal user fees and informal out of pocket payments [9]. However, changes to the organisation and delivery of some services have been limited, especially as 1 Feldshers are medical auxiliaries with a much more limited training than primary care physicians. They can deal with a range of common non-severe health matters.
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regards the mental health, tuberculosis, HIV and sexually transmitted infections services that still continue to be delivered through vertical programmes. Poor mental health is a major contributor to the burden of ill health in the country. The problems of socio-economic hardship during the recent transition may have had a greater impact on those with mental health problems, and led more generally to an increase in societal stress because of the rapid nature of change [10]. This is further compounded by the related problems of substance abuse and alcohol addiction. While many mental health problems are chronic in nature and increase morbidity rather than mortality, suicide rates for men in Russia have increased three-fold since 1991 [11,12], and are the second highest in the world at 69.3 per 100,000 population for men, surpassed only in Lithuania, while rates for women are also comparatively high at 11.9 per 100,000 [13]. The number of individuals registered as disabled because of mental health problems has increased between 1990 and 2000 by 17.4% to 861,650, now accounting for 20% of all those registered disabled [14,15]. According to recent estimates by the National Centre for Mental Health of the Russian Academy of Medical Science, approximately 25–30% of the population have varying degrees of “psychic deviations” (in the Russian text) and the government has admitted that more could be done to promote good mental health. Although health system changes and how health system factors impact on communicable diseases, such as tuberculosis and HIV/AIDS, have been explored [16–19] much less attention has been paid to the impact of health systems factors on psychiatric services. This paper describes a study which uses the Sverdlovsk Oblast2 as a lens to study how health system factors impact on mental health service provision in Russia.
2. Methods The study was undertaken, by a multi-disciplinary team of UK-based and Russian researchers, including mental health experts, health economists and management experts, in the Sverdlovsk Oblast (Box 1), as one of a number of different elements within a technical 2 An Oblast is an administrative zone or area within the Russian Federation.
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Box 1: Sverdlovsk region The Sverdlovsk Oblast, an administrative region of the Russian Federation, is situated in the Ural Mountains in north central Russia, about 2000 km east of Moscow. It is similar in size to France, with the area of 194,300 sq km, and has a population of 4.481 million. It is sparsely populated, with 23.1% of the population residing in the six principal administrative cities within the Oblast. The capital Ekaterinburg, is the largest city with a resident population of approximately 1.29 million. Sverdlovsk is broadly representative of the economic development and health system structure found throughout the country. Total healthcare expenditure per capita in Sverdlovsk oblast in 2002 was equivalent to approximately US$ 57, similar to levels spent elsewhere in Russia. assistance programme led by RJ and funded by the UK Department for International Development (DFID).3 Qualitative and quantitative methods of inquiry were employed in data generation. Primary research used qualitative methods. We used ‘purposive sampling’ with ‘snowballing’ to capture a multi-level multi-stakeholder sample [20] of key individuals involved in policy design, development and implementation, who were interviewed using a proprietary semi-structured questionnaire. Initial informants were identified prior to fieldwork, partly through contacts built up by the project leader RJ during previous visits to Sverdlovsk, as well as through discussions between the project team and local partners in the Ministries of Health and Social Protection. Subsequently through local meetings with representatives of these ministries and the federal employment agency further key individuals at different levels within the system were identified. Data emerging from interviews were validated internally through triangulation with information from documents, routine data, and other information gathered prior to, during and after fieldwork. 3 See http://www.iop.kcl.ac.uk/international/?project id=44 for more information on the project.
Secondary research included a search for relevant published literature in the US National Library of Medicine Medline and the International Bibliography of the Social Science databases, complemented by a limited handsearch of key health policy journals. Papers in both English and Russian were retrieved. This in turn was supplemented by documentary analysis of published research reports including those by non-governmental organisations working in the area, health-related surveys, legal instruments and policy documents at both the Federal and Oblast level. In addition, we liased with the Oblast Ministry of Health Statistics Division in order to obtain mental health service data routinely collected by the regional health authority. We also visited the local office of the Department of State Statistics to browse their publications in order to identify additional basic socio-economic and demographic information on the Oblast.
3. Results 3.1. Organisation and financing of mental health services Russia has a long history of mental health services delivered as a “vertical programme”––with ‘ringfenced’ funding from general and local budgets and delivered mainly in parallel to general health care services. Although a system of compulsory medical insurance was introduced in 1993 this does not apply to vertical programmes such as mental health, which continue to be funded through taxation alone. Within each Oblast, mental health services are the responsibility of the Oblast Ministry of Health and municipal administrations. Additional related services are provided outside the healthcare system and involve the social service provision system and employment services in particular. The Federal Ministry of Health and lead research institutes develop legal and regulatory frameworks, strategies and policy guidance for the delivery of all vertical programmes. In turn, the Oblasts develop local strategies within these regulatory frameworks and deliver services to the population. For vertical programmes including mental health, resource allocation and provider payment systems administered at both Oblast and municipal level remain largely unchanged from Soviet times. They are based
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on historic patterns of expenditure and inputs, such as available infrastructure, number and occupancy rate of hospital inpatient beds and the number of staff in the ambulatory sector, which in turn are determined by federal norms. Under this system as long as an institution maintains a level of bed occupancy close to a pre-determined level, irrespective of the merits of keeping an individual in hospital or the quality of service provided, it will continue to receive its full predetermined level of funding. This funding mechanism was acknowledged by stakeholders interviewed to be a key barrier to any potential downsizing of institutional care, instead providing very strong incentives to institutions to maintain a high number of beds. For instance the largest institution, the Oblast psychiatric hospital, has 1010 beds but reducing this even to 999 beds would reclassify the facility within a smaller size category where the budget allocation for staffing and provision of services would be much lower. This is of particular significance given that wages are very low and individuals often have to fill more than one job within a facility in order to earn a living wage. We found that across the Oblast that on average adult and child psychiatrists, respectively, in the Oblast had 1.8 and 1.7 full time jobs in 2002. Salaries for psychiatrists were 25% higher than those for comparable professionals in other medical sectors, but unlike these other sectors they had little opportunity to boost salaries through informal payments or private sector activity. Although there is no reason to believe that funding for mental health in Russia is any better than that found in most ex-Soviet countries it remains almost impossible to obtain accurate information on the level of funding available for mental health. At a national level no official estimate of expenditure is provided [21] while at Oblast and municipal levels we found that accounting systems make it difficult to easily obtain such information, although one crude estimate suggests that approximately 250 roubles per day (around US$ 8–9) was spent on psychiatric inpatient care. There was, however, a consistent view among those we interviewed that the level of funding for the system was insufficient to deliver services, with a typical comment being that ‘no-one gets the funds they want’. One stakeholder suggested that only around one-third of the funds required to fully meet psychiatric needs were made available.
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Another interviewee highlighted the difficulties caused by some services being funded through budgets held by the municipalities and some by the Oblast and felt that a key step would be to pool these budgets. Some municipalities provide few services directly and instead provide funds for services delivered elsewhere in the Oblast. Published rates for transferring funds between municipalities were perceived to be low; this was linked to the low level of funding for the publicly funded health system with one individual stating that ‘very often the overall public budget is not sufficient, health is not a top priority’. While in other parts of the health system user charges and voluntary health insurance can help to supplement the level of funding available, there appeared to be little scope for such additional funds to be generated within the mental health system. Overall it was clear that respondents interviewed felt the system was under resourced, but recognised the need to develop more community-based services and reduce the reliance on institutional care. The current financing mechanism would not guarantee that any reduction in institutional care would mean that resources were transferred to community-based services. Some stakeholders recognised that funds might best be transferred to other sectors such as employment or social protection to deliver some community services, but again commented that the current funding system did not permit such a development and moreover that historically co-ordination and co-operation across sectors had been limited. 3.2. Changes in the legal environment As noted in Box 2, like many other state services, it is widely acknowledged that psychiatry had been used as tool for the abuse and discrimination of political opponents during the 1960s and 1970s with some individuals within the psychiatric system denied their fundamental human rights [10,22,23]. More generally there were limitations on legal, educational and employment rights. Major changes in the organisation of psychiatric care were initiated by the Law on mental health care and guaranties of rights of citizens in mental care provision [24], enacted in 1992 and consequently amended in 2002 and 2003, obliging the government to fund and provide a package of mental health services, including emergency psychiatric care,
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Box 2: History of mental health in the Russian Federation The Soviet Union was the first nation to provide universal free access to health care services including those for mental health, and the system originally had a tradition of recognising and providing opportunities both for vocational rehabilitation and for employment, working both with patients, their families and public organisations. However, particularly from the 1960s, it is widely acknowledged that the psychiatric system was increasingly used for political abuse and access to developments in western psychiatry were highly restricted. This culminated in exclusion from the World Psychiatric Association in 1982 with readmission in 1989. In 1992, the Russian Federation passed its first mental health law protecting rights of people with mental health problems and setting out the fundamental elements of psychiatric care [10]. consultative and diagnostic care, treatments, rehabilitation in outpatient and inpatient settings and assistance in finding employment. The law protects the rights of patients, sets out the role of guardians and defines when involuntary treatment may be required. In 2001, in line with the recommendations of the World Health Report 2001 on mental health [25], a Sectoral Programme for Mental Health was developed, aimed at reorganising psychiatric care over the period 2003–2008 [26]. The programme emphasised treating patients in the community wherever possible, integrating mental health with general health services and indicating that many services, currently provided in hospitals, could be delivered in day-care and/or outpatient settings. The programme signalled a recognition and willingness to reform mental health services, with high-level political support at the Federal level for health system changes to improve mental health services. Key programme recommendations included: decentralisation of services with territorial planning in which catchment areas are assigned to local facilities; the downsizing of large mental hospitals (>500 beds);
integration of mental services into general services to help overcome isolation of patients from society; improvements in continuity of care; differentiation of services by patients’ age groups (children, working age and old age) and a more optimal (efficient) allocation of services. The programme also recognises that different models of psychiatric care service delivery are required in different settings such as rural and urban areas, or dense/scattered populations. Developments taking place at a local level in Sverdlovsk include the introduction of training courses to improve the management and detection of common mental health problems, and strengthened co-operation between the health, social protection and employment agencies in particular, recognising the need for a multi-sectoral approach to interventions. 3.3. Mental health services in Sverdlovsk By end of 2002, there were 112,668 registered patients with psychiatric disorders in Oblast (2.6% of the 4.5 million total population). Of these, 98,385 patients were registered with mental health services. Mental health care services in Sverdlovsk are still largely provided in hospitals, although the need for more community-based and rehabilitation services is widely recognised. There are 11.5 psychiatric beds available per 10,000 population in the Oblast; this ratio is similar to that seen nationally. Currently there are 15 specialist psychiatric hospitals in the Oblast with 4730 beds. Almost 40% of all bed capacity is located in two hospitals. In addition, there are eight psychiatric departments in general municipal hospitals with 445 beds. Ambulatory psychiatric teams operate in large urban areas. There are outpatient services (known as dispensaries), including some specifically for children, in almost every municipality. Around 12% of municipalities within the Oblast have day facilities with 510 beds (an increase of 8% since 2000). Sheltered accommodation is still very limited with only three hostels in the Oblast providing between 15 and 30 places each. Occupational therapy facilities are also limited, as employment opportunities, in the current economic environment, for people with mental health problems are poor. There are 390 psychiatrists, 41 psychotherapists and 131 psychologists but only 29 specialist social workers employed in the mental health services. This is comparable to levels seen in other Russian regions.
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Fig. 1. Management of mental health patients in Sverdlovsk region of Russia.
Fig. 1 illustrates potential pathways through the mental health system using a flow diagram. This emphasises that contact with services is likely to be iterative and goes beyond the health sector. Recognition of common mental health problems such as depression in primary care settings has historically been low; consequently, individuals are much more likely to come to the attention of the mental health system if a crisis (such as a suicide attempt) occurs or if an individual is diagnosed as having a psychotic disorder. Acute events are followed by a period of initial hospitalisation, followed by assessment by the Medical and Social Assessment Commission to determine whether the individual should be registered as disabled, which entitles them to some welfare benefits and for a plan to be drawn up for occupational and social rehabilitation. Following hospitalisation, individuals may be discharged to the community and receive follow-up care and rehabilitation on an outpatient basis, or alternatively, if they are not deemed capable of rehabilitation or if no place in the community is available or their family is unwilling to support them, they may be placed in a social care
home called “internat”: an undesirable outcome as few individuals ever return from internats to the community. As Fig. 1 indicates the Medical and Social Assessment Commission therefore plays a critical role in acting as the bridge between the social and health sectors, which remain separate in terms of organisational structure and financing. It also plays a critical role in reintegration into the community; without a Commission recommendation that an individual is capable of employment, in practical terms it is almost impossible to obtain work. Once discharged to the community most patients are subject to mandatory outpatient observation for followup and treatment. In 2002 there were 790,750 visits to psychiatrists, as compared with 818,082 in 2001 and 813,303 in 2000, with an average of 7.3 visits per patient per annum. There has been little change in the rates of hospitalisation. In 2002, 38,095 patients were hospitalised due to mental health problems (a hospitalisation rate of 86.7 per 10,000 people), as compared with 38,260 in 2001. Of these, 66% were first time and 34% repeat admissions. The average length of stay per adult patient in 2002 was 49.9 days. In the same
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period, the number of patients seen in day-care4 facilities increased from 2945 in 2001 to 3911 in 2002.
4. Discussion Despite attempts at reforming the mental health system in Russia, with commitments at both the Federal and Oblast levels to establish a more communityoriented mental health service, the system remains highly hospital-centric with rates of hospitalisation much higher than those found in western Europe [27]. Stakeholders interviewed highlighted both funding mechanisms and the challenge of co-operation and co-ordination across sectors as major barriers to change. Much care is still provided in large-scale psychiatric hospitals, characterised by lengthy hospitalisation and repeat admissions. This is predominantly because the provider payment systems based on inputs, such as number of beds, historic activity levels and historic resource base encourages the preservation of big hospitals with large numbers of beds and staff. Furthermore, as with tuberculosis services, due to the lack of funding and available housing for independent living within the social protection system, such hospitals perform a social function, in that they provide shelter and sustenance for individuals that they might otherwise not be able to obtain [28]. International experience, which suggests that mental health services can be shifted successfully to the community and be more cost-effective than hospitalbased care [27], suggests that there is considerable scope for improving the efficiency of mental health services in the Russian Federation, in particular, through modification of case management among patients currently treated as inpatients. However, such a shift can only be considered if (a) alternative community-based services that are at least as effective as the existing use of inpatient care are put in place and (b) if measures are taken to ensure that the already low level of resources used for mental health are re-invested in these alternative community-based mental health and social care services. In Russia, our analysis suggests that there are five important barriers to the rationalisation of the hospital4 Institutions where individuals literally the majority of their day in bed receiving treatment and then return home at night.
based mental health system and the development of a community-based mental health service that will need to be addressed: first, hospital funding is based on the existing number of beds and bed occupancy, which in turn determine numbers of staff and other inputs. This provides perverse incentives for providers of mental health services to maintain existing beds and hospitalise psychiatric patients; second, funding increases and resource allocation for hospital infrastructure are based on historic patterns and norms rather than on any measure of psychiatric needs or cost effectiveness (indeed we found little appetite for the use of cost effectiveness information by stakeholders). Third, regulations relating to the management of mental health cases stipulate periods of hospitalisation. Fourth, large numbers of staff posts exist in mental health hospital, with many individuals having more than one job to boost income. Reducing or redeploying the human resources to the community may be politically difficult to achieve, as isolated hospitals may be the principle source of employment in rural communities and staff may need significant levels of retraining. Outpatient services for mental illness, as well as primary care and social support for the large share of patients that are unemployed are poorly developed, making it hard to implement potential cost effective alternatives to inpatient care. Finally, administrative laws and financing regulations in Russia (as in many other industrialised countries) can hamper the shifting of funds from health to social (or other) sectors, or the pooling of health and social sector budgets, limiting the opportunities for multi-sectoral policies that might address the broader challenges of reintegrating or maintaining individuals in the community. In the current financing system, any reduction in resources used by reducing the use of institutional care would not necessarily be reinvested in mental health services within or outside the health sector such as in social care, hence creating a significant barrier to change. Restructuring of the existing structures to develop a community-oriented mental health services requires changes to existing resource allocation mechanisms, provider payment systems and incentives for both mental health services and the health system as a whole. Moreover, additional transitional funding will be ideally required to develop the necessary alternative community- and general hospital-based services, while the excess, institutional-based care, is phased-out. As
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there are no mechanisms to protect any efficiency savings realised from the hospital sector it is likely that any proposals to promote cost effectiveness in mental health hospitals will be strongly opposed by health professionals. In Russia, financial resource allocation mechanisms and provider payment systems for vertical health programmes including mental health need to be reformed, so that resources can follow individuals regardless of whether they are treated in hospital or in the community. Incentives need to be built into the system to encourage such change. Approaches to consider might include the introduction of per capita funding, diagnosis related group reimbursement fees for mental health, pooled budgets across sectors or even the introduction of direct payment schemes where individuals with mental health problems are empowered to purchase services matching their own needs. However, such a major health system shift can only be achieved through changes at the Federal level and would require major political will. This is something that would inevitably have an impact on the system more widely not just on the mental health sector, but there is substantial evidence from other parts of the globe that changing financial incentive structures can act as a powerful incentive for mental health system reform [29]. Our findings have important policy implications for mental health services in Russia and the wider former Soviet Union where similar systems exist. Psychiatric hospitals shoulder costs of extensive periods of hospitalisation for clinical care but also a substantial burden of non-clinical social support. Improving the efficiency with which existing resources are used will require reform of health system norms and regulations related to planning, financing and clinical care, and the introduction of new, cost neutral approaches to case management for service users with social needs. However, in the absence of such radical health systems reforms, modernisation of mental health services will continue to be challenging. The nature of mental health disorders mean that this is not a problem faced within the health system alone, and greater attention needs to be placed also on how to maximise the cross sector benefits and many social needs such as access to normal housing, supported housing, support from community social services, vocational rehabilitation and access to employment all of which lie outside the health sector, especially within the social protection and employment
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sectors. The recent merger of the Federal Ministry of Health with the Federal Ministry of Social Protection affords an opportunity to address these issues in an integrated way. References [1] Shishkin S. Reforms of financing of healthcare in Russia. Vol. proceedings No. 25R. Institute of Economy in Transition; 2000. [2] Tragakes E, Lessof S. Health care systems in transition: Russian Federation. Copenhagen: European Observatory on Health Systems and Policies; 2003. [3] Bloom D, Malaney P. Macroeconomic consequences of the Russian mortality crisis. World Development 1998;26:2073–85. [4] Levintova M, Novotny T. Noncommunicable disease mortality in the Russian Federation: from legislation to policy. Bulletin of the World Health Organization 2004;82:875–80. [5] Andreev E, McKee M, Shkolnikov V. Health expectancy in the Russian Federation: a new perspective on the health divide in Europe. Bulletin of the World Health Organization 2003;81(11):778–87. [6] Shkolnikov V, McKee M, Leon D. Changes in life expectancy in Russia in the 1990s. Lancet 2001;357:917–21. [7] International bank for reconstruction and development, transition: the first ten years 2002. Washington DC: World Bank; 2004. [8] Drobniewski F, Atun RA, Coker R. The ‘bear trap’: the colliding epidemics of tuberculosis and HIV in Russia. International Journal of STD and AIDS 2004;15:641–6. [9] Government of the Russian Federation. Methodological recommendations for calculating of tariffs for medical services; 1992. [10] Poloshij B, Saposhnikova I. Psychiatric reform in Russia. Acta Psychiatrica Scandinavica 2001;104(Suppl. 410):56–62. [11] Brainerd E. Economic reform and mortality in the former Soviet Union: a study of the suicide epidemic in the 1990s. European Economic Review 2001;45:1007–19. [12] World Bank. Dying too young: addressing premature mortality and ill health due to non-communicable diseases and injuries in the Russian Federation. Washington DC: Europe and Central Asia Human Development Department, The World Bank; 2005. [13] World Health Organization. Sucide rates by country. Most recent year available. Geneva: World Health Organization; 2004. [14] Government of the Russian Federation. On the federal target programme urgent measures for improvement of psychiatric care for the period of 1995–1997; 1995. [15] Russian Federation MoH Collegium. Proceedings of MOH Collegium on mental health care; 2001. [16] Atun RA, Lennox-Chhugani N, Drobniewski F, Samyshkin Y, Coker R. A framework and toolkit for capturing the communicable disease programmes within health systems: tuberculosis control as an illustrative example. European Journal of Public Health 2004;14:267–73. [17] Coker R, Atun R, McKee M. Health care system frailties and public health control of communicable disease on the European Union’s new eastern border. Lancet 2004;363:1389–92.
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[18] Coker R, Dimitrova B, Drobniewski F, Samyshkin Y, Balabanova Y, Kuznetzov S, et al. Tuberculosis control in Samara Oblast, Russia: institutional and regulatory environment. International Journal of Tuberculosis and Lung Disease 2003;7(10):920–32. [19] Atun RA, Samyshkin YA, Drobniewski F, Skuratova NM, Gusarova G, Kuznetzov SI, et al. Barriers to sustainable tuberculosis control in the Russian Federation health system. Bulletin of the World Health Organization 2005;83(3):217–23. [20] Strauss A, Corbin J. Basics of qualitative research techniques and procedures for developing grounded theory. 2nd ed. London: Sage Publications; 1998. [21] World Health Organization. Atlas. Mental health resources around the world. Geneva: World Health Organisation; 2005. [22] Bloch S, Reddaway P. Soviet psychiatric abuse. The shadow over world psychiatry. London: Victor Gollancz; 1984. [23] Korolenko CP, Kensin DV. Reflections on the past and current state of Russian psychiatry. Anthropology and Medicine 2002;9(1):51–63.
[24] Duma of the Russian Federation. On psychiatric care and guaranties of rights of citizens during its provision; 1992. [25] World Health Organization. The World Health Report 2001—mental health: new understanding, new hope. Geneva: World Health Organization; 2001. [26] Russian Federation MoH Collegium. Sectoral programme of development of reorganisation of the network of psychiatric care in the Russian Federation for the period of 2003–2008, in Prekaz No. 98, 27; 2002. [27] McDaid D, Thornicroft G. Balancing institutional and community based care. Copenhagen: European Observatory on Health Systems and Policies; 2005. [28] Atun RA, Samyshkin YA, Drobniewski F, Kuznetzov SI, Fedorin IM, Coker RJ, et al. Seasonal variation and hospital utilization for tuberculosis in Russia: hospitals as social care institutions. European Journal of Public Health 2005;15(4):350–4. [29] Knapp M, Funk M, Curran C, Prince M, Grigg M, McDaid D. Mental health in low- and middle-income countries: economic barriers to better practice and policy. Health Policy and Planning 2006, in press.
Health system factors impacting on delivery of mental health services in Russia: Multi-methods study David McDaid a,b,∗ , Yvevgeniy Aleksievich Samyshkin c , Rachel Jenkins d , Angelina Potasheva e , Alexey Nikiforov f , Rifat Ali Atun c a
LSE Health and Social Care, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, United Kingdom b European Observatory on Health Systems and Policies, London School of Economics and Political Science, Houghton Street, London, United Kingdom c Centre for Health Management, Tanaka Business School, Imperial College, London, United Kingdom d WHO Collaborating Centre, Institute of Psychiatry, King’s College, London, United Kingdom e Chief Psychiatrist, Sverdlovsk Oblast Psychiatric Service, Ekaterinburg, Russian Federation f Deputy Minister for Social Protection, Sverdlovsk Oblast Ministry of Social Protection, Ekaterinburg, Russian Federation
Abstract Objective: To evaluate how the regulatory environment and health system organisation, financing and provider payment systems influence the delivery of mental health services in the Sverdlovsk region of the Russian Federation. Methods: A multi-methods study was conducted including analysis of routine data and key informant interviews supplemented by analysis of published literature, legal and regulatory documents, ministerial orders and reports. Results: Mental health care services are still largely provided in hospitals, although the need for more community-based and rehabilitation services is widely recognised. Resource allocation and provider payment systems remain largely unchanged from Soviet times and favour large inpatient institutions, creating incentives for hospitals to maintain a large number of beds and staff. Community-based social services and human resources remain limited, especially in the areas of social work, housing support and vocational rehabilitation, but co-operation across sectors at local level is growing. Conclusion: In Russia, the pace of reform in the mental health system will be helped if financial resource allocation mechanisms and provider payment systems are also reformed, so that resources follow individuals regardless of where they are treated. Such major health system shifts can only be achieved through changes at the Federal level and require major political will. Additional transitional funding is also required to help develop the necessary alternative community-based services. The nature of mental health disorders mean that this is not a problem faced within the health system alone, greater attention needs to be placed also on how to maximise the cross sector benefits especially with the social protection and employment sectors. © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Mental health policy; Health and social systems; Russian Federation; Healthcare organisation and financing
∗
Corresponding author. Tel.: +44 207 955 6381. E-mail address: [email protected] (D. McDaid).
0168-8510/$ – see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.healthpol.2005.12.014
D. McDaid et al. / Health Policy 79 (2006) 144–152
1. Introduction Russia’s health care system, established in 1918 with the aim of ensuring universal access to free health services, is characterised by centralised planning and administration, government financing and public provision of services [1]. There are several vertical programmes and related infrastructures for priority diseases including tuberculosis, mental disorders, sexually transmitted infections, diabetes, vaccine preventable diseases, substance abuse, cancer and HIV/AIDS. The health system as a whole and the vertical programmes in particular are dominated by inpatient care delivered through an extensive network of general and specialised hospitals. In 2001, there were 9.1 beds per 1000 population, compared to figures of 2.4 and 4.1 for the UK and European Union, respectively [2]. Although an extensive primary care network, comprising polyclinics, ambulatory care centres and feldsher stations1 exists, the role of primary care has focused on referral rather than “gate keeping” and patient management. Since the break up of the Soviet Union in 1991, Russia has experienced profound political, economic and social changes with increased unemployment and an expansion in the informal and criminal economies. Although economic stability and resumption of growth has been achieved, this has only benefited a segment of society with uneven income distribution, widened inequalities and increased poverty all adversely impacting on population health with reduced life expectancy, increased morbidity and an explosion of communicable diseases, placing the health system under great pressure [3–8]. In response, Russia has introduced structural and financing reforms to the health system. The responsibility for financing and delivering general health care was devolved to the regions. A mixed financing model has replaced the Semashko model, which was funded from general taxes. Financing now comes from four sources: federal taxes, in the form of budget transfers; compulsory medical insurance collected at regional level; formal user fees and informal out of pocket payments [9]. However, changes to the organisation and delivery of some services have been limited, especially as 1 Feldshers are medical auxiliaries with a much more limited training than primary care physicians. They can deal with a range of common non-severe health matters.
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regards the mental health, tuberculosis, HIV and sexually transmitted infections services that still continue to be delivered through vertical programmes. Poor mental health is a major contributor to the burden of ill health in the country. The problems of socio-economic hardship during the recent transition may have had a greater impact on those with mental health problems, and led more generally to an increase in societal stress because of the rapid nature of change [10]. This is further compounded by the related problems of substance abuse and alcohol addiction. While many mental health problems are chronic in nature and increase morbidity rather than mortality, suicide rates for men in Russia have increased three-fold since 1991 [11,12], and are the second highest in the world at 69.3 per 100,000 population for men, surpassed only in Lithuania, while rates for women are also comparatively high at 11.9 per 100,000 [13]. The number of individuals registered as disabled because of mental health problems has increased between 1990 and 2000 by 17.4% to 861,650, now accounting for 20% of all those registered disabled [14,15]. According to recent estimates by the National Centre for Mental Health of the Russian Academy of Medical Science, approximately 25–30% of the population have varying degrees of “psychic deviations” (in the Russian text) and the government has admitted that more could be done to promote good mental health. Although health system changes and how health system factors impact on communicable diseases, such as tuberculosis and HIV/AIDS, have been explored [16–19] much less attention has been paid to the impact of health systems factors on psychiatric services. This paper describes a study which uses the Sverdlovsk Oblast2 as a lens to study how health system factors impact on mental health service provision in Russia.
2. Methods The study was undertaken, by a multi-disciplinary team of UK-based and Russian researchers, including mental health experts, health economists and management experts, in the Sverdlovsk Oblast (Box 1), as one of a number of different elements within a technical 2 An Oblast is an administrative zone or area within the Russian Federation.
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Box 1: Sverdlovsk region The Sverdlovsk Oblast, an administrative region of the Russian Federation, is situated in the Ural Mountains in north central Russia, about 2000 km east of Moscow. It is similar in size to France, with the area of 194,300 sq km, and has a population of 4.481 million. It is sparsely populated, with 23.1% of the population residing in the six principal administrative cities within the Oblast. The capital Ekaterinburg, is the largest city with a resident population of approximately 1.29 million. Sverdlovsk is broadly representative of the economic development and health system structure found throughout the country. Total healthcare expenditure per capita in Sverdlovsk oblast in 2002 was equivalent to approximately US$ 57, similar to levels spent elsewhere in Russia. assistance programme led by RJ and funded by the UK Department for International Development (DFID).3 Qualitative and quantitative methods of inquiry were employed in data generation. Primary research used qualitative methods. We used ‘purposive sampling’ with ‘snowballing’ to capture a multi-level multi-stakeholder sample [20] of key individuals involved in policy design, development and implementation, who were interviewed using a proprietary semi-structured questionnaire. Initial informants were identified prior to fieldwork, partly through contacts built up by the project leader RJ during previous visits to Sverdlovsk, as well as through discussions between the project team and local partners in the Ministries of Health and Social Protection. Subsequently through local meetings with representatives of these ministries and the federal employment agency further key individuals at different levels within the system were identified. Data emerging from interviews were validated internally through triangulation with information from documents, routine data, and other information gathered prior to, during and after fieldwork. 3 See http://www.iop.kcl.ac.uk/international/?project id=44 for more information on the project.
Secondary research included a search for relevant published literature in the US National Library of Medicine Medline and the International Bibliography of the Social Science databases, complemented by a limited handsearch of key health policy journals. Papers in both English and Russian were retrieved. This in turn was supplemented by documentary analysis of published research reports including those by non-governmental organisations working in the area, health-related surveys, legal instruments and policy documents at both the Federal and Oblast level. In addition, we liased with the Oblast Ministry of Health Statistics Division in order to obtain mental health service data routinely collected by the regional health authority. We also visited the local office of the Department of State Statistics to browse their publications in order to identify additional basic socio-economic and demographic information on the Oblast.
3. Results 3.1. Organisation and financing of mental health services Russia has a long history of mental health services delivered as a “vertical programme”––with ‘ringfenced’ funding from general and local budgets and delivered mainly in parallel to general health care services. Although a system of compulsory medical insurance was introduced in 1993 this does not apply to vertical programmes such as mental health, which continue to be funded through taxation alone. Within each Oblast, mental health services are the responsibility of the Oblast Ministry of Health and municipal administrations. Additional related services are provided outside the healthcare system and involve the social service provision system and employment services in particular. The Federal Ministry of Health and lead research institutes develop legal and regulatory frameworks, strategies and policy guidance for the delivery of all vertical programmes. In turn, the Oblasts develop local strategies within these regulatory frameworks and deliver services to the population. For vertical programmes including mental health, resource allocation and provider payment systems administered at both Oblast and municipal level remain largely unchanged from Soviet times. They are based
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on historic patterns of expenditure and inputs, such as available infrastructure, number and occupancy rate of hospital inpatient beds and the number of staff in the ambulatory sector, which in turn are determined by federal norms. Under this system as long as an institution maintains a level of bed occupancy close to a pre-determined level, irrespective of the merits of keeping an individual in hospital or the quality of service provided, it will continue to receive its full predetermined level of funding. This funding mechanism was acknowledged by stakeholders interviewed to be a key barrier to any potential downsizing of institutional care, instead providing very strong incentives to institutions to maintain a high number of beds. For instance the largest institution, the Oblast psychiatric hospital, has 1010 beds but reducing this even to 999 beds would reclassify the facility within a smaller size category where the budget allocation for staffing and provision of services would be much lower. This is of particular significance given that wages are very low and individuals often have to fill more than one job within a facility in order to earn a living wage. We found that across the Oblast that on average adult and child psychiatrists, respectively, in the Oblast had 1.8 and 1.7 full time jobs in 2002. Salaries for psychiatrists were 25% higher than those for comparable professionals in other medical sectors, but unlike these other sectors they had little opportunity to boost salaries through informal payments or private sector activity. Although there is no reason to believe that funding for mental health in Russia is any better than that found in most ex-Soviet countries it remains almost impossible to obtain accurate information on the level of funding available for mental health. At a national level no official estimate of expenditure is provided [21] while at Oblast and municipal levels we found that accounting systems make it difficult to easily obtain such information, although one crude estimate suggests that approximately 250 roubles per day (around US$ 8–9) was spent on psychiatric inpatient care. There was, however, a consistent view among those we interviewed that the level of funding for the system was insufficient to deliver services, with a typical comment being that ‘no-one gets the funds they want’. One stakeholder suggested that only around one-third of the funds required to fully meet psychiatric needs were made available.
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Another interviewee highlighted the difficulties caused by some services being funded through budgets held by the municipalities and some by the Oblast and felt that a key step would be to pool these budgets. Some municipalities provide few services directly and instead provide funds for services delivered elsewhere in the Oblast. Published rates for transferring funds between municipalities were perceived to be low; this was linked to the low level of funding for the publicly funded health system with one individual stating that ‘very often the overall public budget is not sufficient, health is not a top priority’. While in other parts of the health system user charges and voluntary health insurance can help to supplement the level of funding available, there appeared to be little scope for such additional funds to be generated within the mental health system. Overall it was clear that respondents interviewed felt the system was under resourced, but recognised the need to develop more community-based services and reduce the reliance on institutional care. The current financing mechanism would not guarantee that any reduction in institutional care would mean that resources were transferred to community-based services. Some stakeholders recognised that funds might best be transferred to other sectors such as employment or social protection to deliver some community services, but again commented that the current funding system did not permit such a development and moreover that historically co-ordination and co-operation across sectors had been limited. 3.2. Changes in the legal environment As noted in Box 2, like many other state services, it is widely acknowledged that psychiatry had been used as tool for the abuse and discrimination of political opponents during the 1960s and 1970s with some individuals within the psychiatric system denied their fundamental human rights [10,22,23]. More generally there were limitations on legal, educational and employment rights. Major changes in the organisation of psychiatric care were initiated by the Law on mental health care and guaranties of rights of citizens in mental care provision [24], enacted in 1992 and consequently amended in 2002 and 2003, obliging the government to fund and provide a package of mental health services, including emergency psychiatric care,
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Box 2: History of mental health in the Russian Federation The Soviet Union was the first nation to provide universal free access to health care services including those for mental health, and the system originally had a tradition of recognising and providing opportunities both for vocational rehabilitation and for employment, working both with patients, their families and public organisations. However, particularly from the 1960s, it is widely acknowledged that the psychiatric system was increasingly used for political abuse and access to developments in western psychiatry were highly restricted. This culminated in exclusion from the World Psychiatric Association in 1982 with readmission in 1989. In 1992, the Russian Federation passed its first mental health law protecting rights of people with mental health problems and setting out the fundamental elements of psychiatric care [10]. consultative and diagnostic care, treatments, rehabilitation in outpatient and inpatient settings and assistance in finding employment. The law protects the rights of patients, sets out the role of guardians and defines when involuntary treatment may be required. In 2001, in line with the recommendations of the World Health Report 2001 on mental health [25], a Sectoral Programme for Mental Health was developed, aimed at reorganising psychiatric care over the period 2003–2008 [26]. The programme emphasised treating patients in the community wherever possible, integrating mental health with general health services and indicating that many services, currently provided in hospitals, could be delivered in day-care and/or outpatient settings. The programme signalled a recognition and willingness to reform mental health services, with high-level political support at the Federal level for health system changes to improve mental health services. Key programme recommendations included: decentralisation of services with territorial planning in which catchment areas are assigned to local facilities; the downsizing of large mental hospitals (>500 beds);
integration of mental services into general services to help overcome isolation of patients from society; improvements in continuity of care; differentiation of services by patients’ age groups (children, working age and old age) and a more optimal (efficient) allocation of services. The programme also recognises that different models of psychiatric care service delivery are required in different settings such as rural and urban areas, or dense/scattered populations. Developments taking place at a local level in Sverdlovsk include the introduction of training courses to improve the management and detection of common mental health problems, and strengthened co-operation between the health, social protection and employment agencies in particular, recognising the need for a multi-sectoral approach to interventions. 3.3. Mental health services in Sverdlovsk By end of 2002, there were 112,668 registered patients with psychiatric disorders in Oblast (2.6% of the 4.5 million total population). Of these, 98,385 patients were registered with mental health services. Mental health care services in Sverdlovsk are still largely provided in hospitals, although the need for more community-based and rehabilitation services is widely recognised. There are 11.5 psychiatric beds available per 10,000 population in the Oblast; this ratio is similar to that seen nationally. Currently there are 15 specialist psychiatric hospitals in the Oblast with 4730 beds. Almost 40% of all bed capacity is located in two hospitals. In addition, there are eight psychiatric departments in general municipal hospitals with 445 beds. Ambulatory psychiatric teams operate in large urban areas. There are outpatient services (known as dispensaries), including some specifically for children, in almost every municipality. Around 12% of municipalities within the Oblast have day facilities with 510 beds (an increase of 8% since 2000). Sheltered accommodation is still very limited with only three hostels in the Oblast providing between 15 and 30 places each. Occupational therapy facilities are also limited, as employment opportunities, in the current economic environment, for people with mental health problems are poor. There are 390 psychiatrists, 41 psychotherapists and 131 psychologists but only 29 specialist social workers employed in the mental health services. This is comparable to levels seen in other Russian regions.
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Fig. 1. Management of mental health patients in Sverdlovsk region of Russia.
Fig. 1 illustrates potential pathways through the mental health system using a flow diagram. This emphasises that contact with services is likely to be iterative and goes beyond the health sector. Recognition of common mental health problems such as depression in primary care settings has historically been low; consequently, individuals are much more likely to come to the attention of the mental health system if a crisis (such as a suicide attempt) occurs or if an individual is diagnosed as having a psychotic disorder. Acute events are followed by a period of initial hospitalisation, followed by assessment by the Medical and Social Assessment Commission to determine whether the individual should be registered as disabled, which entitles them to some welfare benefits and for a plan to be drawn up for occupational and social rehabilitation. Following hospitalisation, individuals may be discharged to the community and receive follow-up care and rehabilitation on an outpatient basis, or alternatively, if they are not deemed capable of rehabilitation or if no place in the community is available or their family is unwilling to support them, they may be placed in a social care
home called “internat”: an undesirable outcome as few individuals ever return from internats to the community. As Fig. 1 indicates the Medical and Social Assessment Commission therefore plays a critical role in acting as the bridge between the social and health sectors, which remain separate in terms of organisational structure and financing. It also plays a critical role in reintegration into the community; without a Commission recommendation that an individual is capable of employment, in practical terms it is almost impossible to obtain work. Once discharged to the community most patients are subject to mandatory outpatient observation for followup and treatment. In 2002 there were 790,750 visits to psychiatrists, as compared with 818,082 in 2001 and 813,303 in 2000, with an average of 7.3 visits per patient per annum. There has been little change in the rates of hospitalisation. In 2002, 38,095 patients were hospitalised due to mental health problems (a hospitalisation rate of 86.7 per 10,000 people), as compared with 38,260 in 2001. Of these, 66% were first time and 34% repeat admissions. The average length of stay per adult patient in 2002 was 49.9 days. In the same
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period, the number of patients seen in day-care4 facilities increased from 2945 in 2001 to 3911 in 2002.
4. Discussion Despite attempts at reforming the mental health system in Russia, with commitments at both the Federal and Oblast levels to establish a more communityoriented mental health service, the system remains highly hospital-centric with rates of hospitalisation much higher than those found in western Europe [27]. Stakeholders interviewed highlighted both funding mechanisms and the challenge of co-operation and co-ordination across sectors as major barriers to change. Much care is still provided in large-scale psychiatric hospitals, characterised by lengthy hospitalisation and repeat admissions. This is predominantly because the provider payment systems based on inputs, such as number of beds, historic activity levels and historic resource base encourages the preservation of big hospitals with large numbers of beds and staff. Furthermore, as with tuberculosis services, due to the lack of funding and available housing for independent living within the social protection system, such hospitals perform a social function, in that they provide shelter and sustenance for individuals that they might otherwise not be able to obtain [28]. International experience, which suggests that mental health services can be shifted successfully to the community and be more cost-effective than hospitalbased care [27], suggests that there is considerable scope for improving the efficiency of mental health services in the Russian Federation, in particular, through modification of case management among patients currently treated as inpatients. However, such a shift can only be considered if (a) alternative community-based services that are at least as effective as the existing use of inpatient care are put in place and (b) if measures are taken to ensure that the already low level of resources used for mental health are re-invested in these alternative community-based mental health and social care services. In Russia, our analysis suggests that there are five important barriers to the rationalisation of the hospital4 Institutions where individuals literally the majority of their day in bed receiving treatment and then return home at night.
based mental health system and the development of a community-based mental health service that will need to be addressed: first, hospital funding is based on the existing number of beds and bed occupancy, which in turn determine numbers of staff and other inputs. This provides perverse incentives for providers of mental health services to maintain existing beds and hospitalise psychiatric patients; second, funding increases and resource allocation for hospital infrastructure are based on historic patterns and norms rather than on any measure of psychiatric needs or cost effectiveness (indeed we found little appetite for the use of cost effectiveness information by stakeholders). Third, regulations relating to the management of mental health cases stipulate periods of hospitalisation. Fourth, large numbers of staff posts exist in mental health hospital, with many individuals having more than one job to boost income. Reducing or redeploying the human resources to the community may be politically difficult to achieve, as isolated hospitals may be the principle source of employment in rural communities and staff may need significant levels of retraining. Outpatient services for mental illness, as well as primary care and social support for the large share of patients that are unemployed are poorly developed, making it hard to implement potential cost effective alternatives to inpatient care. Finally, administrative laws and financing regulations in Russia (as in many other industrialised countries) can hamper the shifting of funds from health to social (or other) sectors, or the pooling of health and social sector budgets, limiting the opportunities for multi-sectoral policies that might address the broader challenges of reintegrating or maintaining individuals in the community. In the current financing system, any reduction in resources used by reducing the use of institutional care would not necessarily be reinvested in mental health services within or outside the health sector such as in social care, hence creating a significant barrier to change. Restructuring of the existing structures to develop a community-oriented mental health services requires changes to existing resource allocation mechanisms, provider payment systems and incentives for both mental health services and the health system as a whole. Moreover, additional transitional funding will be ideally required to develop the necessary alternative community- and general hospital-based services, while the excess, institutional-based care, is phased-out. As
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there are no mechanisms to protect any efficiency savings realised from the hospital sector it is likely that any proposals to promote cost effectiveness in mental health hospitals will be strongly opposed by health professionals. In Russia, financial resource allocation mechanisms and provider payment systems for vertical health programmes including mental health need to be reformed, so that resources can follow individuals regardless of whether they are treated in hospital or in the community. Incentives need to be built into the system to encourage such change. Approaches to consider might include the introduction of per capita funding, diagnosis related group reimbursement fees for mental health, pooled budgets across sectors or even the introduction of direct payment schemes where individuals with mental health problems are empowered to purchase services matching their own needs. However, such a major health system shift can only be achieved through changes at the Federal level and would require major political will. This is something that would inevitably have an impact on the system more widely not just on the mental health sector, but there is substantial evidence from other parts of the globe that changing financial incentive structures can act as a powerful incentive for mental health system reform [29]. Our findings have important policy implications for mental health services in Russia and the wider former Soviet Union where similar systems exist. Psychiatric hospitals shoulder costs of extensive periods of hospitalisation for clinical care but also a substantial burden of non-clinical social support. Improving the efficiency with which existing resources are used will require reform of health system norms and regulations related to planning, financing and clinical care, and the introduction of new, cost neutral approaches to case management for service users with social needs. However, in the absence of such radical health systems reforms, modernisation of mental health services will continue to be challenging. The nature of mental health disorders mean that this is not a problem faced within the health system alone, and greater attention needs to be placed also on how to maximise the cross sector benefits and many social needs such as access to normal housing, supported housing, support from community social services, vocational rehabilitation and access to employment all of which lie outside the health sector, especially within the social protection and employment
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