Reform of BG. Psychiatry 

INTRODUCTION

For the aims of this document the reform of Bulgarian mental health services is presented as an organized act, which combines in a number of steps the completion of seven separate tasks. These tasks are as follows:

• Establishing the principles of the new (reformed) services;
• Clarification of limiting factors;
• Needs assessment of population;
• Evaluation of existing services;
• Formulating the strategic plan for development of a local system of mental-health services;
• Implementation of services at a local level;
• Monitoring, followed by new cycle of evaluation.

Principles of the reformed services

The reformed psychiatric services in Bulgaria be guided by the following principles:

Public health approach.

This principle requires that mental patients should remain a part of the community to which they belonged as healthy individuals.

• measuring the health and social condition of the general population, and not only on information, collected by health services to monitor their utilization by the population.
• policy, formulated and conducted to achieve particular aims;
• the results from the implementation of this policy are measured through indicators, the choice of which is scientifically grounded.

Modern policy in psychiatry requires a shift from institutional services to a complex of community-based services, which consists of six components:

• inpatient psychiatric wards
• outpatient psychiatric wards
• half-way houses
• group houses;
• day-care centers

At present Bulgarian psychiatry does not practice any of these six components in a way that meets international standards.

The usual objectives of modern mental health care programmes are:

• decreasing case incidence and prevalence;
• decreasing death rate related to mental illness;
• decreasing other negative circumstances, related to mental disorders (ill somatic health, disturbed psychosocial functioning, low social status, family burden);providing appropriate services and interventions;
• changing negative attitudes towards mental illness and people affected by it; establishing a positive social climate; improvement of quality of life for people with mental disorders;
• exploration of reasons, consequences and care programmes related to particular mental disorders.

Indicators recommended for measuring the results from implementation of health policy in the mental-health sphere are:

• increasing the competence to recognize depression.);
• increasing the percentage of mental health service needs met;
• reversal of tendency towards increasing of suicide rate.

System approach.

This principle assumes that the services designed to meet the needs of mental patients in a certain community are viewed in their interrelation, i.e. planning one component of services (emergency beds) requires information about all kinds of services available in the community (home-based treatment). Besides inner co-ordination of the different psychiatric services, the psychiatric programme should be co-ordinated with other programmes too: general practice, programmes for elderly people, alcoholism, social services, social assistance, vocational occupation and housing policy.

From the perspectives of this principle Bulgarian psychiatry is faced with the imperative need to carry out two major changes:

• a transition from hospital-based services to services which are not based in hospitals; and
• a transition from planning, service provision and accountability of mental health services on piece-rate basis (each unit being separate) to planning, service provision and accountability in the context of interrelation of services (system approach).

Human rights.

This principle requires that human rights of mental patients should be confirmed through legislation and their observance ensured by means of procedures and rules. Mental patients take part in the decision-making process concerning the ways in which their needs should be met. International charts and recommendations bringing the statute of psychiatric services in line with the statute of the other medical services should be announced and should become guidelines for service provision.

This principle enforces that the psychiatric institutions should develop an organizational culture and a therapeutic setting by adopting new methods for clinical work:

• elaborating the clinical profile of the institution will be distributed;
• establishing a procedure for admission, announcement and case work for new cases;
• organizing the clinical and psychosocial interventions in care programmes and their implementation in line with the protocols endorsed;
• adopting the principle of the personal therapist and the team meeting;
• establishing procedures and work schedule for consultations and supervision;
• binding the programme for the development of the service with the professional development of staff.

LIMITING FACTORS

The limiting factors determine the actual parameters of mental health reform through regulating the "entrance" and the "exit" of it. These factors are:

• size of target community (geographic area);
• interface between general practice and psychiatric programmes (selective permeability);
• interface between psychiatric program and social service programmes;
• interface between different components of the psychiatric programme.

However, limiting factors are such (due to inheritance from the socialist health care system) that there are no rules about neither the connections between the different components of the psychiatric program, nor the interface between psychiatric programmes and general health care practice and social services.

NEEDS ASSESSMENT OF THE POPULATION

Gathering valid data about the needs of the population in Bulgaria today requires conducting a survey of the total population. The main reason for that is the low reliability of statistics data gathered to meet the needs of psychiatric services. Distortion of information is a grave consequence from the policy of centralized planning of psychiatric services. In the last years a growing understanding has been achieved for the pervasive effect of centralized control over Eastern Europe. Readiness has been expressed for technological support to be provided to countries such as Bulgaria to conduct their first survey of the needs of the population. Bulgaria and a Bulgarian team are leading in an international group including six European countries and experts from Europe (World Health Organization and World Psychiatric Organization) for designing and conducting such a survey. In November, 1998, the first conference on this project will be convened in Sofia, preceding the annual meeting of BPA. Funding is provided by Geneva Initiative on Psychiatry The needs assessment is an ongoing

Co-operation should be sought from BPA for elaborating a position statement on the issue.

EVALUATION OF CURRENT STATE OF SERVICES

"Measuring" psychiatric practice by means of the statistical measure "bed," that has been the practice for decades, is inappropriate for the reformed mental health practice, since the share of services requiring admission to a hospital bed remains too small.

Measuring the reformed mental health practice is enabled by the partition of different components of care on the grounds of operational definitions. This could be achieved through changing the organizational culture of present psychiatric institutions. The key step here is to break up care procedures, which should be followed by self-description of services in the so-called clinical profile of the service, i.e. pointing the types of cases and problems ensuing from them, which the particular institution is equipped to treat. (Under chapter 2 above the principles of this conceptualization have been pointed out; particular technologies, grounded on the Bulgarian experience, are now developed in the Department of Psychiatry, Sofia.)

Before carrying out of such a "mapping" of mental health network in Bulgaria, it is pointless to formulate standards and initiate accreditation of services in line with these standards.

FORMULATING A STRATEGIC PLAN FOR A LOCAL MENTAL HEALTH CARE SYSTEM

Each of the local strategic plans should: be designed by a team in which all the groups interested should be presented; be based on the principles of the reformed psychiatric practice, on local needs assessment, and on a survey of the already existing local services; have an annual plan and evaluation of costs and to be organised in terms of projects to attract funding and co-operation.

EDUCATION FOR MENTAL HEALTH REFORM

The core component of this training is the matter, which has recently become wide known as “managing the change”. Plenty of international experience has been piled that reveals the advantages of the so called “matrix model” for mental health reform. Essential for this approach is to encompass the unbounded of the phenomenon of reform through situating it in two dimensions: time and space.. Decisions about sequence and the type of changes, taken on these grounds, turn out to be much more reasonable.

FINANCING MENTAL HEALTH REFORMS

Mental health reform is a long lasting process and its speed will significantly depend on both readiness for reform of psychiatric practice and resources available. A fund should be set up which should be distributed through project grants (local and central).