Case Study Mental Health Patient Advocates

Citation: Raja S, Underhill C, Shrestha P, Sunder U, Mannarath S, Wood SK, et al. (2012) Integrating Mental Health and Development: A Case Study of the BasicNeeds Model in Nepal. PLoS Med 9(7): e1001261. https://doi.org/10.1371/journal.pmed.1001261

Published: July 10, 2012

Copyright: © 2012 Raja et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: DFID, UK, provided funding for implementing the Mental Health and Development Model in Nepal. Vikram Patel is supported by a Wellcome Trust Senior Research Fellowship in Clinical Science. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: SR, US, SM, and SKW are employed by BasicNeeds, a mental health and development organization. CU founded BasicNeeds. At the BasicNeeds Nepal programme, their partners in Nepal (LEADS) contacted a Nepalese pharma company—Asian Pharmaceutical Company—for assistance in providing medicines to the Users who access services in the programme's operational districts of Baglung and Myagdi in the Western region. As a result, the company agreed to provide free medicines for up to 200 users attending the MH camps organised by LEADS at the district hospitals. They have so far supplied twice. Discussions are currently going on for their continued help and for them to supply directly to the two district hospitals in future. This provision of medicines is done without any formal contractual arrangement with LEADS (or BasicNeeds) and there is no direct financial association between our organizations and Asian Pharmaceutical Company. In a nutshell, the sum total of the association is the provision of free medicines for 200 patients (and possibly more in the future). PS is employed by LEADS, a non-profit organisation which provides medical treatment and other support services to individuals with mental illness. VP is a guest editor of the Global Mental Health Practice Series and was involved in the selection of commissions, including this particular paper, but he was not involved in the peer review or editorial decision making about this article.

Abbreviations: CBW, community-based worker; FCHV, female community health volunteer; HMIS, health management information system; LEADS, Livelihoods Education and Development Society; LMIC, low- and middle-income country; MHC, Mental Health Camps; MHD, Mental Health and Development; PPP, purchasing power parity; SHG, self-help group; WHO, World Health Organization; WRH, Western regional hospital

Provenance: Commissioned; externally peer reviewed.

This case study is part of the PLoS Medicine series on Global Mental Health Practice.

Mental Health and Development

People who live in conditions of social disadvantage are at greater risk of developing mental illness [1]. Access to treatment in low- and middle-income countries (LMICs) is limited and can be expensive [2]. Stigma makes it difficult to secure already limited employment and education opportunities [3]. While a mental health treatment gap has been widely acknowledged, less attention has been paid to addressing the poverty gap, which often accompanies mental illness [4]. The recent World Health Organization (WHO) report on mental health and development concluded that people with mental health conditions met all the criteria for vulnerability and merit targeting by development strategies and plans [5].

BasicNeeds was founded in 2000 and developed its community-based integrated Mental Health and Development (MHD) model, inspired by development theory, which emphasizes user empowerment and community development, as well as strengthening health systems and influencing policy [6],[7]. Figure 1 shows each component of the MHD model.

Figure 1. The BasicNeeds Mental Health and Development Model.

The vision for the model is that the basic needs of all people with mental illness or epilepsy throughout the world are satisfied and their basic rights are recognized and respected. The purpose is to enable people with mental illness or epilepsy to live and work successfully in their communities.

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In practice, the five modules of the MHD model work in conjunction to address the treatment, capabilities, and opportunities gaps experienced by affected individuals. Evidence suggests that community-based models that integrate health care and social interventions can have a positive impact on clinical outcomes and social and economic functioning for affected individuals in low-resource settings [8],[9]; and the BasicNeeds Model offers a feasible method of integrating mental health into existing community-based interventions [10].

BasicNeeds has witnessed exponential growth in response to requests for MHD programmes. In 2011, BasicNeeds operated MHD programmes in a total of 98 districts in 11 countries (Ghana, Uganda, Kenya, Tanzania, India, Sri Lanka, Nepal, Lao PDR, and Vietnam, with new programmes being initiated in China and the United Kingdom), working with 55 local partners, reaching 39,518 affected individuals. A major challenge has been sustaining existing programmes while adding new ones. After extensive consultations, BasicNeeds planned further scale up through a social franchise of the MHD model, i.e., a commercial franchising approach to replicate and share organizational models for greater social impact [11].

This paper will focus on a description of one particular MHD program in Nepal. The Nepal program was chosen because this allows highlighting operations in a fragile state where the government is unable to deliver even the most basic services, particularly in remote regions [12]. Nepal is also the first country where BasicNeeds has not set up a country office but operates through a direct partnership with an independent local nongovernmental organization, with expertise in community-based rehabilitation (CBR) and related training, called Livelihoods Education and Development Society (LEADS)—an operational prototype for future franchisees.

MHD in Nepal—A Case Study

Nepal is a Himalayan country, sandwiched between China and India, with a population of 28.2 million people [13]. The country is divided into 75 districts and almost 90% of the population lives in rural areas [14]. Nepal's gross national income per capita at purchasing power parity (PPP) in 2010 was US$1210, ranking 148 out of 167 [15]. The life expectancy at birth is 68 years and the literacy rate is 59% [12]. Long-standing political conflict has created additional hardships. Less than 1% of health expenditure is spent on mental health (0.14%), and there is no mental health legislation [16]. Nepal currently has only one public sector psychiatric hospital offering inpatient services and 32 psychiatrists. United Mission Nepal's Community Mental Health programme between 1990 and 2004, despite challenges of sustainability, was an excellent effort in advocating for integrating mental health into primary care in Nepal [17],[18].

The Nepal MHD programme, funded through the Department for International Development, UK, is a 4-year programme (May 2010–March 2014) operating in Baglung and Myagdi districts, with populations of 270,009 and 113,731, respectively. The majority depend on agriculture for their livelihood. A baseline situational analysis revealed the absence of any government mental health services and an absence of mental health trained human resources. The economic burden for those who sought treatment was heavy [19], estimated at 25,000 Nepalese rupees (US$312) for a family per year [20].

Figure 2 describes the programme matrix of the Nepal MHD model. The matrix demonstrates the role of diverse sectors in implementing the model, including the close links with the districts' government-run health facilities and existing community structures—a key strategy to integrate, and sustain, mental health and development.

Figure 2. The Nepal Mental Health and Development programme matrix.

Detailed description of key activities, locations, and resources pertaining to the Nepal Mental Health and Development Programme. Mental Health Camp is a concept popular in India, and refers to a collaborative activity in which a team of health professionals carry out out-patient clinics in community settings at regular intervals. VDC (Village Development Committee) is an elected government body at the lowest level of governance (small group of villages) in Nepal. Primary Health Care in Nepal is provided through a decentralized system. Health Posts (HP) cover an area of 3 to 4 Sub Health Posts (SHP). A Health Assistant (HA) is the In-Charge of a HP. SHP are established in all VDC areas. Auxiliary Health Worker (AHW) heads a SHP. Other staff in a SHP are Auxiliary Nurse Midwife, Maternal & Child Health Worker, and Village Health Worker. Female Community Health Volunteers (FCHVs) are volunteers attached to the SHP/HP and are involved in health education in their communities. They receive an annual incentive from the government. Mothers' Groups are community-level women's groups that are encouraged by the government through the VDCs and specifically linked to the primary health care facilities. Mothers' group meetings are facilitated by the FCHVs. Community-Based Workers (CBWs) are community-based staff recruited by LEADS for the project.

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The initial identification of affected individuals was done by appropriately trained key local stakeholders who mobilized these individuals to seek care from the mental health program (Figure 3 has details; [21]). Service provision followed a collaborative care model [22].

Figure 3. Characteristics and benefits of the users of the Nepal Mental Health and Development Programme.

Upper left: Breakdown of diagnoses for all users of the program. Total number of users is 311, with 134 males and 177 females. Upper right: breakdown by gender of new individuals accessing treatment during the periods (I) July–September 2010, (II) October–December 2010, and (III) January–March 2011. Center: breakdown of diagnoses patterns for new individuals accessing treatment during each of the periods (I) July–September 2010, (II) October–December 2010, and (III) January–March 2011. Bottom: source of identification of new individuals accessing treatment during each of the periods (I) July–September 2010, (II) October–December 2010, and (III) January–March 2011. *Common mental disorders refers to anxiety, depression, phobia, and psychosomatic disorders.

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Treatment services started in August 2010 when the first Mental Health Camps (MHC) were held at the district hospitals in Baglung and Myagdi. Dr. Lumeshor, chief psychiatrist at the Western regional hospital (WRH), Pokhara, attends the camps with his team. The appointment of a senior health assistant as “mental health focal person” in November 2010 in both district hospitals greatly helped to manage the “flow” of mental health activities. However, it soon became clear that the district hospitals could not remain the only point of service provision. The number of patients increased but the frequency of the camps could not be increased, as the psychiatric team was unable to come more often. Besides, for many patients, accessing the hospitals meant four hours to walk each way. Thus, follow-up clinics were started at the Health Posts with the District Health Offices permitting the newly trained health personnel to run them. They, however, needed further coaching and supervision. LEADS provided them with SIM cards for their mobile phones, which they use on clinic days to maintain contact with the chief psychiatrist at WRH.

Starting in October 2010, individuals/families were prioritized for livelihoods support (diagnoses, process, and criteria for prioritizing, see next section) through skills training and/or cash grants for setting up a business or in kind. Simultaneously affected persons were linked into existing self-help groups (SHGs), opening up opportunities to integrate into mainstream groups and ensuing opportunities. LEADS' community-based workers (CBWs), coordinators, and female community health volunteers (FCHVs) made home visits to provide continuing support to the families and to also identify more affected individuals.

Impact, Barriers, and Opportunities

Figure 3 provides an overview of the characteristics of and benefits for persons affected by mental illness accessing the MHD program in the short span of the 8 months since its inception.

The most common diagnoses were common mental disorders, followed by psychosis and epilepsy [23]. Qualified psychiatrists made diagnosis using WHO ICD-10 criteria, and thereafter recorded follow-up assessments in individual clinical information sheets. Of the 311 patients registered with the program until March 2011, 269 have been reported to show improvement. Over time we saw an increasing number of identifications from home visits and some self-referrals.

Baseline data collected at MHC showed 142 had accessed pharmacological treatment earlier, the vast majority from private providers in Kathmandu (4 days travel) or Pokhara (2 days). Apart from the travel costs, these families also paid for the consultation and medicines. All of them now attend MHC at the district hospital (4 hours travel maximum) and follow-up clinics in their local health posts, do not pay for services or medicines, are registered as Out Patient Department (OPD) patients, and are therefore part of the district health management information system (HMIS).

Of the 311 persons who have so far accessed the program, 32/214 (15%) of those who were not in an income-generating occupation began earning an income, and 22/48 (46%) of persons who were not engaged in any form of productive work (e.g., household chores) began such work. While this is low proportion relative to the estimated epidemiological need, the capacity of the health facilities requires further strengthening to provide mental health services to a larger number of patients.

Between October 2010 and March 2011, 55 affected individuals, showing significant clinical improvement, were assessed by LEADS for eligibility for livelihoods interventions. A checklist was used followed by discussions with the individuals themselves and their families. The indicators were: work before illness, interest to work, ability to work, traditional skills, family involvement, and market scope. Thirty-one individuals, with varying diagnoses (psychotic disorders-11, epilepsy-11, common mental disorders-9) were prioritized for support. In October 2011, LEADS carried out an evaluation of the outcomes of these 31 individuals. Data collected were: details of business plans, investment made, expenses incurred, income and savings details as well as their views about progress, problems, family support, financial situation, and future plans. Initial findings showed that all 31 were earning in a range of occupations including running a tea/grocery shop, chicken and goat rearing, tailoring, and embroidery. The six who earned prior to the program observed an increase in income ranging between 17% and 108%. Two individuals with epilepsy were doing skilled work (tailoring and making copper pots) and reported monthly earnings well above the stipulated minimum wage. Two persons diagnosed with depression, whose occupations were running a provision shop or tailoring, earned close to the minimum wage. The rest have incomes below the minimum wage. Ten have deposited savings with LEADS to be transferred into the account of a livelihoods co-operative that has been initiated.

The program has experienced a number of barriers in its implementation. Villages in both districts are remote, almost entirely inaccessible by road, and distances are still measured in number of days to walk. Despite the inhospitable terrain and associated difficulties, demand for services is growing and a key challenge is to keep pace with supply—i.e., availability of psychiatrists, trained health personnel, and medicines. At present, MHC held at the district hospitals every alternate month are the nearest point where/when the psychiatrist is available. LEADS is currently talking to a local private hospital for additional psychiatric support.

The increased or regained capacity of affected persons to work and earn has been a motivator. However, opportunities are few and earnings are low by any standards. The lack of development in the region limits the scope of available livelihoods options. The hilly terrain and sparse population makes it difficult to bring together a reasonable number of persons from different villages to form SHGs that can be sustained over time for self-advocacy. Integrating affected persons into the innumerable existing village-level SHGs (which can also help address stigma) posed problems, as existing members resisted the idea of mentally ill people joining. Incentivizing the SHGs with revolving micro-credit funds and skills training has helped to integrate affected persons to some extent.

In Nepal, primary health care is offered through a decentralized system [24]. The MHD programme already works through this. Continued engagement with health facilities, support to affected persons and families for livelihoods, and repeated awareness activities over time will help integrate the model into the routine activities of the existing providers and communities, but funds for sustaining these activities will be required. Continued political instability in Nepal has delayed LEADS' plans for engaging with the government more substantially.

Looking to the Future

In the two districts the plan is to expand access and sustain the program by building capacity in local resources by training more local doctors in mental health (both private and government); holding MHC in remote locations so persons living there have easier access to specialist attention; training and supporting all health posts to include mental health records in HMIS; widening the scope of training for health workers and FCHVs to support livelihoods interventions; establishing a livelihoods cooperative; training affected persons to evaluate services; and forming district-level advocacy groups of affected persons. LEADS will step up its engagement with the Primary Health Care Revitalization Division for policy changes, especially on psychotropic medicines allowed at the primary care level and budgetary allocations for mental health. Ultimately, lessons from the experiences in Baglung and Myagdi, and evidence from a cohort intervention study (underway), will be used for designing a scaled-up programme in six more districts in the Western Region.

BasicNeeds has implemented the MHD model in nine countries. Many of the older programmes have encountered and negotiated the kind of difficulties we are currently observing in Nepal, and lessons from those experiences may have relevance in Nepal. In Uganda, for example, advocacy groups now engage directly with district officials to lobby for improved treatment services. In Ghana, groups have come together as a registered national association, the Mental Health Society of Ghana (MEHSOG), for advocacy. In Lao PDR, mental health services are available through primary care in nine districts of Vientiane capital region. There are a number of lessons from BasicNeeds' total experience in 10 years that can be relevant more widely in scaling up community-oriented mental health interventions in LMICs as well as developed countries.

Strategic engagement and effective working relationships with and involvement of government and other local/national stakeholders is critically important if a demonstration project has to influence mental health practice and policy for scale up. Involvement of affected persons and families is fundamental for maintaining relevance and effectiveness of interventions even if they are evidence based. Advocacy by affected persons is powerful and must be supported to become effective. Community involvement is important, as it supports affected persons and families in the process of recovery and can effectively support delivery of services. Involving affected persons, families, and communities requires detailed planning and has to be intrinsic to the intervention programme. Tapping into local or in-country resources, skills, and capabilities will help sustain service delivery. Designing simple yet rigorous records and data collection systems for complex community-based mental health programmes is feasible and crucial for monitoring quality and can substantially aid evaluations; such evaluations must be intrinsic to the intervention programme.

Above all, the MHD model is not in parallel or an alternative to government and other local efforts for effective mental health interventions. The model works to provide the “great push” required to set up mental health and development services in places where they are not on the agenda of government or civil society [25].

Acknowledgments

We wish to acknowledge the valuable contributions made by Dr. Lumeshor, Chief Psychiatrist, Western regional Hospital, Pokhara, Nepal, and the following individuals from LEADS, Nepal: Sarita KC, Bir Bahadu Thapa, Mona Bhandari, Padam Gautam, Mim Kumari Poudel, Meena Pun, Ratika Mijar, Shoba Kaucha, Than Maya Srish, Laxmi Thapa, Geeta Mizar, Chitra Thapa, Padma Shrestha, Santosh Limbu.

We are grateful to Sabina Jancy and Lata Jagannath from the BasicNeeds Policy and Practice Office, Bangalore, India, for their administrative support.

Finally, we give our special thanks to the individuals with mental illness and epilepsy who have participated in the Mental Health and Development programme in Nepal.

Author Contributions

Analyzed the data: SR US SM VP. Wrote the first draft of the manuscript: SR. Contributed to the writing of the manuscript: SR CU PS US SM SKW VP. ICMJE criteria for authorship read and met: SR CU PS US SM SKW VP. Agree with manuscript results and conclusions: SR CU PS US SM SKW VP. Created the Model for Mental Health and Development: CU.

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Summary Points

  • The BasicNeeds model of Mental Health and Development (MHD) emphasizes user empowerment, community development, strengthening of health systems, and policy influencing.
  • The MHD model works in partnership with governments to provide the “great push” that is required to set up services where mental health and development has not been a priority.
  • The model is comprised of five key components: capacity building, community mental health, livelihoods, research, and management.
  • Involving affected individuals, their families, and communities in a program, as well as tapping into local resources, is essential to the success and sustainability of a program.
  • Strategic engagement with government and other stakeholders is critical to demonstrating a project's capacity to influence mental health practice and scale up.

Citation: Makhashvili N, van Voren R (2013) Balancing Community and Hospital Care: A Case Study of Reforming Mental Health Services in Georgia. PLoS Med 10(1): e1001366. https://doi.org/10.1371/journal.pmed.1001366

Published: January 8, 2013

Copyright: © 2013 Makhashvili, van Voren. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: No specific funding was received for writing this manuscript.

Competing interests: NM is Director of Global Initiative on Psychiatry-Tbilisi (GIP-Tbilisi), which is involved in mental health reform programs in Georgia. RV has declared that no competing interests exist.

Abbreviations: MoLHSA, Ministry of Labour, Health and Social Affairs; NGO, non-governmental organization

Provenance: Commissioned; externally peer reviewed.

This case study is part of the PLOS Medicine series on Global Mental Health Practice.

Introduction

Psychiatric services in the former Soviet Union were characterized by high rates of institutionalization and a strong focus on biological treatment. In the post-Soviet states, these features remain—there is strong resistance to the introduction of modern, community-based, and user-oriented services [1]. In many cases, psychiatric reform programs have come to a halt or even been reversed [2]. It is against this backdrop that Georgia began a critical phase of its mental health reform program almost two years ago.

Georgia, which has a population of 4.4 million and ranks 75th on the United Nations Development Programme's Human Development Index, is one of the three Caucasian countries that regained independence in 1991. Its recent history has been turbulent. The country was ravaged by a bitter civil war from 1991 to 1993, the economy almost came to a standstill, and the health care system collapsed. It took until the end of the 1990s for basic health care services to be reestablished. Progress continued during the first years of this century, with health systems reforms that included moving away from the “Semashko system" (a Soviet system of state-owned health facilities and state-funded health professionals [3]), changes in health care financing and provision, development of private health care insurance, and the privatization of health care providers.

The recent National Health Care Strategy 2011–2015[4] developed by the Ministry of Labour, Health and Social Affairs (MoLHSA) stresses the importance of mental health care and of ensuring a balance between providing community-based and hospital-based mental health services. In this article, we provide an overview of the mental health reform process, including its complexities and challenges. The reform process is still very much in progress, which makes it difficult to assess its impact. Nevertheless, the case of Georgia might provide insights that can help other countries that are embarking on a similar mental health reform program.

The Mental Health Situation

In 1995, Georgia adopted a mental health care program (as part of a new general health care program) in which people with mental disorders on the national psychiatric register under the Ministry of Labour, Health and Social Affairs received free-of-charge services and treatment at both hospitals and outpatient clinics [5]. Six psychiatric institutions with an average of 1,000 beds provided hospital care (30.27 beds per 100,000 population). However, these mental health care reforms were accompanied by a significant decrease in funding for hospital beds, without providing any alternative outpatient care. This was a general trend in post-Soviet countries, as illustrated in Figure 1, which shows that there has been an almost five-fold reduction in the number of psychiatric beds since 1995, because of insufficient financing of mental health services [6]. Unfortunately, this decline in hospital services in Georgia was not counterbalanced by the development of outpatient and community-based services.

At present, aside from psychiatric hospitals, there are 18 outpatient psychiatric clinics (“dispensaries") in the country. However, there is an unequal distribution of mental health services across the country: there is less access, and a lower quality of services, in poor, remote regions. Nearly half (48%) of all licensed psychiatrists are working in the capital city, Tbilisi.

The number of people registered with a mental disorder in 2010 was 79,216 (out of a total population of 4.4 million) [7]. This figure is likely to be an underestimate of the true burden of mental illness, since it does not capture patients who visit private doctors or who do not access formal psychiatric services; thus, only those who have severe mental disorders are registered at dispensaries.

Health care expenditures have significantly increased over the past several years and in 2011 reached 10.1% of the country's gross domestic product [8]. However, only 2.11% of the total health budget is spent on mental health. Mental health care is delivered within the framework of the State Program for Mental Health Care and is administered by the MoLHSA. The budget of the program more than doubled between 2006 and 2011, reaching 12 million Georgian lari (US$7.3 million). Until recently, the state allocated about US$8–11 per day for patients admitted to institutions (2008–2010) and US$7–8 per day for outpatient treatment. This was hardly enough to cover salaries, heating, and food, which resulted in ineffective care. Table 1 shows changes in the state budget and services for psychiatric care between 2006 and 2011. The table illustrates a gradual increase in funding and diversification of the package of services that is offered to people with mental health disorders. However, it also shows the priority for funding of hospital care, the stagnation of funding for psychosocial rehabilitation, and the fact that only a very small portion of finances is reserved for outpatient care.

Social Exclusion and Human Rights

Until recently, patients with mental health problems were kept in large institutions, where people were forced to live in inhuman conditions or sometimes even left to die [1]. Georgia has yet to complete the fundamental transformation from the old Soviet mental health care structure into a humane system that meets basic human rights standards [9].

Recent studies carried out in Georgia show the magnitude of the problem and reveal a strong link between mental ill health, social exclusion, and poverty [10]. Reports from the Public Defender's Office [11], based on regular monitoring of closed psychiatric institutions, highlight gross violations of all basic rights of inpatients. Such violations range from inappropriate involuntary hospitalization (which is now forbidden by the new Law on Psychiatric Care, introduced in 2007) to violations of a patient's right to privacy, information, and rehabilitation. The European Committee for the Prevention of Torture has repeatedly criticized the Georgian government for the poor conditions in the country's mental institutions [12],[13]. But the tide is now changing: the evidence on human rights violations that was presented to policymakers over the years was a strong impetus for the mental health reform process.

The Push for Change

The Legal Framework

One of the prime outcomes of human rights lobbying was the adoption of the new Law on Psychiatric Care [14], which is generally considered to be progressive and rights-based [15]. The law entered into force in 2007 and instituted a number of new practices, such as making a court decision for any involuntary hospitalization obligatory. Several bylaws introduced practical procedures, for example, procedures related to the use of physical restraint. In 2009, Georgian psychiatric care experts analyzed the law's implementation [16], and several further modifications were adopted, particularly related to procedures in forensic psychiatric treatment and prison mental health.

The Crucial Involvement of Non-Governmental Organizations

One of the essential elements in the reform process was the strong voice of the non-governmental sector. The activity of civil society organizations, professional societies, user groups, and family member organizations created the momentum that was essential for a movement towards rights-based and humane mental health care. As representatives of one of these organizations, the Global Initiative on Psychiatry, we have intimate knowledge of the influence of the non-governmental organization (NGO) sector upon the mental health reform process. The NGO sector often functioned as the conduit for international expertise and knowledge about best practices in other countries. To provide an overview of NGO-originated interventions, we describe them here from the grassroots to the national level.

Reforms at the grassroots level.

In searching for innovative, locally appropriate, and implementable models, new projects and activities were developed by mental health NGOs such as Global Initiative on Psychiatry and the Georgian Association for Mental Health, following World Health Organization [17],[18] and other international [19]–[21] recommendations. State standards regarding these new initiatives were adopted (e.g., regarding psychosocial rehabilitation and child day care service), and after they were proven to be effective and appropriate, these initiatives were replicated and integrated into the existing state health care system. Many new community-based services, such as crisis intervention and home care, were rolled out through this approach of small pilot projects followed by national scale-up. A recent example is the creation of crisis intervention teams that deal with emergency cases within certain catchment areas in the capital [22].

Reforms to mental health training.

In challenging the old model of psychiatry and introducing contemporary approaches, capacity building activities have been promoted. These include the translation and publication of modern mental health literature into Georgian; the opening of the Mental Health Resource Center at Ilia State University in Tbilisi; a wide range of intensive trainings, workshops, and conferences; and the organization of exchange visits and research activities.

Reforms at the national level.

At the national level, the main strategy of the NGO community was to influence the government and other mental health policymakers to adopt legislation and to abide by the new laws, to develop relevant mental health policies and plans (e.g., juvenile delinquency prevention), and to create monitoring mechanisms to ensure the protection of human rights. The efforts have been directed towards development of a coherent national mental health system. Some of the initiatives were successful, though they required long-term advocacy and much effort; others failed, such as the attempt in 2009 to introduce a mental health policy that would outline the direction reforms should take.

International Donors

Many of the initiatives were made possible with funding from the international donor community. Whereas for many years the donor community often forgot to push for sustainability and embedding of programs within the local context, this changed after 2005. In the mental health field, the Dutch Ministry of Foreign Affairs, the European Commission, the United Nations Development Programme, and the Romanian Ministry of Foreign Affairs (channeling their funds through the United Nations Development Programme) provided the essential financial means to carry out pilot programs and finance them until local resources could take over.

Reforms Take Shape

Several stages can be discerned in the process of reforming Georgian mental health care services. Increased funding as a result of the doubling of the state budget for mental health since 2004 allowed the MoLHSA to gradually scale up existing mental health services. This included improving the quality of treatment, rehabilitating some of the main psychiatric institutions, improving the living conditions of patients undergoing forensic treatment, and initiating a psychosocial rehabilitation program. In 2008 the introduction of a new funding model for hospital care gradually led to a reduction of the number of inpatients. However, these reforms still did not go far enough. Essential treatment methods, such as psychological treatment, remained unavailable, and there was still a lack of community services. Multidisciplinary teamwork and case management were still absent, and there was widespread low motivation, apathy, and resistance of the system to innovations. The long preparatory stage equipped the stakeholders with relevant knowledge and experience, which proved useful when designing further reforms. Acknowledging that “conditions, in which the patients of mental health care institutions live and undergo treatment, require urgent intervention," the MoLHSA announced a new and fundamental reform program at the end of 2010, and implementation started soon after.

The priorities of this recent program [23] are very much in line with international requirements and standards set by, for example, the World Health Organization [24],[25]. The MoLHSA's National Health Care Strategy 2011–2015[4] reiterated the importance of mental health care. The stated goal of this strategy is to improve the population's health by reducing disease burden and mortality by 2015. Strategic objectives include reducing inequalities in access to care; improving quality of services; protecting patients' rights; promoting prevention, preparedness, and response; and improving management of the health sector. A special chapter identifies “increased physical and geographical access to services" as a top priority and stresses the need to develop balanced, integrated, and continuous care for persons with mental disorders. To implement the desired changes, the MoLHSA created a Consultative Council on Reform consisting mostly of psychiatrists. High officials from the ministry take active part in the discussions and consultations.

Initial Steps in the New Reform Process

Deinstitutionalization

The most important dimension of the new reform process, deinstitutionalization, took place in early summer of 2011. Symbolically, the most significant step was probably the closing of one of the largest psychiatric hospitals in the country, the vast and dilapidated Asatiani Psychiatric Hospital in the center of Tbilisi, which had 250 beds at the time of its closure. Acute beds (in units of 30 beds) were relocated to newly opened psychiatric units in general hospitals (four departments are now functioning in multi-profile hospitals); a new child mental health ward with ten beds was opened in a general hospital; and a separate mental health center was established in Tbilisi, with a variety of services: an acute ward, a long-term treatment department, and an outpatient service, including a crisis intervention center with a mobile team. In addition, long-term residential facilities were opened in several towns (each with 40 beds), and crisis teams started functioning in some other cities of Georgia, for example, Batumi, Rustavi, and Kutaisi. Guidelines and codes of conduct were elaborated, and a service development policy was drafted.

These reforms immediately resulted in a fall in the length of stay for patients with acute mental illness, from an average of two to three months before the reforms to an average of 21 days now. The length of stay for a patient with acute mental illness refers to the time from initial hospitalization to either discharge or transfer to a long-term department.

For the next stage of the reform program, the MoLHSA plans to develop multifunctional community centers in three cities.

Capacity Building

One of the priorities of the new reform program is the professional development of the mental health workforce. In 2011 a strategy for human resources development was elaborated, and basic modules for retraining were developed. Training for local professionals was led by European experts, and the first phase of retraining started in the summer of 2011. All mental health professionals from Tbilisi were invited to attend selected training courses and were enrolled free of charge. Pre- and post-course tests showed that 67% of the trainees acquired the necessary knowledge and skills. By now, more than 300 mental health workers have been trained; the basic training lasts 160 hours, and extended training lasts up to 240 hours. Regular supervision of workers by the expert trainers is provided to some services, to ensure proper implementation of acquired skills in the daily routine.

As in other former Soviet republics, mental health professionals have virtually no contemporary mental health literature in their own language. Western psychiatric literature was inaccessible in the Soviet Union for many decades. Although publication programs in the past 20 years have helped fill the gap, most of this literature was published in Russian, which many Georgian mental health professionals cannot read. The new reforms in Georgia attempt to tackle this problem with a publication program that has resulted in new textbooks of psychiatry in Georgian, as well as the first Georgian language manual for psychiatric nursing [26]. A glossary of mental health terminology is under development in order to standardize the language used in publications.

In October 2011, multidisciplinary working groups, which included service users, initiated a revision of the Georgian national clinical treatment guidelines for schizophrenia and depression. These revised guidelines have now been submitted to the MoLHSA for approval. Research is being carried out by a group of Georgian psychiatric experts to identify the most relevant topics in child and adolescent mental health care.

Conclusions, Challenges, and Perspectives

Structural reform of a national mental health care system requires a long-term commitment. Such reform is likely to face repeated obstacles and setbacks that need to be overcome. Below we discuss four key challenges.

1. Developing a Clear Mental Health Plan

The MoLHSA needs to prioritize and clearly plan ahead—for example, the plan must account for the different mental health needs of people living in urban versus rural areas. An action plan for the coming years should be developed, which would help to link all existing and proposed mental health service components into one coherent and consecutive chain of services. This plan should include concrete strategies and activities to overcome financial and geographic barriers to accessing care, the development of a chain of well-coordinated community-based services, the integration of mental health into primary care, and the integration into the general care mental health care program of several domains such as prison mental health, psychotrauma care, and juvenile delinquency. The World Health Organization argues that the development and implementation of such a plan could have “a significant impact on the mental health of the population concerned" [17].

2. Improving Research Capacity

A robust research and information system should be put in place that collects and synthesizes relevant mental health data. Evidence is needed to demonstrate that services are effective and to justify the introduction of innovative care (which is often met with strong resistance). Evidence is also crucial in helping to guide sound policy decisions and to steer the reform process in the right direction.

3. Integrating Existing Services and Developing Care for Vulnerable Groups

One of the big challenges in the reform process is to integrate fragmented programs and services and to close the treatment gap by developing services that are needed for effective and continuous care.

Two major barriers to overcoming this challenge are the lack of psychosocial rehabilitation services and insufficient empowerment of service users. Though service users' voices are increasingly being heard and incorporated into the decision-making process, support programs for users are still scarce. The integration of health and social services is an essential element of the new reform process, yet achieving such integration is a huge challenge. Integration calls for a careful and diplomatic approach, since it requires overcoming vested interests and anxieties about future professional roles and positions. Similarly, the mental health care service within the Georgian penitentiary system requires major reforms [27], and it is vital to develop an appropriate care model and integrate it into general civil mental health services.

Another group that needs to be targeted for care is the war-affected population. The available data indicate high levels of psychological trauma, anxiety, depression, and substance abuse among members of war-traumatized communities [28]. The reform process needs to ensure that appropriate services are available to this group.

4. Overcoming Stigma and Resistance to Reform

Among the main factors that contribute to the continuation of ineffective and inhuman mental health care in Georgia are the stigma and discrimination that are widespread in the media, in governmental policies, and in society at large. In order to reduce stereotyping and discrimination, and promote more positive societal attitudes towards people with mental health problems, a major anti-stigma campaign is needed.

Resistance from service providers themselves is a last, but very important, challenge to mental health care advancement in Georgia, as in many other countries in the region. In general, psychiatrists might act as a considerable obstacle to the goal of closing the treatment gap [29]. This obstacle is widespread throughout former Soviet Union countries, where anxiety about the future is a general feature, and reform is often automatically seen as a risk to one's livelihood.

Author Contributions

Wrote the first draft of the manuscript: NM. Contributed to the writing of the manuscript: RV NM. ICMJE criteria for authorship read and met: RV NM. Agree with manuscript results and conclusions: RV NM.

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