Mental health policy and practice across Europe: an overview

Policy in former eastern bloc countries 411
partnership and community participation has established very few roots in the
cultures of post-totalitarianism.
The tradition of central planning for health makes it difficult for new governance
structures to call for an enlightened citizen and employer partnership in
establishing adequate health funds, but nevertheless many countries are making
significant progress in terms of pooling financial resources. Where most
countries stumble is in the management of available funds, largely due to a lack
of expertise and fiscal instruments.
Physical resources for health care are in poor condition and often there
are problematic issues of ownership. This impedes shifting to a needs-based
practice governed by a service culture informed by consistent quality assurance
of care. This is a huge barrier to good health management. Adopting a
managerial as well as a clinical perspective appears to be a major task for
staff retraining now that the economic viability of the health systems in the
region needs to be demonstrated continuously with the help of evidence on
outcomes.
Provision and utilization of mental health services
Data on the provision of services in the region traditionally has been limited to a
few general categories, allowing few conclusions to be drawn. Service utilization,
to the degree to which it can be studied, is much less than estimated need,
comparing poorly to the rest of Europe. Data on provision are reported to the
local and central administrations and pooled for annual health statistics reports.
This practice is not guided by articulated managerial needs to gauge progress on
policy because policy (to the extent that it exists) is seldom translated into
operational plans or expected changes in outcomes.
Focus groups run during a study on the attitudes of front-line health managers
(Schider et al. 2004) revealed that people felt they were left out of the cycle
of decision-making. The participants, who were usually medical specialists by
training, expected to enforce the authority of the ministry of health and to
streamline and oversee the collection of statistics tailored to needs other than
their own. There was consensus in the focus groups that they produced work of
poor quality. This attitude was explained by the lack of ownership of their work,
and a feeling of being divorced from the governance aspects of service provision.
The groups also agreed that the methods employed by health administrations,
and even more so by the health insurance operatives, had an alienating
influence. Their attitude was described as dictatorial and subversive to progress,
in terms of both the humane and technological aspects of care provision. Issues
of effectiveness, quality of life or satisfaction with mental health services were
not seen as relevant or of general concern for the current operation of clinical
services in the region. This was due to technological backwardness and a lack of
prospects for investment. These sentiments, however, could not find expression
in official reports or policy documents: they were shared only off the record
(Mladenova et al. 2002).
Process analysis of mental health care at either local or central level has not
been informed by a tradition of managerial, evidence-based decision-making.