Mental health care reform in Macedonia: a good practice that turned into a bad example

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.

http://www.who.int/mental_health/macedonia_who_aims_report.pdf