Mental health policy and practice across Europe: an overview

Policy in former eastern bloc countries 409
In adult psychiatry, two major areas of needs stand out as woefully underestimated
and unaccounted for in service design. These are the vocational,
residential and psychosocial rehabilitation needs of people with severe mental
illness on the one hand, and the needs of people with common mental illnesses
on the other. Major areas of unacknowledged needs across the region include
community care for patients with dementia (old-age psychiatry), educational
needs and family support services (child and adolescent psychiatry) and prison
services and risk management (forensic psychiatry). All these examples of gaps
in services expose one of the direst consequences of institutional care in the
former eastern bloc: the disastrous lack of collaboration across sector boundaries.
Once again, this is essentially a failure of governance rather than a lack of
proper mental health expertise.
Several conclusions can be drawn. Politically, a period of particularly misguided
social practice came to an end around 1989. The economic and social
consequences are numerous, have varying profiles and intensities across the
countries, and have only recently been acknowledged. The transition to a free
market economy by the former eastern bloc countries has come at a time of
globalization, which adds further frustrations to those based on the need to
drop passivity and accept social participation. The complications of globalization
arise from the fact that the challenge is no longer to find a dependable
employer or patron but to compensate for dependency needs by adopting an
entrepreneurial stance, i.e. organizing psychiatric services in ways that enable
interdependence (Daulaire 1999; Lee 2000). A huge proportion of the ageing
population in the region appears to be completely deprived of the chance to
ever make this transition. An awareness of being doomed filters into the minds
of millions but has not been stated authoritatively or on the basis of strong
evidence in any of the eastern bloc countries. However, it does manifest itself
strongly in sociodemographic statistics.
The human toll of transition is huge, but so far no governance structure
appears to have risen to the task of predicting a realistic future and the way
ahead for health systems. The persistent failure of governance in the communities
of the former eastern bloc is predicated on the deeply instilled culture
of dependency and corruption in the workplace. The evil indifference of, and
attack on, individuality was the hallmark of previous regimes, as the example of
the political abuse of psychiatry illustrates. This painful issue is still disavowed
by governance structures.
Health resources
Health policies adopted by most countries in the region since 1989 have been
based on the belief that health markets can function well and improve health
care without the need for much governance. The transition to systems funded
through social health insurance stands out as a core component of health
reforms and has driven changes in legislation, taxation, ownership and the
management of health systems. The fragility of economies has meant that
most countries depend on international loans and have to accept restrictions
enforced on their health budgets. Central health administrations are still