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2.
The activities
2.1.
The demands and the methods
The
task force has answered assessment requests through evaluative
visits to the countries and the establishment of reports and
recommendations. However, before taking any engagement, it has
had to clarify which were the instances asking for an evaluation
and what could be the extent and limits of the assessment that
could be offered. An assessment could be, in effect, solicited
by supranational organizations (such as the United Nations
or the WHO itself), or some private instances (such as
like the World Psychiatric Association and non-governmental
organizations), but until now the consultancies have been requested
(directly or indirectly) by Member States themselves, who wish
to change policies and utilize WHO as having the required knowledge
and objectivity. Obviously, the kind of assessment to be carried
out depends on the source and reason of the requirement.
In
the accomplishment of its mission the task force has sought
the following information:
-
A panorama of the mental health situation of services in the
country,
-
Needs evaluation of the patient population;
-
Mental health promotion plans;
- Investment
in mental health;
-
Inter-relation of mental and physical components of health;
-
Evaluation of mental health services;
-
Evaluation of the quality of management;
-
Evaluation of equity and human rights legislation.
However
the extent and methodology of the interventions depend largely
on the precise definition of the demand. Thus the assessments
can be carried out through assessment visits, accreditation
procedures or fact-finding missions; they can be focused on
a given target patient population or a complete health organization;
they can use existing or newly created instruments for the evaluation
of needs, operational manuals and indicators of stigma, discrimination
and equity issues.
So
far the task force has made (or is in process of making) several
evaluations and visits to Poland, Kyrgyzstan, Romania, Lithuania
and Slovenia and fact-finding missions were made in Russia and
Georgia (as well to in Malta and Andorra) in order to re-establish
contacts and to introduce the re-emerged mental health program
and its policy, explore the present situation on mental health
and initiate the interest for fundraising regarding the program's
different projects. The time and budget limits are proportional
to the task allowed and the strategy varies from simple consultation
of data provided by the client to in-depth and costly epidemiological
studies. For example, in Romania a quite complete evaluation
has been made allowing to gain insight into all scopes concerned
with mental health. In other of the audits presented here, one
or several members (in the case of Russia the whole task force
itself) visited the countries, in "fact-finding missions"
looking at some specific areas. They met with political and
health officials, mental health professionals and representatives
of organizations active in mental health. Furthermore they visited
educational and research institutions and mental health facilities,
mostly hospitals. Of course, the origin of funding is a critical
issue in terms of impartiality and efficiency of the task.
Results
of these audits will be published in more detail in a separate
article elsewhere. A positive result of all assessments has
been to put mental health issues in the focus of policy. On
the whole, an increasing interest and sensitivity for mental
health issues has led to the request for a in depth mental health
evaluations in some of the countries. Various other countries
have applied for evaluation and are expected to be visited soon.
The seven South East European countries (previously refereed
to as Balkan's countries) having signed the sa called "Stability
pact" in 1999 have recently asked the help of the task
force to develop an evaluation instrument on Mental Health in
order to have common data for the reform of Mental Health Services
and Plans in the different countries.
2.2.
Networking
Continuous
and productive exchange in themes of mental planning has taken
place with the World Federation for Mental Health (WFMH) "Mental
Health Europe" and the World Psychiatric Association (WPA).
Quite intensive cooperation with the Regional Office has also
taken place, for instance, in the review of data of mental health
service provision throughout Europe, collected in 1994. Members
of task forces and networks of the Regional Office are frequently
contacted, forming a consistent group of temporary advisers
and experts in different areas of mental health.
The
task force has been actively involved in awareness-raising activities
specially during the WHO and the UN "year of mental health
2001" and has engaged all European ministries of health
in a pan-European conference on mental health, held in October
2001 and hosted by the government of Belgium. At a recent WHO/European
Union (EU) meeting, also held in Brussels on the need for mental
health impact assessment, it was decided to spread the task
force assessment approach to other European countries as a joint
effort of WHO and EU. Agreements of cooperation has also been
made with the Geneva Initiative on Psychiatry (GIP) to promote
mental health reforms in eastern European countries.
2.3.
Enhanced Collaboration between the WHO collaborating centers
in Europe
Two
collaborating centers meetings have been organized in Copenhagen
in 1999 and Lille in 2001 and more than six meetings of this
task force have taken place, enhancing the group's cohesion.
The 51 EU Member States were asked in 1999 to nominate a national
counterpart for the WHO mental health program at the Regional
Office. So far, 47 countries have nominated a counterpart. The
members of these networks and task forces constitute now a highly
credible WHO European Network on Mental Health.
2.4.
Compilation of National Data
In
September 1998, the Regional Office adopted a new health information
system including data about mortality data, incidence of communicable
diseases, international organizations, agencies and publications
and health statistics that can be collected from three databases
( ). A finding was that insufficient reliable data exist for
mental health. The work of this task force is providing valuable
quantitative but mainly qualitative information on the area.
3.
Scope and limitations
Three
years after the beginning of the assessments and in view of
the above-described results, we can make some comments on the
extent and shortages of this kind of endeavor:
3.1.
Evaluation of Individual Patient Needs
The
trend in mental health services provision is now to make programs,
which are "needs-lead" instead of "service-lead".
However, in the process of our audits, when faced with the task
of evaluating the needs of a particular population, we lack
a consensus on the instruments for identifying different types
of needs. Existing instruments . focus on individuals in target
populations and the evaluation of the whole groups' needs necessitates
costly and lengthy field studies, which are rarely possible
in the context of this kind of audit.
3.2.
Evaluation of Mental Health Systems
The
evaluation of mental health systems should ideally include the
structure (the description of the different services), the process
(technical knowledge and the ethical framework in which the
services are delivered) and the results. The client nations
can provide some simple reliable data but more sophisticated
information could only be obtained through ad hoc enquiry. However,
time, budget and sufficient commitment of the clients is rarely
assured.
3.3.
Indicators
Too
many criteria, norms, standards and indicators have been described
in mental health. The trend is to select a few feasible "indicators",
which are measurable and well-defined variables in relation
to the results of medical activities. At the above mentioned
meeting of WHO European collaborating centers (Lille, 2001),
a large study which is being undertaken by a team of researchers
in London in order to obtain simple and reliable mental health
was discussed. Furthermore, a sub-group of our WHO task force
is working on selecting five general indicators on mental health
to be added to the WHO HFA-21 database. These efforts will hopefully
lead to the availability of widely accepted, simple instruments
to be used in the future.
3.4..Evaluation
of a Psychiatric Service
The
task force has eventually to concentrate on the evaluation of
a particular psychiatric service. It has to include the description
of the environment, the manual of procedures, the quality
of accommodation provided, the motivation of human resources,
etc. All of these aspects can be easily evaluated with existing
tools.
Quantitative
clinical indicators (resources, activity,functioning) are
easily accessible for the task force in most countries. However,
qualitative indicators are more difficult to obtain without
specific studies. Clinical quality in psychiatric services
has, in fact, been studied over the years by many organizations
leading to manuals of accreditation and the creation of commissions
on the accreditation of hospitals. Today existing require energy,
skills and adequate budget seldom available in the usual circumstances
of the national evaluations.
3.4.
Detection of Clinical Problems
In
the course of our audits, several situations have been identified
in relation to the clinical quality that called our attention
to some inadequacies of some services or systems throughout
the study of clinical records and could ask for further inquiry.
However most of the problems could only be adequately evaluated
through a longer process of in-site evaluation which has not
been the case in our visits until now.
4.
Conclusion
During
the 3 years of work, the task force following the recommendations
of the policy paper of the Regional Office, HEALTH21 , that
stressed the need for inter-sectorial cooperation, was able
to collect evidence-based knowledge on health assessment, produce
a position paper on the state-of-the-art in Europe and develop
strategies to carry out a number of assessments and fact-finding
missions in seven east European countries. The assessments described
here showed the existence of important inequities between these
and other more developed nations, regarding socioeconomic determinants
of health, lifestyles, mental health resources and access to
health services.
The
task force has discussed many instruments for the evaluation
of the population needs, the resources and the efficacy of the
systems and some were used during the audits but many seemed
inadequate. A great effort should thus be made in the future
to agree on simple and reliable procedures for assessing these
parameters and monitoring evolution.
The
time and budget limits greatly conditioned the task allowed
but an overall appraisal of models of the system its boundary
conditions, the population need and the current provision could
be made in many cases. Some recommendations were made in some
cases for a strategic plan for a local system of mental health
services. On the whole, an increasing interest and sensitivity
for mental health issues has put mental health issues in the
focus of policy in most of the countries. Some of them have
made the request for a in depth mental health audit that could
lead to implementing the service components at the local level
and eventually to Establishing a monitoring and review cycle.
However
most politicians and administrators remain reticent about mental
health issues and argue that no clear relation exist between
diagnosis and needs and that there are difficulties in evaluation
of the results .To improve the situation we would need to give
simple, relevant, information to general population, employers,
groups at risk, patients and families, primary care professionals,
educators, mental health professionals and administrators. But
of course these are costly and long term interventions.
Partially
due to the activities of this task force, cooperation with the
EU is in a stage of bilateral development. The wish for synergistic
activities, co-ordination of work and exchange of experience
as well as mutual technical assistance has been underlined from
both sides. A joint conference and brainstorming session on
mental health promotion and a European conference on mental
health promotion has been presented as a joint effort. On the
other hand, the Regional office has strengthened the links with
WHO headquarters, other networks of the Regional Office, WHO
advocacy groups, the World Federation of Mental Health (WFMH)
and the World Psychiatric Association (WPA).
References
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1999
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