Mental health policy and practice across Europe: an overview

86 Mental health policy and practice
these were determined by reference to historical precedent or political judgement
rather than on the basis of an objective measure of population health
needs. The methods used are unlikely to target resources on areas where they
have the greatest chance of being effective and may also allow inequities to
persist, for instance if resources continue to be concentrated in major cities,
neglecting rural areas within a country. Stigma could mean that mental health
does not receive a fair share of the budget, and there may also be prejudice
against funding non-institutional programmes.
Methods of resource allocation can be even more complex in countries dominated
by social health insurance systems. Some funding, for example for public
health and health promotion services, will be provided through taxation, but
the majority of funding may be in the form of direct reimbursements from sickness
funds to service providers. The MHEEN group reported an increasing use of
diagnosis-related group (DRG) tariffs to reimburse service providers for mental
health-related services in both social insurance and tax-dominated countries of
western Europe. The use of such DRGs in some countries has led to underfunding
for mental health, as reimbursement rates have not always fully taken
into account all of the costs associated with chronic mental health problems.
Resource challenges
Reflecting on the frameworks, structures and evidence described in this chapter
it is clear that there are a number of resource challenges facing mental health
systems in Europe, as indeed there are globally (Knapp et al. 2006a).
Resource barriers
One of the most common of the challenges to be addressed across Europe is
resource insufficiency: not enough financial resources are made available for mental
health. This is clearly a major issue for countries where the percentage of
GDP devoted to health care is low, or where the percentage going to mental
health is limited. If few funds are allocated to mental health there is clearly
limited scope for building an effective, accessible system of services. But regardless
of a country’s GDP, attitudes can put up a powerful barrier to the allocation
of resources to mental health. A population survey in Germany found that the
public were far less willing to safeguard spending on mental health compared
with other health conditions (Matschinger and Angemeyer 2004). Only 10 per
cent and 7 per cent of respondents placed schizophrenia and depression,
respectively, within their top three areas where budgets would be protected,
compared with 89 per cent prioritizing cancer, 51 per cent HIV/AIDS and
49 per cent cardiovascular disease. The low priority accorded mental health was
attributed in part to ignorance that conditions could be treated, a belief that
they were self-inflicted and an underestimation of individual susceptibility to
mental illness. The public may also have prioritized immediate life-threatening
conditions over other health concerns.
Current shortages of skilled staff in many countries, and the future likelihood