Russia’s mental health services: barriers to change

Health care in Russia since the early 20th Century has been centralised and dominated by inpatient treatment. The structure and financing of the heath system underwent reforms after the break-up of the Soviet Union in 1991.  But in some areas, including mental health, changes have been limited.

Poor mental health is a majorproblem in Russia. The country has the second highest rate of suicide for menin the world, and mental health problems account for 20 percent of all thoseregistered as disabled. A study by UK and Russian-based researchers set out todiscover the impact of health system factors on the delivery of mental healthservices. They focused on the region of SverdlovskOblast, in the Ural Mountains in north-central Russia.

Russia’s compulsory healthinsurance scheme, introduced in 1993, does not extend to mental healthservices, which are funded through central taxation. Regional Ministries ofHealth are responsible for delivering mental health services. The system ofallocating resources and making payments has not changed since Soviet times.Allocation is based on considerations that include the number of inpatient bedsand available infrastructure.

The organisation of care has beenreformed to protect patients’ rights. A SectoralProgramme for Mental Health was developed in 2001, following World HealthOrganization recommendations. It emphasised decentralisation of services,treatment in the community and integrating mental health with general healthservices.

Despite these attempts atreform, Russia’s mental health system is still dominated by hospital basedcare. Services could be potentially made more efficient by a shift to treatmentin the community. However, this shift can only be considered if effectivecommunity-based health and social care services are put in place and theexisting funding is re-directed towards them. A number of barriers wererevealed by the study:

• Funding based on the existing number of beds andbed occupancy creates an incentive for staff to hospitalise patients.
• Funding increases and resource allocation is notbased on any measure of psychiatric need or cost effectiveness.
• The period of time a patient spends in hospitalis stipulated in regulations on management of mental health cases.
• Mental health hospitals are important providersof employment and social care. Reducing or redeploying staff elsewhere maybe politically difficult to achieve, while outpatient and primary careservices for unemployed patients are poorly developed.
• Administrative laws and financing regulationsmake it difficult to reallocate or pool resources between health andsocial sectors.

Overcoming these barriers todeveloping community-oriented mental health services will require considerablepolitical will at the federal level. Policies will need to include:

• changes to the mechanism for allocatingresources, payments to service providers and incentives for both themental health sector and the health system as a whole
• extra funding, at the same time asinstitutionalised care is being phased out, to develop services based inthe community and at general hospitals
• incentives to overcome opposition to change amonghealth professionals
• funding mechanisms that allow resources to followthe patient, regardless of where they are treated
• greater consideration of, and provision for, theneeds of metal health patients in the housing, social protection andemployment sectors - including access to housing, community socialservices, vocational rehabilitation and jobs.