Mental health policy and practice across Europe: an overview

226 Mental health policy and practice
income countries essential mental health services remain beyond the reach of
rural populations, indigenous groups and others. Even within these scenarios, it
is clear that the integration of mental health services and awareness within primary
care, rather than the establishment of a high-cost specialist service, has
the greatest impact in terms of increasing access and promoting the equitable
and efficient delivery of mental health care. From within the interventions
outlined above, it is the low-cost interventions which improve access to services
which have the greatest potential to improve the health of the population.
Educational strategies, together with funding for a limited list of essential
drugs such as antidepressants and antipsychotics, delivered within primary
care, are a feasible strategy, although the effectiveness of educational strategies,
by themselves, has not been determined within low resource health care systems.
Costly collaborative care strategies are not realistic, nor should they be a
priority.
Medium resource countries
In countries in this scenario, some resources are available for mental health,
such as centres for treatment in big cities or pilot programmes for community
care. But these resources do not provide even essential mental health services to
the total population. These countries are likely to have mental health policies,
programmes and legislation, but they are often not fully implemented. The
government budget for mental health is typically less than 5 per cent of the total
health budget, a situation that is relevant to a number of countries undergoing
economic transition in central and eastern Europe.
In these countries, unlike medium resource countries in other parts of the
world, there is usually no shortage of psychiatrists; in fact, the opposite may
be the case. However, the system is usually heavily institutionalized with
little availability of community-based professionals such as social workers or
community-based psychiatric nurses to serve the population. Primary care providers
are largely untrained in mental health care. Within these scenarios, the
development of a comprehensive primary care-led mental health service and a
rebalancing of institutional compared with community-based care is more of
a priority than the development of a fully functioning and comprehensive
specialist mental health service. Education and training of primary care
professionals and the devolution of the management of common mental health
problems to primary care workers such as nurses should become a priority, and
these strategies can be well supported from some low intensity collaborative
care and educational strategies. There are, however, many barriers to the greater
development and investment in the provision of mental health services within
the primary care sector, not least perverse incentives in the way in which mental
health systems may be funded that may not easily allow resources to be
transferred away from institutional based care (see Chapter 4).