1. ACCESS TO MENTAL HEALTH CARE IN ROMANIA Adina BITFOI M.D., Psychiatrist Romanian League for Mental Health

2. Background Three successive traumas Three successive traumas  abrupt and damaging exit from the falsely protective atmosphere of communist period  complex and difficult “transition” period  the fading away of promised “future society” The “legacy” - the system The “legacy” - the system  Mental health care – exclusively within psychiatric hospitals  Low number of mental health professionals  Pharmacological model

3. WHO National Audit for Mental Health  2000  Performed by a group of WHO experts, at the request of the Romanian Ministry of Health. Performed by a group of WHO experts, at the request of the Romanian Ministry of Health. First evaluation of “strengths and weaknesses” First evaluation of “strengths and weaknesses”  The role of NGO’s in promoting mental health – “good practice” models  Declining health care services, with unresolved major health care reform issues and under-developed preventive services  Negative perception of the general population about the persons with mental health problems → isolation, deprivation and social exclusion

4. LAW CONCERNING THE PROMOTION OF MENTAL HEALTH AND THE PROTECTION OF THE PERSONS WITH MENTAL DISORDERS  2002 

5. Chapter 4 The System of Mental Health Care Mental health facilities Mental health facilities Standards of care Standards of care Art. 32. The purpose of the care provided to any person with mental disorders shall be the protection and enhancing of his/her personal autonomy Art. 34. The treatment and care provided to the person with mental disorders shall be based on an individual therapeutic plan, discussed with the patient, reviewed regularly, revised as necessary and provided by qualified professional staff. The rights of persons with mental disorders The rights of persons with mental disorders Admission to a Mental Health Facility - Involuntary admissions Admission to a Mental Health Facility - Involuntary admissions

6. Strategic Modules of Mental Health Policy of the Romanian Ministry of Health

7. “System of Care” Module The Ministry of Health considers that the reform of the mental health system of care has to be done respecting the following principles, validated by the worldwide experience: The Ministry of Health considers that the reform of the mental health system of care has to be done respecting the following principles, validated by the worldwide experience:  of territoriality  of therapeutic team  of the continuity of care  of specialization (multi-criteria: age, pathology, therapeutic approach)  of community orientation The mental health center has to become the main unit of the psychiatric care because it actually represents the change of the emphasis from the hospitalization to the ambulatory care, an alternative to hospitalization that allows a better monitoring of treatment and rehabilitation programs and the realization of an optimal cost-efficiency rate. The mental health center has to become the main unit of the psychiatric care because it actually represents the change of the emphasis from the hospitalization to the ambulatory care, an alternative to hospitalization that allows a better monitoring of treatment and rehabilitation programs and the realization of an optimal cost-efficiency rate.

8. “Legislation” Module The Mental Health Law: “ ” The Mental Health Law: “Law Concerning the Promotion of Mental Health and the Protection of the Persons with Mental Disorders ”  respects the “Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care” adopted by the United Nations  respects the WHO recommendations The ongoing elaboration of the Norms of Implementation of the Mental Health Law The ongoing elaboration of the Norms of Implementation of the Mental Health Law

9. TWINNING LIGHT PROGRAM Action Plan for the Implementation of the Mental Health Policy of the Romanian Ministry of Health

10. Action Plan for the Implementation of the Mental Health Policy Mental health promotion and prevention of mental illness Mental health promotion and prevention of mental illness Community Mental Health Centres Community Mental Health Centres Training and Education (for nurses, GP’s, Training and education in social psychiatry etc.) Training and Education (for nurses, GP’s, Training and education in social psychiatry etc.) Plan for quality improvement mental hospitals Plan for quality improvement mental hospitals Adjustment of laws that influence the quality of care Adjustment of laws that influence the quality of care

11. WHERE ARE WE NOW?

12. SYSTEM OF CARE 39 psychiatric hospitals 39 psychiatric hospitals 4 psychiatric hospitals with high security measures 4 psychiatric hospitals with high security measures 62 psychiatric wards in general hospital 62 psychiatric wards in general hospital 17000 psychiatric beds 17000 psychiatric beds 1000 psychiatrists 1000 psychiatrists 4000 nurses 4000 nurses

13. SYSTEM OF CARE Average stay in acute hospitals – 14 days Average stay in acute hospitals – 14 days Average stay in chronic patients hospitals – 26 days Average stay in chronic patients hospitals – 26 days All hospitals are state owned and the funding is coming from: All hospitals are state owned and the funding is coming from: Contract with the national insurance house for medical services Contract with the national insurance house for medical services Running costs from budget of the Ministry of Health Running costs from budget of the Ministry of Health National Mental Health Program National Mental Health Program Own income Own income

14. System of Care Psychiatric hospital Psychiatric hospital - Still one of the main facilities which provides care - Still the pharmacological model is prevalent (encouraged by the health insurance system) - Number of psychiatrists/ clinical psychologists is modest - Admission possible for insured patients, but also for patients without insurance in case of psychiatric emergency (regardless of the type of admission – voluntary or compulsory) - Availability of a wide range of drugs including the most modern molecules - Consistent resources used for rehabilitation of the institutions

15. System of Care Outpatient services Outpatient services - Community mental health centers or other alternative structures : insufficient number - Independent psychiatry offices have in care the patients after they are discharged from the hospital (compliance issue) - Big majority of psychotropic drugs are partially or totally paid by National Health Insurance House - Psychotherapy – fast change of attitude of users and society – explicit demanding – increasing addressability - also the number of therapists and schools of psychotherapy is increasing, their number is still insufficient - not paid by insurance company, only by patients (average price= 20-50 € / session)

16. Primary Care System Great gap between the PCS and the mental health professionals Great gap between the PCS and the mental health professionals Increasing GP’s request for training and information regarding mental health promotion and mental disease prevention Increasing GP’s request for training and information regarding mental health promotion and mental disease prevention Now working on: training programs for professionals in the PCS designed to provide them instruments and competence to recognize and tackle in the most adequate and efficient way MH problems Now working on: training programs for professionals in the PCS designed to provide them instruments and competence to recognize and tackle in the most adequate and efficient way MH problems

17. Thank you!