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
Table of contents
Table of contents
Acknowledgements
Abstract
List of abbreviations
Introduction
CHAPTER 1: Background Information of the Thesis
Country information
Health care system and budgeting
Overview of epidemiology of mental disorders
Problem statement
Aim and objectives of the thesis
CHAPTER 2: Methodology and Analytical Frameworks
Methodology
Theoretical frameworks
Theories on mental health services delivery
Framework of mental health services analysis
Theories on transition
Indicators of transition
CHAPTER 3: Overview of Mental Health Services in Ukraine
Structure of mental health services delivery
Individual level
Primary care services
Outpatient services
Inpatient services
Community care services
Problems of mental health services
Identification of elements of services to be included in transition
Country/regional level
Local level (catchment area)
Patient level
CHAPTER 4: Transition of Mental Health Services
Periods of transition
1991-2000 hospital level
1991-2000 community level
2001-2006 hospital level
2001-2006 community level
Factors of slow transition
CHAPTER 5: Discussion, Conclusions, Recommendations
Discussion
Conclusions
Recommendations
References
Appendix I. Map of Ukraine
Appendix II. Organizational Chart of Health Care System
Appendix III. Financial Flow Chart of Health Care System
Appendix IV. Definitions
Appendix V. Coding of Respondents
Appendix VI. Interview Guide
Appendix VII. Structure of Email Communication with Experts
Appendix VIII. Scheme of Mental Health Services
Appendix IX. Matrix Model of Mental Health Services
Appendix X. Pathways to Mental Health Services
Appendix XI. Comparison of the Periods of Transition of Mental Health Services
Appendix XII. Number of Mental Health Facilities 1991-2000
Appendix XIII. Process of Transition of Mental Health Services in Ukraine
Appendix XIV. Process of Transition in Lithuania: Vasaros Hospital
Appendix XV. Future Developments of Transition
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.
Abstract
This 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: outdatedcurriculum 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.
List of abbreviations
CMHS – Community mental health services
DALY – Disability adjusted life year
DSM - The diagnostic and statistical manual of mental disorders
EU- European Union
FSU- former Soviet Union
GIP – Global Initiative on Psychiatry (formerly Geneve Initiative for Psychiatry)
GP – General practitioner
HCS – Health care system
IBPP – Institutional Building Partnership Program
ICD - International classification of diseases
ICF - International classification of functioning, disability and health
IO – International organization
MD – Mental disorder
MH – Mental health
MHS- Mental health services
MHSM – Mental health system
MoF- Ministry of Finances
MoH – Ministry of Health
MSPL - Ministry of Social Policy and Labor
NGO – Non-government organization
PHC – Primary health care
PMD – People with mental disability
TACIS- Technical assistance for the Commonwealth of Independent States
UPA – Ukrainian Psychiatric Association
There is no health without mental health.
Helsinki, 1999
Introduction
All 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 system[1] and mental health system[2]. Such changes include four key processes of MHSM: transition, de-institutionalization, institutionalization and mental health[3] reform. They are often confused and thus need to be clarified.
Firstly, the author of the thesis defines transition as the process of changeof the delivery of mental health services[4]from one model ofMHS to the otheron 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 disorders[5], 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
CHAPTER 1: Background Information of the Thesis
Country information
Ukraineis a former Soviet Unionlow 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 budgeting
The 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 Health[6] 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 Finances[7] 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).
“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 disorders
The overview provides general information on the factors which cause MDs in Ukraine, epidemiology of MDs according DSM-IV[8]. 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 overall DALY[9] 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 100000 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 statement
MHSM 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 thesis
This 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:
- to examine the need for transition of MHSusing service delivery, service analysis matrix (Tansellaand Thornicroft 1998) and theories on transition;
- to analyze periods and processes of transition of MHS in Ukraine from 1991 till 2006;
- to formulate conclusions on the reasons for slow transition;
- 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 Union[10] countries.
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 expertswere conducted after the author has experienced a lack of information on the topic in the existing literature.