Care for persons with mental health conditions is mainly provided in
public psychiatric wards, although care from private providers is also
available. The public system is represented by the Specialised Psychiatric
Hospitals and the University Clinic of Psychiatry with inpatient and day care
services, both located in the capital Skopje, and several day centres for
mental health care, prevention and treatment of depression located within the
Health Centres.
The mental health reform was in line with the strategic
determination in social protection is for deinstitutionalisation, towards
community-oriented service delivery in line with the EU strategy (Ministry of
Labour and Social Policy, 2008) and then adopted WHO European Mental Health
Action Plan. Activities were pursued accordingly; in cooperation with WHO and
the Council of Europe, the aim was to develop socially oriented psychiatry and
to set up more mental health centres in the community, taking local needs into
account. However, a World Bank loan was used to perform reconstruction works on
the psychiatric hospitals in Skopje and Negorci, which is not in line with
deinstitutionalisation and gives a wrong message to the actors involved.
In 2006, the Law on Mental Health was enacted, regulating the rights
and responsibilities of both health care providers and persons with mental
health conditions. Due to the importance of mental health in the community, the
law also provides legal grounds for establishing a Mental Health Committee in
each unit of local government, enabling close monitoring of the implementation
and protection of the rights of the persons with mental conditions. In very few
cases, municipalities have established such committees; however, their work is
not publicised or widely disseminated to the public. For many years, the
country has had an annual public health programme for mental health that mainly
comprised of providing education to the population, and adolescents in
particular, as well as counselling persons with severe mental health conditions
including suicidal intentions among the young (Milevska Kostova et al., 2017).
Health care for persons with mental health problems is provided on
three conventional levels: primary, secondary and tertiary. Primary health care
physicians are the first contact between the patient and the health system and
they serve as gatekeepers to detect the problem and refer patients to higher
levels of health care. Secondary health care is provided by the neuropsychiatry
consultative-specialist outpatient services that function within the Health Centres
throughout the country, as well as the Institutes for Children and Youth in
Skopje and Bitola. Neuropsychiatry wards within 13 Medical Centres throughout
the country provide in-patient secondary care (wards provide hospitalisation of
both neurological and psychiatric patients; in general, most patients suffer
from neurological disorders). The
tertiary level is represented with three specialist psychiatric hospitals:
Psychiatric hospital Bardovci (Skopje), Psychiatric hospital Demir Hisar and
Psychiatric hospital Negorci, which have been and still are mainly providing
care for patients with mental health problems. Patients are hospitalised on a
principle of residing in the respective region. Additional tertiary inpatient
mental health care is provided by the University Clinic of Psychiatry and
Neuropsychiatry ward in the City General Hospital ‘8 Septemvri’ in Skopje (WHO,
2009).
The reforms of the Ministry of Health created the foundation for the
Mental Health Project of WHO, Country Office Skopje, which has created several
community mental health services since 2000. Seven Community Mental Health
Centres (CMHC) have been established in various parts of the country: Prolet, Idadija
and Vlae in Skopje, in Prilep, in Tetovo, Strumica and in Gevgelija. WHO
Country Office in Skopje has provided the training for the multi-disciplinary
teams working in the CMHCs (WHO, 2009).
The focus was on changing the approach in the treatment towards
psychiatry oriented in the community, not only in the forms of providing care but
also in the essence of the content of the care. Particular attention was paid
to the reintegration of the patients in the community.
The psychosocial approach for successful integration of the users in
the community was supported by establishing Social clubs within the CMHCs,
where different skills training, family interventions, self-help groups were
organised. In addition, the protected living arrangements were promoted as
alternative to long-term hospitalisation.
This reform process was further developed by establishing social
firms where people with mental health issues had the possibilities to be
employed according the Law on Employment of persons with Disabilities. But,
with the changes of the Law in 2005, people with mental health issues were no
longer eligible as employees according the Law, which led to closure of the
social firms.
WHO supported the reform, it was well planned and implemented, but
it was not sustainable. While WHO was implementing the process (there was an
agreement with MoH), the services were functioning in a good manner, but once
the project finished, the Government lost the interest –resulting in closure of
few services. Somehow, there was lack of attention, resources and political
will to continue with the action plan. Also, the resistance to change (closure
of the hospitals especially) by the staff (medical personnel) was emphasised
that significantly obstructed the process. Once a successful process, now it is
an example of the opposite. At this
point, there is an ongoing initiative to re-establish the National group on
mental health that will work on the new mental health strategy.
Claimer: This blog is intended as a part of Situation Analysis
and Assessment/ Evaluation Report of Implementation of National Strategy on
Deinstitutionalisation 2008–2018, which will be soon presented to the
public within the EU framework project Technical assistance support for the
deinstitutionalization process in social sector. For this blog, Vlado Krstovski
is considered to be co-author.
References:
Milevska
Kostova, N., Chichevalieva, S., Ponce, N.A., van Ginneken, E., Winkelmann, J.
(2017) ‘The former Yugoslav Republic of Macedonia: Health system review’. Health Systems in Transition, 2017;
19(3):1–160. http://www.euro.who.int/__data/assets/pdf_file/0006/338955/Macedonia-HiT-web.pdf?ua=1
Republika
Makedonija (2005) Nacionalna strategija
za unapreduvanje na mentalnoto zdravje vo Republika Makedonija.
2005/2012
(National Strategy on Promotion of Mental
Health in the Republic of Macedonia 2005/2012).
WHO-AIMS
(2009) Report on Mental Health System in
The former Yugoslav Republic of Macedonia. Skopje: WHO and
Ministry of Health.
