Mental health system reform: a multi country comparison

In recent years many countries have embarked on various types of health and mental health reform. These reforms have in large part been driven by governments' concerns for cost containment which has, in turn, been driven by an increasing process of global marketization and the need to control national deficits. A critical issue in these reforms is the increased emphasis on the use of "market mechanisms" in the delivery of health and mental health services. This paper uses a policy analysis framework to compare recent developments in the mental health sector in Canada, the United States, Britain and Australia. The common framework to be used for this will focus on: the defining characteristics of the society; legislative mandate; sectorial location (within or separate from health sector); funding streams; organising values of the system; locus of service delivery; service technologies; the role of social work; interprofessional dynamics; the role of consumers; and evaluation of outcomes at multiple levels. This analysis provides an opportunity to explore similarities and differences in mental system reform and in particular identify the challenges for social work in the field of mental health in the 21st century.     

The Changing Role of the Social Worker in the Mental Health System

ABSTRACT

The purpose of this paper is to discuss the role of the social work profession in the mental health service arena. It analyzes the changing mental health environment and the challenges facing social work. It stresses that the profession must adapt to the dramatic changes that have been taking place since the advent of deinstitutionalization and the need for community care for mentally ill persons.

Historical analysis of the social work profession shows that its involvement in the mental health field has started during the early stages of the development of the profession. Psychiatric social work has been considered a prestigious area of practice within the profession. Historically, social workers in the mental health field rarely challenged the dominance of the psychiatric profession. This position seems to have restrained social work from providing its full potential contribution to this field of practice and to the population it served.

Assessment of the continuing problems and current issues of the mental health system shows the potential central role of social work in this area. However, changes must take place in the practice of social workers in the mental health service system, as well as in the education and training of social workers. The paper discusses factors that facilitate or hinder the profession from appropriately adapting to the current service needs of the mentally ill persons, their families and communities, providing quality mental health and social services to this population and society as well.     

Changing Practice

Abstract

Changes to professional work now ensure that social care and health care workers should be accountable to service users, and not only to their professional colleagues. This paper seeks to explore how this may eventually be realised in new working relationships that will profoundly affect mental health social work.

These changes are driven by factors that are external to the social work profession-in policy initiatives that introduce measures of performance that incorporate the service user in both evaluating and planning services, in efforts to build new relationships, and in a breakdown of barriers between social work practitioners and service managers. While these changes are sometimes likely to be resisted by practitioners and service users alike, the demands of policy makers for a new professional accountability to service users can be used to pave the way for effective dialogue. The paper outlines the steps necessary to build confidence among both service users and service providers. This requires sensitive management and leadership. It also requires that action demonstrably follows from such dialogue. The paper uses evidence from Community Mental Health Teams in Swansea, over a three-year period, to demonstrate how the policy and management imperatives faced by service providers can be reconciled with the expressed desires of mental health service users.     

Health system reform and safe abortion: A case study of Mongolia

Abstract

Unsafe abortion serves as a marker of global inequity as it is concentrated in the developing world where the poorest and most vulnerable women live. While liberalisation of abortion law is essential to the reduction of unsafe abortion, a number of challenges exist beyond this important step. This paper investigates how popular health system reforms consonant with neoliberal agendas can challenge access to safe abortion. We use Mongolia, a country that has liberalised abortion law, yet, limited access to safe abortion, as a case study. Mongolia embraced market reforms in 1990 and subsequently reformed its health system. We document how common reforms in the areas of finance and regulation can compromise the safety of abortions as they foster challenges that include inconsistencies in service delivery that further foment health inequities, adoption of reproductive health programmes that are incompatible with the local sociocultural context, unregulated growth of the private sector and poor enforcement of standards and technical guidelines for safe abortion. We then discuss how this case study suggests the conversations that reproductive health policy-makers must have with those engineering health sector reform to ensure access to safe abortion in a liberalised environment.     

Mental health care reforms in Britain and Italy since 1950: a cross-national comparative study

This paper discusses a cross-national comparative study, which compares the implementation and geographical outcomes of mental health reforms in Britain and Italy since 1950. Working within a cross-national framework, the research adopts a sensitivity to the role of place by exploring the social and spatial restructuring of mental health care service provision in two localities - Sheffield and Verona. By focusing upon the local experiences of mental health care reform, the research strives to gain a clearer understanding of why local geographies of mental health care provision appear to vary across space, both within national boundaries and across them.     

Ethnic differences in women’s use of mental health services: do social networks play a role? Findings from a national survey

Objectives: The reasons for ethnic differences in women’s mental health service use in England remain unclear. The aims of this study were to ascertain: ethnic differences in women’s usage of mental health services, if social networks are independently associated with service use, and if the association between women’s social networks and service use varies between ethnic groups.

Design: Logistic regression modelling of nationally representative data from the Ethnic Minority Psychiatric Illness Rates in the Community (EMPIRIC) survey conducted in England. The analytic sample (2260 women, aged 16–74 years) was drawn from the representative subsample of 2340 women in EMPIRIC for whom data on mental health services, and social networks were available.

Results: Pakistani and Bangladeshi women were less likely than White women to have used mental health services (Pakistani OR?=?0.23, CI?=?0.08–0.65, p?=?.005; Bangladeshi OR?=?0.25, CI?=?0.07–0.86, p?=?.027). Frequent contact with relatives reduced mental health service use (OR?=?0.45, CI?=?0.23–0.89, p?=?.023). An increase in perceived inadequate support in women’s close networks was associated with increased odds of using mental health services (OR?=?1.91, CI?=?1.11–3.27, p?=?.019). The influence of social networks on mental health service use did not differ between ethnic groups.

Conclusions: The differential treatment of women from Pakistani and Bangladeshi ethnic groups in primary care settings could be a possible reason for the observed differences in mental health service use.     

Challenges for psychosocial rehabilitation services in the Lisbon Metropolitan Area: A qualitative approach

In Portugal, a mental health reform process is in place aiming to redefine the model of service provision. In 2008, a National Mental Health Plan (NMHP) was approved to provide policy guidance over the transition period. The NMHP intended, among others, to develop community‐based services, with a specific focus on rehabilitation and deinstitutionalization. This study aims to explore the perspectives of service managers of psychosocial rehabilitation services regarding the main challenges to support the community living of persons with severe mental illnesses (PWSMI) in the Lisbon Metropolitan Area (LMA). The paper also contextualises the provision of psychosocial services within the country's mental health reform process and characterises the profile of service users in socio‐occupational units (SOUs) of the LMA. Semi‐structured interviews were performed with all SOUs’ managers of the LMA (n = 13). Information regarding service user characteristics was collected based on service records (n = 344). Interviews were analysed according to the framework methodology. The results of the interviews were triangulated using document analysis. Fieldwork took place between June and July 2016. The findings suggest that the development of the mental health reform ensured significant changes to service delivery. Community‐based mental health organisations are an important actor for service provision. However, important asymmetries were identified in the provision of psychosocial care within the LMA. At the same time, family carers are perceived as responsible for ensuring a large part of the social needs of the PWSMI but there is an increasing concern with their own ageing processes. As a conclusion, it is highlighted the current inequality between services and the need to contemplate a life‐course perspective that comprehends the ageing process of caregivers poses an emerging challenge for psychosocial rehabilitation. These findings are also important for other low‐ and middle‐income countries passing through similar reforms.     

Posing A Framework To Guide Government's Role In Payment And Delivery System Reform

Innovative payment reform initiatives occur in both the public and private sector, but the optimal role in such reforms of the public sector, specifically the Centers for Medicare and Medicaid Services, is up for debate. In this article we examine recent experiences with public-private collaboration on payment and delivery reform and present a framework for determining the role of the government in spurring reform. We argue that as a purchaser, the government should consider the scale and maturity of private-sector activity in determining how to approach designing and implementing payment and delivery system reform. The government can further spur innovation by implementing payment reform for providers less ready to participate in it-such as smaller provider groups with limited organizational and technological capacity to implement reform-through identifying best practices related to attribution models and quality benchmarks and promoting dialogue with the private sector about the testing of new reform programs.     

Correlates of Mental Health Service Use Among Lesbian,Gay, and Bisexual Mothers and Prospective Mothers

ABSTRACT

Lesbian, gay, and bisexual women undertake parenting in a social context that may be associated with unique risk factors for perinatal depression. This cross-sectional study aimed to describe the mental health services used by women in the perinatal period and to identify potential correlates of mental health service use. Sixty-four women who were currently trying to conceive, pregnant, or the parent of a child less than one year of age were included. One-third of women reported some mental health service use within the past year; 30.6% of women reported a perceived unmet need for mental health services in the past year, with 40% of these women citing financial barriers as the reason for their unmet need. Women who were trying to get pregnant or who were less “out” were most likely to have had recent mental health service use. Women who had conceived by having sex with a man or who reported more than three episodes of discrimination were most likely to report unmet needs for mental health services. Providers may benefit from additional knowledge about the LBG social context that is relevant to perinatal health, and from identifying a strong referral network of skilled and affordable counsellors.     

Utilization of social workers in home care: An analysis of service use

ABSTRACT

Social workers are well positioned to address mental health complications impacting home care populations, yet social work has one of the lowest utilization rates of offered home care supports in Ontario. This study analyzed care plan data of frontline in-home social work services. Results identified adjustment to illness as the most common category and that seniors required significantly fewer visits and days on service than non-seniors. Most patients were able to accomplish their social work-based goals. Results highlight a need for further research and for capitalizing on the untapped potential value of social work home care services for patients.     

Our roles are not at ease: The work of engaging a youth advisory council in a mental health services delivery organization

ObjectivesThere is growing policy impetus for including youth voices in health services research and health system reform. This article examines the perspectives of professionals in a mental healthcare organization charged with engaging young people as advisors in service transformation.MethodsAn institutional ethnography of a youth mental health services organization in Ontario, Canada, was conducted. Fieldwork consisted of twelve months of observation of meetings, interviews with youth advisors and adult service providers, with subsequent text analysis of engagement training and policy materials. The present article reports data from six adult professionals and related field observations.ResultsService providers’ efforts to engage youth were observed in three areas: a) supporting youth''s development as advisors, b) retaining and deepening youth participation while waiting for organizational change and c) embedding relationships between youth and adults at various levels within the system of care. This work denotes existing tensions between the values and ideals of youth engagement and the everyday demands of services delivery.ConclusionIn this setting, a fundamental dimension of this work consisted of negotiating tensions between the policy enthusiasm for engagement and its realization in a health services context. In describing these contextual challenges, we outline implications for consideration by other youth mental health services. Engagement efforts that are authentic and sustained require resources and flexibility, and leadership commitment to instil service users’ perspectives throughout multiple levels within the organization.     

Systems of Care for Persons Who Are Homeless in the United States

SUMMARY

Occupational therapists work within various systems that provide services to persons who are homeless, including housing, health care, social service, education, and work programs. This article describes the typologies of homelessness, the continuum of care, trends in service delivery, the federal organization and primary sources of funding for homeless services. It is important for therapists to understand these systems and resources in order to deliver and advocate for effective services for persons who are homeless.     

Schutz vor Zoster

Background

Discussions on health sector reform in low-income and middle-income countries increasingly focus on the recognition of private-sector health care providers.

Aim

A review of recent literature presents trends of private stakeholder involvement as well as the potential for private sector participation in health system development and primary health care in these countries.

Results

Appropriate incentive structures may encourage private sector investments in health care as well as in service delivery in an efficient way and at reasonable cost – not only for the better-off. The role of government lies with regulation, health politics, and stewardship for health system financing. This approach may constitute an important contribution to achieving the goal of universal access to health care in the 21st century.     

La Revolución Ciudadana and social medicine: Undermining community in the state provision of health care in Ecuador

ABSTRACT

Under President Rafael Correa (2007–2017), Ecuador’s Ministry of Health established a state-centred health care regime that incorporates elements of Latin American social medicine into post-neoliberalism. These initiatives – which are part of ‘The National Plan for Good Living (Buen Vivir)’ – include free healthcare, greater attention to social determinants of health, a focus on equity and inclusion, and increased coordination across welfare, health, and development sectors. However, the reforms also use health services to build a sense of inclusive, participatory citizenship, with the Ecuadorean state as the central figure in service provision. In this paper, we demonstrate that state-centred health care reforms have paradoxically weakened community organising for collective health. Drawing on seventeen years of ethnographic research and health solidarity work in rural Northwest Ecuador, we illustrate how Ecuador’s health reforms have reconfigured relations among local civil society, transnational NGOs, and the state. Established modes of community participation and international collaboration have been undermined largely because these reforms ignore community sovereignty and self-organisation and overemphasise the threat of neoliberalism. The lessons about balancing the state-based fulfilment of rights with community power are relevant to social medicine advocates, particularly those working in rural communities that are already organising creatively for their own health and well-being.     

Does a working day keep the doctor away? A critical review of the impact of unemployment and job insecurity on health and social care utilisation

While the negative impact of unemployment on health is relatively well established, the extent to which that impact reflects on changes in health and social care utilisation is not well understood. This paper critically reviews the direction, magnitude and drivers of the impact of unemployment and job insecurity on health and social care utilisation across different care settings. We identified 28 relevant studies, which included 79 estimates of association between unemployment/job insecurity and healthcare utilisation. Positive associations dominated mental health services (N = 8 out of 11), but not necessarily primary care (N = 25 out of 43) or hospital care (N = 5 out of 22). We conducted a meta-analysis to summarise the magnitude of the impact and found that unemployed individuals were about 30% more likely to use health services compared to those employed, although this was largely driven by mental health service use. Key driving factors included financial pressure, health insurance, social network, disposable time and depression/anxiety. This review suggests that unemployment is likely to be associated with increased mental health service use, but there is considerable uncertainty around primary and hospital care utilisation. Future work to examine the impact across other settings, including community and social care, and further explore non-health determinants of utilisation is needed. The protocol was registered in PROSPERO (CRD42020177668).

     

Political violence, psychosocial trauma, and the context of mental health services use among immigrant Latinos in the United States

Objectives. We present the prevalence of exposure to political violence (PV) among Latino immigrants in the US, and perceived need for and correlates of mental health services use among this population.

Methods. We use the National Latino and Asian American Study (NLAAS), a nationally representative epidemiological survey of US Latinos, including a probability sample of 1630 immigrant Latinos. Our conceptual framework assumes a strong role of social and cultural factors in understanding the risk for psychopathology and mental health service use.

Results. Eleven percent of all immigrant Latinos reported PV exposure and 76% described additional lifetime traumas. Among those with a history of PV, an increased likelihood of using mental health services was associated with female gender, English language proficiency, experiencing personal assaults, higher perceived discrimination, and having an anxiety or substance disorder. Latino men and specific subgroups of Latinos were less likely to access mental health services after experiencing PV. Perceived need for mental health services use is the strongest correlate of any lifetime and last-12-months service use.

Conclusions. Individuals who come from countries with a history of political violence often have multiple traumatic experiences. This suggests a need for systematic screening for trauma and related psychiatric disorders. Specific outreach interventions focused on perceptions of need could be helpful for subgroups of Latinos including men who are particularly underrepresented in mental health services but who exhibit significant trauma histories.     

International Perspectives on Psychosocial Working Conditions,Mental Health,and Stress of Dairy Farm Operators

ABSTRACT

Dairy farm operators—farmers, workers, and family members—are faced with many demands and stressors in their daily work and these appear to be shared across countries and cultures. Dairy operators experience high psychosocial demands with respect to a hard work and production ethos, economic influences, and social and environmental responsibility. Furthermore, both traditional and industrial farms are highly dependent on external conditions, such as weather, fluctuating markets, and regulations from government authorities. Possible external stressors include disease outbreaks, taxes related to dairy production, and recent negative societal attitudes to farming in general. Dairy farm operators may have very few or no opportunities to influence and control these external conditions, demands, and expectations. High work demands and expectations coupled with low control and lack of social support can lead to a poor psychosocial work environment, with increased stress levels, ill mental health, depression, and, in the worst cases, suicide. Internationally, farmers with ill mental health have different health service options depending on their location. Regardless of location, it is initially the responsibility of the individual farmer and farm family to handle mental health and stress, which can be of short- or long-term duration. This paper reviews the literature on the topics of psychosocial working conditions, mental health, stress, depression, and suicide among dairy farm operators, farm workers, and farm family members in an international perspective.     

Preconditions for health reform: experiences from the OECD countries

This paper discusses the basic conditions necessary for the successful implementation of health sector reforms. Lessons from health sector reforms in the 24 western industrialized member countries of the Organization for Economic Cooperation and Development (OECD) are discussed and applied in the context of reform efforts in developing countries. Reform areas addressed include: public and private institutional infrastructure development, financing arrangements, benefit design, eligibility determination, reimbursement and cost control methods, and service delivery system configurations.     

Health systems and gender in post-conflict contexts: building back better?

The post-conflict or post-crisis period provides the opportunity for wide-ranging public sector reforms: donors fund rebuilding and reform efforts, social norms are in a state of flux, and the political climate may be conducive to change. This reform period presents favourable circumstances for the promotion of gender equity in multiple social arenas, including the health system. As part of a larger research project that explores whether and how gender equity considerations are taken into account in the reconstruction and reform of health systems in conflict-affected and post conflict countries, we undertook a narrative literature review based on the questions “How gender sensitive is the reconstruction and reform of health systems in post conflict countries, and what factors need to be taken into consideration to build a gender equitable health system?” We used the World Health Organisation’s (WHO) six building blocks as a framework for our analysis; these six building blocks are: 1) health service delivery/provision, 2) human resources, 3) health information systems, 4) health system financing, 5) medical products and technologies, and 6) leadership and governance.The limited literature on gender equity in health system reform in post conflict settings demonstrates that despite being an important political and social objective of the international community’s engagement in conflict-affected states, gender equity has not been fully integrated into post-conflict health system reform. Our review was therefore iterative in nature: To establish what factors need to be taken into consideration to build gender equitable health systems, we reviewed health system reforms in low and middle-income settings. We found that health systems literature does not sufficiently address the issue of gender equity. With this finding, we reflected on the key components of a gender-equitable health system that should be considered as part of health system reform in conflict-affected and post-conflict states. Given the benefits of gender equity for broader social and economic well-being, it is clearly in the interests of donors and policy makers to address this oversight in future health reform efforts.