Mental health policy and practice across Europe: an overview

74 Mental health policy and practice
European Network (MHEEN) reported that 8 out of 17 west European countries
levied some out-of-pocket charges for specialist mental health services within
their publicly funded health systems (Knapp et al. 2006b). In Ireland, for
instance, while the bottom third of the population are exempt from charges, the
remainder of the population will pay a variable fee for primary care consultations
and indeed pay a hotel charge towards the costs of inpatient stays. Access
to mental health services under private health insurance is limited so there may
also be out-of-pocket payments for behavioural and occupational therapy
(O’Shea and NiLeime 2004). In Iceland, individuals must make co-payments for
most services, although there are reductions for those who are registered as
having a disability (Tomasson 2004), while in Belgium there are fixed fees for
specialist mental health services, but these are reimbursable under the social
health insurance scheme (Dierckx 2004). Out-of-pocket payments have been
introduced for psychiatric services in Poland as one consequence of economic
transition (Zaluska et al. 2005). We return later in the chapter to the issue of low
utilization of services when discussing equity.
Donor aid for mental health
Donor aid can be an important source of health system funding in countries
undergoing economic transition or recovering from conflict. The proportion of
donor aid allocated to mental health is not known for most countries, but there
is little evidence to indicate that mental health has been much of a priority,
despite its major contribution to the overall disease burden.
Even where funding has been made available for mental health, there can be
problems in the way that these funds are used. In Bosnia and Herzegovina, all
the major international aid organizations, as well as over 50 NGOs, were working
directly or indirectly on mental health issues. While there were a number of
positive aspects to this aid, such as placing mental health on the health reform
agenda and providing technical support and training to local professionals,
some negative consequences have also been highlighted (Funk 2005). Because
most funding for reform came from abroad, the proposed changes were resisted
either actively or passively by local agencies. In any case, some of the projects
were inappropriate for local population needs. This lack of consideration of
local circumstances, together with fragmentation and lack of coordination
between donors, often meant that the sustainability of mental health reforms
was not considered. No realistic national plan for mental health reform was
developed. Ideally governments would take an interest in the funding priorities
of external donors, and work in partnership to ensure that funds are allocated in
ways that are consistent with the immediate and longer-term aims of national
mental health policy.
Movement out of the health sector
We have already noted how many services used by people with mental health
problems are both funded and delivered outside the health sector. As the