Seventh meeting of the European national counterparts for the WHO Mental Health Programme: report on a WHO meeting: Copenhagen, Denmark, 11–13 December 2003

Seventh Meeting of the European National Counterparts for the WHO Mental Health Programme Report on a WHO meeting Copenhagen, Denmark 11–13 December 2003

Seventh Meeting of the European National Counterparts for the WHO Mental Health Programme

Report on a WHO meeting Copenhagen, Denmark 11–13 December 2003

ABSTRACT The mental health programme of the WHO Regional Office for Europe has established a network of mental health professionals in the Member States who have provided the necessary liaison between the WHO Regional Adviser for Mental Health and the mental health services in countries. These counterparts have been officially nominated by their health ministries and are often working in the ministry or are the most senior government mental health professionals. The network meets twice yearly in different locations. The Seventh Meeting of the European National Counterparts for the WHO European Mental Health Programme was held in Copenhagen from 11 to 13 December 2003. Representatives of 35 countries took part. Also present were representatives of various task forces of the mental health programme, representatives of the Steering Committee of the WHO European Ministerial Conference on Mental Health: Facing the Challenges, Building Solutions to be held in Helsinki in 2005 and members of the evaluation team that assessed the WHO European mental health programme. The Meeting programme included a presentation on the Mental Health Policy and Service Guidance Package prepared by WHO headquarters and a presentation of the project Monitoring Mental Health Systems and Services carried out by WHO headquarters. The counterparts were asked to reflect and debate on the topics raised in the presentations. An update on the Ministerial Conference preparations was presented, and the counterparts worked and discussed on the selected Conference themes and proposed outcomes.

Keywords MENTAL HEALTH SERVICES – organization and administration – trends HEALTH POLICY STRATEGIC PLANNING FINANCING, HEALTH CONGRESSES – organization and administration EUROPE EUROPE, CENTRAL EUROPE, EASTERN EUROPE, SOUTHERN

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CONTENTS

Page Official opening.............................................................................................................................................1 Mental health in Europe: problems, processes and challenges .....................................................................1 Mental health policy and service development – the WHO strategy ............................................................2 Group work on the WHO strategy for mental health policy and services development ...............................3 Workshop 1: Quality improvement and organization of services.......................................................3 Workshop 2: Financing, planning and budgeting for service delivery ...............................................4 Workshop 3: Legislation, human rights and service delivery.............................................................5 Workshop 4: Policy and planning .......................................................................................................5 Country updates.............................................................................................................................................6 Workshop 1: Western Europe .............................................................................................................6 Workshop 2: Southern Europe ............................................................................................................6 Workshop 3: Central Europe...............................................................................................................7 Workshop 4: Eastern Europe ..............................................................................................................8 WHO task forces and networks – an update (part 1).....................................................................................9 Task Force on National Assessments..................................................................................................9 Task Force on Child and Adolescent Mental Health ..........................................................................9 WHO European Ministerial Conference on Mental Health: Facing the Challenges, Building Solutions, Helsinki, Finland, 12–15 January 2005.......................................................................10 Group work on the Conference themes.............................................................................................11 Monitoring of Mental Health Systems and Services project.......................................................................11 Initial findings of the Monitoring of Mental Health Systems and Services survey – the case of Albania ..............................................................................................................................................12 Group work on the selection of mental health domains....................................................................13 WHO task forces and networks – an update (part 2)...................................................................................15 Task Force on Stigma and Discrimination........................................................................................15 Task Force on Helplessness and Stress-related Disorders ................................................................16 Feedback from the Conference Secretariat..................................................................................................16 The way forward .........................................................................................................................................17 Feedback from the counterparts ........................................................................................................17 Closing the meeting.....................................................................................................................................18 Annex 1. List of participants .......................................................................................................................19

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Official opening Wolfgang Rutz, WHO Regional Office for Europe

Wolfgang Rutz welcomed the participants and extended his greetings to the newly appointed national counterparts. He then explained the aims of the meeting: exchanging knowledge and experience among counterparts, discussing the WHO headquarters project Monitoring Mental Health Systems and Services and focusing on preparing the WHO European Ministerial Conference on Mental Health: Facing the Challenges, Building Solutions to be held in Helsinki in 2005. He also said that an evaluation team was present at the meeting and that interviews would be carried out with some of the participants to evaluate the activities of the WHO European mental health programme.

Mental health in Europe: problems, processes and challenges Wolfgang Rutz, WHO Regional Office for Europe

A panorama of trends and problems across the European Region was described, emphasizing stress-related morbidity, especially in countries in transition, attention and conduct disorders among children and adolescents and the mental health problems occurring outside mental health services. Other issues addressed were the increasing importance of values and human rights to integrity and health and the tendency of psychiatry to focus on research and to ignore or neglect the real problems. Wolfgang Rutz also highlighted the need to meet the problems where they are – workplaces, schools, communities and networks – and called for considering the accessibility and allocation of resources and ways of involving primary health care in community-based mental health services. The WHO report evaluating the effectiveness of mental health services (What are the arguments for community-based mental health care?1) indicated this perspective. Regarding challenges for the future, several issues were emphasized: the quality and quantity of evidence and cost–benefit evaluation of evidence, challenges arising from the regionalization of Europe, accessibility and allocation of resources for community-based mental health care and challenges related to terrorism and threats. Wolfgang Rutz concluded by highlighting the importance of partnerships and cooperation with other government organizations, such as the European Union and the Council of Europe, with Member States, with WHO headquarters, within the WHO Regional Office for Europe and with other WHO regions. He also pointed out that the network of counterparts would be continuously involved in preparing the WHO European Ministerial Conference on Mental Health: Facing the Challenges, Building Solutions and related pre-conferences.

1

Thornicroft G, Tansella M. What are the arguments for community-based mental health care? Copenhagen, WHO Regional Office for Europe, 2003 (http://www.euro.who.int/eprise/main/WHO/Progs/HEN/Syntheses/mentalhealth/ 20030822_1, accessed 4 May 2004).

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Mental health policy and service development – the WHO strategy Michelle Funk, WHO headquarters

Michelle Funk introduced the WHO mental health policy and service strategy and explained the reasons for embarking on this project: countries needed to reform mental health services, the economic costs of mental health problems were high and mental health resources were lacking or, if available, were improperly used. She underlined that, when organizing services, priority should be given to shifting care away from mental hospitals and to developing community mental health services and integrating mental health into general health care systems. Past experience demonstrated that developing groups of users and families and actively involving them in reform improved the quality of services. Seven principles of service reform were then highlighted: accessibility, continuity, comprehensiveness, needs-led, effectiveness, equity and respect for human rights. Regarding financing of mental health care, the level of resources being invested is disproportionately low compared with the disease burden and that considerations related to equity, efficiency and reform should influence financing decisions. Although the workforce is the most valuable asset in mental health care, countries have difficulty in developing and maintaining the workforce. From this perspective, several courses of action have been taken: developing human resources policy; planning for numbers, skill mix and competencies; continuing education, training and supervision; and management strategies. Michelle Funk emphasized that quality is an essential requirement of any mental health service, ensuring that resources are used properly and building trust in the effectiveness of the system. Further, the WHO Mental Health Policy and Service Guidance Package2 developed by WHO headquarters to assist countries with technical guidance was presented briefly. The following modules were approached: • • • • • • • •

the mental health context; mental health policy, plans and programmes; mental health financing; mental health legislation and human rights; advocacy for mental health; organization of services for mental health; planning and budgeting to deliver services for mental health; and quality improvement for mental health.

Michelle Funk said that modules on other topics were being prepared: • • 2

improving access to and use of psychotropic medicines; mental health information systems; For more information and to download the modules, see http://www.who.int/mental_health/policy/en.

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• • • •

human resources and training for mental health; mental health of children and adolescents; research and evaluation of mental health policy and services; and mental health policies and programmes in the workplace.

In conclusion, the modules can be used for training forums and workshops, for country technical assistance in partnership with regional and country offices and for developing a faculty of consultants to provide technical assistance in mental health reforms.

Group work on the WHO strategy for mental health policy and services development Workshop 1: Quality improvement and organization of services Anastas Suli (Albania), Isidore Pelc (Belgium), Cyril Höschl (Czech Republic), Anna Brockmann (Germany), Jan Czeslaw Czabala (Poland), Maria João Heitor dos Santos (Portugal), Aleksandra Milicevic Kalasic (Serbia and Montenegro), Herbert Heise (Switzerland), Nargiza Khodjaeva (Uzbekistan) and Franz Baro (WHO Collaborating Centre on Health and Psychosocial Factors) Facilitator: Jan Czeslaw Czabala Rapporteur: Aleksandra Milicevic Kalasic The group had a short briefing on the WHO module Quality improvement for mental health and discussed in detail the involvement of general practitioners in treating mental disorders and in the process of deinstitutionalization. Although the experience from countries was diverse, the conclusion was that disseminating knowledge is essential as well as being willing to make partnerships and set conditions for intersectoral collaboration. It was commonly agreed that awareness on the identification and treatment of mental disorders still needs to be raised among general practitioners and other primary health care staff and training is needed on this. Various countries described experience and practices related to deinstitutionalization. It was suggested that some facilities be kept and used for some special treatment and care; a small proportion of patients needs long-stay facilities. It was also pointed out that time will be needed for this process. Comments

The need to share experience on how mental health care could be coordinated and how responsibilities should be distributed was strongly emphasized. Attention was drawn to the fear of mental health care staff of losing their jobs and to the paradox of psychiatrists sometimes abandoning their social responsibilities and, subsequently, to the need to build incentives for staff.

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In the ensuing discussion, the topic of the social consequences of deinstitutionalization was debated, and representatives of various countries pointed out the lack of logistics to prepare the community to integrate former mental hospital patients. Other concerns expressed from a management perspective were avoiding duplicating resources and trying to build strong alliances (such as with the police and the education sector). An experience from Finland was shared regarding coordination, and information was given on the existence of a common health record in Finland accessible to all departments and functioning as a vehicle by which continuity can be assured. Workshop 2: Financing, planning and budgeting for service delivery Samvel Torosyan (Armenia), Ismet Ceric (Bosnia and Herzegovina), Helja Eomois (Estonia), Laszlo Tringer (Hungary), Maris Taube (Latvia), Ray G. Xerri (Malta), Bogdana Tudorache (Romania), Peter Breier (Slovakia), Vitomir Micev (The former Yugoslav Republic of Macedonia) Facilitator: Ray G. Xerri Rapporteur: Peter Breier A common trait among the countries participating in the workshop is an unstable political situation with frequent changes of ministers and a need to have a vision for long-term programmes, with consistent political commitment. Other issues discussed were: • • • •

the role and position of psychiatrists in influencing changes in general health care and in improving the financing of mental health care; the importance of effective strategic planning with the need for a ring-fenced mental health budget with incentives; the need for a national policy with one management structure for both hospitals and community care; and the need for technical management and an efficient operational system.

This group believed that continuing communication on new policies upwards and downwards and building alliances with all stakeholders and donor organizations is crucial. Building alliances with some politicians and increasing their recognition of the burden of mental health problems was given as an example of successful practice that helps to move things forward. Comments

A comment was made that budgets should be decentralized and that financial data should be linked to performance. It was stressed that attempting to exercise very effective management by simply using financial data would not provide enough information. However, attention was drawn to the fact that decentralization in many countries places mental health care and service providers at risk.

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Further, it was pointed out that more information and research is needed on mental health expenditure, since most of the information currently available is on salaries and not on the real social and economic costs. Workshop 3: Legislation, human rights and service delivery Agabey Sultanov (Azerbaijan), Joka Simic Blagovcanin (Bosnia and Herzegovina), Kristian Wahlbeck (Finland), Baibre Nic Aongusa (Ireland), Ona Davidoniene (Lithuania), Alexander S. Karpov (Russian Federation), Helena Silfverhielm (Sweden), Valery N. Kuznetsov (Ukraine) Facilitator: Helena Silfverhielm Rapporteur: Kristian Wahlbeck The group discussed the influence of advocacy groups on legislation, starting from the example of the Compulsory Care Act from 1992 in Sweden. Issues debated were ways of promoting respect for patients’ dignity not only through legislation but also through financial incentives or testimonies and reports of ex-patients about their experiences. Minimizing the use of general restrictions on individuals was also discussed as well as various related topics such as: involuntary admission versus treatment, restriction on the use of antipsychotic drugs during the observation phase, a code of ethics, informed consent for treatment, the role and set of powers given to the family, confidentiality and access to information. Workshop 4: Policy and planning Heinz Katschnig (Austria), Pavel Rynkov (Belarus), George B. Naneishvili (Georgia), Roberto Cardea (Italy), Frans Clabbers (Netherlands), Sebastiano Bastianelli (San Marino), Juan LópezIbor (Spain) Facilitator: Heinz Katschnig Rapporteur: Juan López-Ibor The discussions were based on the presentation of two examples of two large mental hospitals that closed in the Federal State of Lower Austria: a success (Donauklinikum Gugging) and a failure (Ostarrichiklinikum Amstetten). The Austrian experience had shown some patterns of resistance to changes such as: lack of knowledge about mental health and mental disorders among people working outside the mental health sector (such as politicians, the general public and others), stigma and fear of stigma, a fragmented system for financing mental health care, poor data on the total costs of mental health care, poor management and professional rivalry. The group also analysed the experience in Italy and the Netherlands and underlined the danger of splitting services, which consisted of difficulty in quality assurance and coordination with social services and responsibilities split between curative services (municipalities responsible) and care services (central government responsible). Attention was drawn also to the lack of coordination due to professional rivalry and to the need to clearly define the responsibilities of the staff.

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Country updates The counterparts split into four groups and gave an update on the situation in their countries. Workshop 1: Western Europe Heinz Katschnig (Austria), Isidore Pelc (Belgium), Kristian Wahlbeck (Finland), Anna Brockmann (Germany), Baibre Nic Aongusa (Ireland), Frans Clabbers (Netherlands), Helena Silfverhielm (Sweden) and Herbert Heise (Switzerland) Facilitator: Heinz Katschnig Rapporteur: Anna Brockmann This workshop reflected on the content and constitution of country reports and proposed a new structure for these reports, which should contain the following items: • • • • • • • • •

background information about the country; mental health legislation; responsibilities for financing mental health care and for providing services; mental health plans and policies; community-based mental health and deinstitutionalization; preventing common mental disorders and promoting mental health; advocacy and empowerment of service users and their families; the strengths and weaknesses of mental health systems; and any other issue considered important.

The length of the report was proposed to be about 900 words, with an average of 90–100 words per section. It was also highlighted that each country should take responsibility for improving the update for reports, and it was felt that it would be much more useful to concentrate on processes and structures than on figures and data. Comments

It was signalled that including figures and evidence-based information is important but that the report should have a certain limitation. The information was given that an electronic board would be created under the auspices of the Mental Health Unit of the WHO Regional Office for Europe, to offer the counterparts the possibility to raise questions and comment on matters of interest. Workshop 2: Southern Europe Roberto Cardea (Italy), Ray G. Xerri (Malta), Maria João Heitor dos Santos (Portugal), Sebastiano Bastianelli (San Marino) and Juan López-Ibor (Spain) Facilitator: Maria João Heitor dos Santos Rapporteur: Juan López-Ibor

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The group indicated several matters of common concern in southern Europe despite the specific characteristics of individual countries: insufficient programmes for promoting mental health and preventing mental disorders; poor mental health information systems; lack of human resources in mental health services for children and adolescents; predominance of the “medical model”; need for the development of transcultural psychiatry on a country basis due to the mobility of users; creation of crisis intervention teams for disasters; continuity of care in areas dealing with alcohol-related problems and drug dependence and coordination with other sectors; development of action in the fields of education, social security, justice and environment; and stigma and its consequences. Attention was also drawn to several areas of progress: the growing visibility of mental health, following the efforts of WHO and the European Union and growing political involvement; existence of a legal framework for mental health national policy in many countries; increasing interest for mental health programmes and their implementation at all levels; and increasing involvement and empowerment of users’ associations and users’ families. Five future targets were highlighted as issues of priority: • • • • •

reducing waste in budgets and in human resources; improving the quality of services; focusing more on evidence-based policies and practices; creating assessment tools that can be easily and regularly used in each of the countries; and improving management structures and systems.

Workshop 3: Central Europe Anastas Suli (Albania), Ismet Ceric and Joka Simic Blagovcanin (Bosnia and Herzegovina), Cyril Höschl (Czech Republic), Helja Eomois (Estonia), Laszlo Tringer (Hungary), Maris Taube (Latvia), Ona Davidoniene (Lithuania), Jan Czeslaw Czabala (Poland), Bogdana Tudorache (Romania), Aleksandra Milicevic Kalasic (Serbia and Montenegro), Peter Breier (Slovakia), Andrej Marusic (Slovenia), Vitomir Micev (The former Yugoslav Republic of Macedonia) Facilitator: Laszlo Tringer Rapporteur: Ona Davidoniene It was first highlighted that countries in central Europe were in continuous development and some still in an uncertain period of transition. Several countries reported on the steps taken towards establishing community mental health structures, especially implementing small psychiatric wards in general hospitals and intensive training for professionals working in mental health. Attention was drawn to the conservatism of stakeholders and to the need to disseminate information and to train managers, policy-makers, general practitioners, psychiatrists and other health care staff. Information was given also on efforts to implement the recommendations of various meetings under the European Union, WHO and the Council of Europe.

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Other countries informed about the work that had been carried out on mental health strategies (Estonia), on positive developments for a health education programme in schools especially emphasizing mental health (Hungary) and the work to set up a state alcohol programme and a suicide prevention programme (Lithuania). Several counterparts mentioned the establishment and role of a national body for mental health in their countries. Several countries reported concern about a lack of professionals, both physicians and others, and a gap between health and social care and lack of continuity in activities because projects are long-term and governments short-term. Workshop 4: Eastern Europe Samvel Torosyan (Armenia), Agabey Sultanov (Azerbaijan), Pavel Rynkov (Belarus), George B. Naneishvili (Georgia), Valery Solojenkin (Kyrgyzstan), Alexander S. Karpov (Russian Federation), Valery N. Kuznetsov (Ukraine), Nargiza Khodjaeva (Uzbekistan) Facilitator: Valery N. Kuznetsov Rapporteur: George B. Naneishvili The group informed about the existence of state programmes on psychiatric care in Georgia, the Russian Federation and Ukraine but pointed out that these programmes cannot cover all needs. Armenia, Azerbaijan, Belarus and Uzbekistan have no such programmes. Other difficulties pointed out were: no system of social care for people with mental health problems; few, if any epidemiological investigations on the increase in mental disorders in the country; and an urgent need for training psychiatric staff. Deficits in health budgets as a percentage of total expenditure across the countries were also reported: Belarus 40%, Russian Federation, Ukraine and Uzbekistan 60% and Azerbaijan 70%. Progress was noted in Georgia, which had implemented a programme for the psychosocial rehabilitation of children and adolescents and had set up a Mental Health Coordination Council gathering various stakeholders from government structures and nongovernmental organizations. However, it was stressed that nongovernmental organizations were local in character and had little power and worked on limited projects related to the psychosocial rehabilitation of various risk groups. A common challenge was outlined: working towards deinstitutionalizing mental health care services and creating a system of psychosocial rehabilitation for people with mental health problems.

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WHO task forces and networks3 – an update (part 1) Task Force on National Assessments Franz Baro, WHO Collaborating Centre on Health and Psychosocial Factors, Brussels, Belgium

Franz Baro informed that the Task Force on National Assessments worked on policy development and carried out mental health assessments at the national or regional level at the invitation of health ministers or other authorities and provided recommendations for action. The assessments consisted of visits to mental health services and facilities and meetings and interviews with various stakeholders such as professional associations, policy-makers, families and users’ associations. The data collected were both quantitative and qualitative, but information was also gathered on political issues related to the nature of mental health reform in the countries. It was highlighted that the data collected were always the property of the country but that analysing and comparing data to illustrate some basic general mechanisms would be useful. The problem of finding funds for these activities was especially stressed. Franz Baro then invited the counterparts from Lithuania, Malta, Romania, Serbia and Montenegro and Slovakia to give more information on the assessments that had been carried out in their countries. The main issues emerging from these experiences were that recommendations still needed support from the WHO Regional Office for Europe to be put into practice, that having international experts, and thus an independent review, helped to make links between psychiatrists and that these assessments contributed to increasing the understanding of politicians of the need to develop outpatient care. Comments

A suggestion was made that the results of these experiences should be shared with other countries and possibly published in reports or international journals. Task Force on Child and Adolescent Mental Health Wolfgang Rutz, WHO Regional Office for Europe

Wolfgang Rutz noted that the Task Force on Child and Adolescent Mental Health was established in January 2003 to work on the mental health of children and adolescents in Europe and to make recommendations for countries. He took this opportunity to mention the names of the members of the Task Force. He also provided information on the first meeting of the Task Force in July 2003, at which the Task Force worked on the clinical implications of crisis management in adolescence and 3

The names and contact details of the members of the task forces are listed at: http://www.euro.who.int/mentalhealth.

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discussed evaluation of the quality of psychiatric services in European countries and the quality of education and training in child and adolescent psychiatry in various European countries.

WHO European Ministerial Conference on Mental Health: Facing the Challenges, Building Solutions, Helsinki, Finland, 12–15 January 2005 Simo Kokko, WHO Regional Office for Europe

Simo Kokko introduced the general principles related to the programme of the WHO European Ministerial Conference on Mental Health and explained that a series of pre-conferences would precede the main Conference and address selected themes. Although the Conference would be a political meeting of the ministers responsible for health and their delegations composed of policy-makers, the target audience of the pre-conferences would be mental health professionals, policy-makers and administrators knowledgeable on mental health. The content and dates of the pre-conferences were described briefly: • • • •

pre-conference on Suicide Prevention Strategies, Brussels, Belgium, 11–12 March 2004; pre-conference on Societal Stress, Moscow, Russian Federation, 3–5 June 2004; pre-conference on the Mental Health of Children and Adolescents, Luxembourg, 20–21 September 2004; and pre-conference on Mental Health and the Working Life, Tallinn, Estonia, 4–5 October 2004.

It was emphasized that all these dates would be confirmed in a second announcement. The draft programme of the Conference was then explained in detail. The plenary session was to have the following main topics: • • • • • • • • •

introduction to the challenges of mental health and ill health in Europe; mental health of children and adolescents; mental health of people of working age; mental health of elderly people; mental health services; implementing national mental health policies; health ministers challenged at the round table – building solutions; round table discussion on stigma; and inclusion and human rights.

Parallel workshops would be organized for each plenary session. Simo Kokko invited the counterparts to think, from the perspective of their countries, about what the outcome of the main Conference should be. He also informed about the WHO proposal to

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have a declaration that would include recommendations for an action plan for both Member States and WHO. Gudjon Magnusson, WHO Regional Office for Europe

Gudjon Magnusson emphasized the complex work that had been done in countries and the huge diversity of initiatives that had been taken to promote raising the profile of mental health on the political agenda. Progress had been made, but collaboration between mental health and public health needs to be increased. He also pointed out the need to consult widely the Member States on the outcome of the Ministerial Conference and stressed that the Regional Office was relying on the counterparts’ assistance to ensure that an appropriate balance of represented parties participates in the Conference. He concluded by encouraging the counterparts to provide feedback on the Conference themes and outcomes and to share information and experience on the developments in their countries. Group work on the Conference themes The counterparts split into three working groups and debated the proposal of conference themes and outcomes. The main issues emerging from discussions were the following. • • • • • •

It was commonly agreed that the outcome of the Conference should be an action plan. It was suggested to take into account the new challenges linked with social changes and the mobility of individuals. It was proposed to include the topic of value-based medicine and research-based medicine in the Conference themes. Three topics were pointed out as important: preventing suicide, restructuring mental health services to community care and integrating mental health services in primary care. It was suggested that each country present a policy paper at a pre-conference and that overlap in Helsinki be minimized. Suggestions were made to give more attention to slogans to send clear messages not only to ministers but also to administrators.

Finally, the counterparts expressed the need for more information on the role they would have in contributing to preparing these documents.

Monitoring of Mental Health Systems and Services project Shekhar Saxena, WHO headquarters

Shekhar Saxena introduced the Monitoring Mental Health Systems and Services project, which had been developed by WHO headquarters during 2003 with the aim of assisting countries in enhancing mental health systems and services by developing a set of indicators to monitor mental health systems and services. The starting-point of the project was the ten recommendations of The world health report 2001: mental health: new understanding, new hope that suggested action from treatment to prevention

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and promotion, and to monitoring and research. It was highlighted that this was in accordance with the WHO Global Action Programme for mental health, the Ministerial Round Tables on mental health of the Fifty-fourth World Health Assembly4 and the project Atlas – Mental Health Resources in the World (http://www.who.int/mental_health/media/en/244.pdf, accessed 4 May 2004). Shekhar Saxena explained that 10 domains had been set up and that the facets of each domain represented the content that should be assessed to monitor the domain. Qualitative and quantitative indicators had been derived from these facets, after consultation with experts and key focal points in developing countries. The 10 domains were then presented, with the proposed facets and indicators. 1.

Mental health in primary health care –

Example of a facet – training of primary care staff: initial and refresher training of primary care staff, including physicians, nurses and health care workers, in mental health care; Example of an indicator – percentage of training hours devoted to psychiatry or mental health during the specialization in primary care, family medicine or general practice for general practitioners and nurses;

–

2. 3. 4. 5. 6. 7. 8. 9. 10.

Availability of psychotropic medicines Mental health services in the community Public education Involvement of communities, families and consumers National policies, plans and legislation Human resources Link with other sectors Monitoring Research.

In conclusion, it was emphasized that implementing the indicators could lead to substantial gains. Thus, countries would be able to monitor the progress in implementing their reform polices, in providing community services and in the activities of the communities and associations of users and families. Moreover, it was stressed that indicators might prompt governments and health system managers to build a data infrastructure, to implement an information system and to foster the use of surveys of mental health disorders. Initial findings of the Monitoring of Mental Health Systems and Services survey – the case of Albania Anastas Suli, National Hospital and University Centre, Tirana

Anastas Suli informed that a National Steering Committee for Mental Health had been set up with the technical support of WHO and that the Minister for Health had approved a national Mental health: a call for action by world health ministers. Geneva, World Health Organization, 2001 (http://whqlibdoc.who.int/hq/2001/WHO_NMH_MSD_WHA_01.1.pdf, accessed 4 May 2004). 4

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mental health policy document containing the main guidelines and recommendations for the reform process. Based on this policy document, a national implementation plan was being developed. In addition, the mental health situation in Albania was presented briefly. The main issues put forward were the following. • • •

Indicators related to mental health were integrated in the general health information system and were mainly related to mental hospital care. Data about mental health and education and family involvement were difficult to collect, but data existed if sentinel sites were reached. Data were mainly collected manually; no information technology was used.

Detailed information was also given on the main findings in domains 1 and 7. Comments

Several speakers pointed out the variety of existing data across the regions and stressed that some countries had a large proportion of data available, whereas others had very few. Attention was also drawn to avoiding duplication and to the need to improve collaboration and coordination. A few examples of data collection exercises in the European Region were given: • • • • •

Eurostat – Statistical Office of the European Communities (http://europa.eu.int/comm/ eurostat/Public/datashop/print-catalogue/EN?catalogue=Eurostat, accessed 4 May 2004); OECD (Organisation for Economic Co-operation and Development) databases (http://www.sourceoecd.org/content/html/index.htm, accessed 4 May 2004); the European Union funded project Minimum Data Set of European Mental Health Indicators;5 the EHDP (Expert Health Data Programming) database for European hospital data (http://www.ehdp.com/index.htm, accessed 4 May 2004); and the EUROHIS project.6

Group work on the selection of mental health domains Group 1

Anastas Suli (Albania), Isidore Pelc (Belgium), Cyril Höschl (Czech Republic), Anna Brockmann (Germany), Aleksandra Milicevic Kalasic (Serbia and Montenegro) and Liliana Urbina (WHO Regional Office for Europe) Facilitator: Anastas Suli Rapporteur: Cyril Höschl

Minimum data set of European mental health indicators. Proposed set of mental health indicators: definitions, description and sources. Helsinki, National Research and Development Centre for Welfare and Health – STAKES, 2001 (http://www.stakes.fi/verkkojulk/pdf/minimum.pdf, accessed 4 May 2004). 6 Nossikov A, Gudex C, eds. EUROHIS – developing common instruments for health surveys. Amsterdam, IOS Press, 2003 (Biomedical and Health Research, No. 57).

5

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The group reported on the heterogeneity of existing data across Europe but also within countries and regions. It was highlighted that data might not be comparable since there were different ways of collecting data. Attention was also drawn to the workload related to collecting the data and to the minimal output related to it as well as to the fact that some items mentioned were impossible to collect at the regional level. Another issue of crucial importance was the need to have a reliable system of statistics from which to extract data. Suggestions were made to clarify or further define the terms (such as the list of essential drugs and refresher training) and to add qualitative information on the decrease in the number of beds. Group 2

Heinz Katschnig (Austria), Ismet Ceric (Bosnia and Herzegovina), Helja Eomois (Estonia) George B. Naneishvili (Georgia), Laszlo Tringer (Hungary), Roberto Cardea (Italy), Maris Taube (Latvia), Bogdana Tudorache (Romania), Sebastiano Bastianelli (San Marino) and Peter Breier (Slovakia) Facilitator: Peter Breier Rapporteur: Heinz Katschnig The group equally pointed out the difficulties in collecting data because of the variety of administrative structures and procedures across countries and regions. Some domains were considered more useful than others such as: domains 3 (mental health services in the community) and 6 (national policies, plans and legislation). The group also discussed the new structure of country reports from the perspective of the mental health domains presented previously. Group 3

Agabey Sultanov (Azerbaijan), Joka Simic Blagovcanin (Bosnia and Herzegovina), Kristian Wahlbeck (Finland), Ona Davidoniene (Lithuania), Alexander S. Karpov (Russian Federation), Andrej Marusic (Slovenia) and Valery N. Kuznetsov (Ukraine) Facilitator: Kristian Wahlbeck Rapporteur: Andrej Marusic It was pointed out that all countries were able to provide data on several domains: domain 2 (availability of psychotropic medicines), 3 (mental health services in the community), 6 (national policies, plans and legislation) and 7 (human resources). It was also stressed that the counterparts should not have sole responsibility for collecting data but that a letter should be sent to health ministers requesting their support in completing the questionnaire. The letter should highlight the objectives and outcomes of this exercise. The suggestion was made to specify which questions should be answered in more detail and which questions could be answered “yes”, “no” or “not applicable”.

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Comments

Shekhar Saxena thanked the counterparts for their comments and suggestions. He emphasized that the project was meant to be an action-oriented exercise and that the aim was to offer assistance to countries if and when this was needed. He also pointed out that the counterparts could decide whether to reply to the questionnaires. He also acknowledged that gathering data was more feasible at the regional level than at the country level and suggested that a benefit of this exercise could be networking with other sectors, such as education and social care. It was reiterated that counterparts would be invited to provide the information available and to indicate what data could be obtained without spending too much time. A booklet would be distributed explaining the terms used and providing clear definitions. In conclusion, Shekhar Saxena suggested that counterparts should give priority to some domains and stressed that this would provide evaluation of different domains.

WHO task forces and networks – an update (part 2) Task Force on Stigma and Discrimination Lars Jacobsson, University of Umeå, Sweden

Lars Jacobsson informed that the Task Force on Stigma and Discrimination had been working for several years on preparing a number of reports and materials due to be ready for the Ministerial Conference in 2005. A first report of the Task Force, in which the counterparts had been involved by means of a questionnaire, focused on stigma and discrimination, looking at activities in countries and issues that were considered problematic. A second report looked at the mental health situation of children and adolescents, comparing the resources allocated to children and adolescents with those allocated to adults. A third activity mentioned was preparing a book on good examples of combating stigma and discrimination, including recommendations on action to be undertaken to raise awareness of these problems. Other activities included finalizing several articles for various international journals. Information was given also on the work of the Trimbos Institute (Netherlands Institute of Mental Health and Addiction) group that gathers people from different disciplines working with stigma and discrimination (such areas as eating disorders, leprosy and HIV/AIDS). Comments

It was suggested to look for more interaction with other task force activities and to join efforts in sharing information, knowledge and methods.

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Task Force on Helplessness and Stress-related Disorders Per Bech, WHO Collaborating Centre on Quality of Life Studies, Hillerød, Denmark

Per Bech informed the participants about the main activities of the Task Force on Helplessness and Stress-related Disorders, which is investigating the treatment of depression in primary care, depression among men (in collaboration with the German Research Network on Depression and Suicidality) and the relationship between cardiovascular diseases and depression. He then briefly presented the European Alliance against Depression (led by Ulrich Hegerl in Munich), which has received funding from the European Commission. The project focuses on awareness-raising campaigns on depression and suicide in various European countries. The objectives are to collect epidemiological, psychosocial and biological data on stress-related disorders, especially depression and suicidal behaviour. Another achievement presented was the second edition of the book How to cope with stress by Peter Tyrer.

Feedback from the Conference Secretariat Liliana Urbina, WHO Regional Office for Europe

Liliana Urbina thanked the counterparts for their valuable comments and suggestions regarding the preparation of the Ministerial Conference and summarized the feedback from the Conference Secretariat. • •

The suggestions to emphasize evidence-based mental health and to introduce value-based mental health were welcomed. The proposal to have a new structure of country reports was considered a positive point. However, it was pointed out that a decision on the future of the country reports needed to be made first. The proposal from Austria to hold a pre-conference on the mental health of elderly people was also welcomed as well as the idea of using new slogans. The suggestion to have an action plan with clear steps, responsibilities and timetable was widely supported. Regarding the comments on the survey Monitoring Mental Health Systems and Services, it was proposed to conduct a feasibility study (by e-mail or by fax) with the counterparts and incorporating the following ratings in the questionnaires: A = readily available B = available after some searching C = only though a study or survey D = only through a sentinel collection E = not available.

• • •

The next steps after this feasibility study would be to develop a proposal based on the results and to send the new version of the questionnaires to the counterparts.

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Comments

A suggestion was made to possibly merge points C and D and to leave more space for narrative comments and explanations.

The way forward Wolfgang Rutz, WHO Regional Office for Europe

Picking up the suggestion to have new slogans for the Conference, Wolfgang Rutz initiated a discussion on various existing and possible slogans. Several examples were debated. • • • • • • • •

No health without mental health. No mental health without human rights and no human rights without mental health. No peace without mental health; no mental health without peace. Mental health is public health. No environment and health without mental health. No health impact awareness and assessment without mental health. No health investment without mental health. Good psychiatrists should have the team within themselves.

He also took the opportunity to announce that he would be leaving his position as Regional Adviser for Mental Health. Feedback from the counterparts Responding to Wolfgang Rutz’s address, a number of counterparts pointed out the benefits of creating this network and the advantages of these meetings: sharing experiences and information, having a reliable back-up and a reference point from which to ask for information and support and having the network’s international background while elaborating strategies to promote mental health. The importance and benefits of the work of task forces were also highlighted, and it was suggested that they should be more engaged in future meetings of the counterparts. The need to receive support from the WHO European mental health programme to continue the activities was reiterated. Suggestions were made to concentrate on more country-action plans and on effective ways of disseminating information and of influencing professionals and policy-makers. Another suggestion regarding the slogans presented before was to avoid “no”-type slogans, taking into consideration that “no” indicated absence, and to put more emphasis on the positive work that had been done. Peer review, peer support and peer development were underlined as highly important, as the experience of the Balkan countries involved in the mental health project of the Stability Pact for South-Eastern Europe had demonstrated. The suggestion was made to discuss in the future ways of getting countries together, grouping them by subregions or by other criteria.

EUR/03/5035055 page 18

A number of counterparts highlighted Wolfgang Rutz’s contribution to strengthening the work on mental health policy at the country level and emphasized his role in coordinating activities, mobilizing resources and creating partnerships.

Closing the meeting Wolfgang Rutz thanked the participants for an intensive and enriching meeting and informed about the intention of the Government of Finland to host the Eighth Meeting of the European National Counterparts for the WHO European Mental Health Programme in Helsinki in 2004. He concluded by thanking the counterparts for their collaboration and commitment and invited them to make every effort to ensure that the spirit of the meetings would continue with the same dedication and professionalism.

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Annex 1

LIST OF PARTICIPANTS Albania Anastas Suli, Chief, Department of Neurology, Neurosurgery and Psychiatry, National Hospital and University Centre, Tirana Armenia Samvel Torosyan, Chief Psychiatrist, c/o Ministry of Health, Yerevan Austria Heinz Katschnig, Professor, Ludwig-Boltzmann Institute for Social Psychiatry, Vienna Azerbaijan Agabey Sultanov, Professor, Chief Specialist, c/o Ministry of Health, Baku Belarus Pavel Rynkov, Professor, Chief Psychiatrist, Ministry of Health, Minsk Belgium Isidore Pelc, Professor, Institut de Psychiatrie et de Psychologie Médicale, CHU Brugmann, Brussels Bosnia and Herzegovina Ismet Ceric, Professor, Clinical Center, University of Sarajevo, Sarajevo Joka Simic Blagovcanin, Ministry of Health and Social Protection, Banja Luka (Republica Srpska) Czech Republic Cyril Höschl, Director, Prague Psychiatric Centre, Prague Estonia Helja Eomois, Chief Specialist, Public Health, Ministry of Health, Tallinn Finland Kristian Wahlbeck, Research Professor, Mental Health, National Research and Development Centre for Welfare and Health – STAKES, Helsinki Georgia George B. Naneishvili, Professor, M. Asatiani Research Institute of Psychiatry, Tbilisi Germany Anna Brockmann, Federal Ministry of Health, Bonn Hungary Laszlo Tringer, Professor, Department of Psychiatry, Semmelweiss Medical School, Budapest

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Ireland Baibre Nic Aongusa, Department of Health and Children, Dublin Italy Roberto Cardea, Senior Medical Officer, Ministry of Health, Rome Kyrgyzstan Valery Solojenkin, Professor, Head, Department of Psychiatry, Drug Medical Academy, Bishkek Latvia Maris Taube, Psychiatry Centre, Riga Lithuania Ona Davidoniene, Director, State Mental Health Centre, Vilnius Malta Ray G. Xerri, Director, Department of Health Policy and Planning, Floriana Netherlands Frans Clabbers, Directorate for Mental Health and Addiction Policy, Ministry of Health, Welfare and Sport, The Hague Poland Jan Czeslaw Czabala, Deputy Director for Research, Institute of Psychiatry and Neurology, Warsaw Portugal Maria João Heitor dos Santos, Direcção-Geral da Saúde, Lisbon Romania Bogdana Tudorache, President, Romanian League for Mental Health, Bucharest Russian Federation Alexander S. Karpov, Head, Division of Psychiatric and Neurological Care, Ministry of Health of the Russian Federation, Moscow San Marino Sebastiano Bastianelli, State Hospital, Neuropsychiatric Services, San Marino Serbia and Montenegro Aleksandra Milicevic Kalasic, City Institute of Gerontology and Home Care, Belgrade Slovakia Peter Breier, Head, Department of Psychiatry, General Hospital Ruzinov, Bratislava Slovenia Andrej Marusic, Director, Institute of Public Health of the Republic of Slovenia, Ljubljana Spain Juan López-Ibor, Professor, Clinica López-Ibor, Madrid

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Sweden Helena Silfverhielm, Medical Adviser, National Board of Health and Welfare, Stockholm Switzerland Herbert Heise, Deputy Director, Universitäre Psychiatrische Dienste, Berne The former Yugoslav Republic of Macedonia Vitomir Micev, Macedonian Medical Association, Skopje Ukraine Valery N. Kuznetsov, Professor, Medical Academy of Postgraduate Training, Kiev United Kingdom John Mahoney, National Institute for Mental Health Eastern Region, Colchester Uzbekistan Nargiza Khodjaeva, Ministry of Health, Tashkent

Rapporteur Roxana Radulescu, Mental Health Europe, Brussels, Belgium

WHO European task forces Franz Baro, Professor, WHO Collaborating Centre on Health and Psychosocial Factors, Brussels, Belgium Per Bech, Professor, WHO Collaborating Centre on Quality of Life Studies, Frederiksborg General Hospital, Hillerød, Denmark Lars Jacobsson, Professor, University of Umeå, Sweden

Steering Committee of the WHO European Ministerial Conference on Mental Health (participated only 12 December) John Henderson, Senior Policy Adviser, Mental Health Europe, Brussels, Belgium Eero Lahtinen, Ministry of Social Affairs and Health, Helsinki, Finland Leen Meulenbergs, Federal Public Service of Health, Food Safety and Environment, Brussels, Belgium

Organization team, WHO European Ministerial Conference on Mental Health Merja Paimensaari, Project Assistant, WHO European Ministerial Conference on Mental Health, National Research and Development Centre for Welfare and Health – STAKES, Helsinki

Evaluation Team José Miguel Caldas de Almeida, Chief, Mental Health Programme Unit, Pan American Health Organization, Washington, DC, United States of America

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John Mahoney, National Institute for Mental Health, London, United Kingdom José L. Vazquez-Barquero, Professor, University of Cantabria, Santander, Spain

World Health Organization WHO Regional Office for Europe Frances Ingels, Programme Assistant, Mental Health Unit Johanna Kehler, Programme Assistant, Mental Health Unit Simo Kokko, Mental Health Conference Coordinator Gudjon Magnusson, Director, Division of Technical Support – Reducing Disease Burden Wolfgang Rutz, Regional Adviser for Mental Health Liliana Urbina, Desk Officer for Mental Health Activities

Headquarters Michelle Funk, Coordinator, Mental Health Policy and Service Development Shekhar Saxena, Coordinator, Mental Health: Evidence and Research

SEVENTH MEETING OF THE EUROPEAN NATIONAL COUNTERPARTS FOR THE WHO MENTAL HEALTH PROGRAMME

EUR/03/5035055 E82939 Original: English



SEVENTH MEETING OF THE EUROPEAN NATIONAL COUNTERPARTS FOR THE WHO MENTAL HEALTH PROGRAMME Seventh Meeting of the European National Counterparts for the WHO Mental Health Programme Report on a WHO meeting Copenhagen, Denmark 11–13 December 2003 EUR/03/5035055 E82939 Original: English Seventh Meeting of the European National Counterparts for the WHO Mental Health Programme Report on a WHO meeting Copenhagen, Denmark 11–13 December 2003 ABSTRACT The mental health programme of the WHO Regional Office for Europe has established a network of mental health professionals in the Member States who have provided the necessary liaison between the WHO Regional Adviser for Mental Health and the mental health services in countries. These counterparts have been officially nominated by their health ministries and are often working in the ministry or are the most senior government mental health professionals. The network meets twice yearly in different locations. The Seventh Meeting of the European National Counterparts for the WHO European Mental Health Programme was held in Copenhagen from 11 to 13 December 2003. Representatives of 35 countries took part. Also present were representatives of various task forces of the mental health programme, representatives of the Steering Committee of the WHO European Ministerial Conference on Mental Health: Facing the Challenges, Building Solutions to be held in Helsinki in 2005 and members of the evaluation team that assessed the WHO European mental health programme. The Meeting programme included a presentation on the Mental Health Policy and Service Guidance Package prepared by WHO headquarters and a presentation of the project Monitoring Mental Health Systems and Services carried out by WHO headquarters. The counterparts were asked to reflect and debate on the topics raised in the presentations. An update on the Ministerial Conference preparations was presented, and the counterparts worked and discussed on the selected Conference themes and proposed outcomes. Keywords MENTAL HEALTH SERVICES – organization and administration – trends HEALTH POLICY STRATEGIC PLANNING FINANCING, HEALTH CONGRESSES – organization and administration EUROPE EUROPE, CENTRAL EUROPE, EASTERN EUROPE, SOUTHERN Address requests about publications of the WHO Regional Office to: • by e-mail publicationrequests@euro.who.int (for copies of publications) permissions@euro.who.int (for permission to reproduce them) pubrights@euro.who.int (for permission to translate them) • by post Publications WHO Regional Office for Europe Scherfigsvej 8 DK-2100 Copenhagen Ø, Denmark © World Health Organization 2004 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Where the designation “country or area” appears in the headings of tables, it covers countries, territories, cities, or areas. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. The views expressed by authors or editors do not necessarily represent the decisions or the stated policy of the World Health Organization. CONTENTS Page Official opening.............................................................................................................................................1 Mental health in Europe: problems, processes and challenges .....................................................................1 Mental health policy and service development – the WHO strategy ............................................................2 Group work on the WHO strategy for mental health policy and services development ...............................3 Workshop 1: Quality improvement and organization of services.......................................................3 Workshop 2: Financing, planning and budgeting for service delivery ...............................................4 Workshop 3: Legislation, human rights and service delivery.............................................................5 Workshop 4: Policy and planning.......................................................................................................5 Country updates.............................................................................................................................................6 Workshop 1: Western Europe .............................................................................................................6 Workshop 2: Southern Europe ............................................................................................................6 Workshop 3: Central Europe...............................................................................................................7 Workshop 4: Eastern Europe ..............................................................................................................8 WHO task forces and networks – an update (part 1).....................................................................................9 Task Force on National Assessments..................................................................................................9 Task Force on Child and Adolescent Mental Health ..........................................................................9 WHO European Ministerial Conference on Mental Health: Facing the Challenges, Building Solutions, Helsinki, Finland, 12–15 January 2005.......................................................................10 Group work on the Conference themes.............................................................................................11 Monitoring of Mental Health Systems and Services project .......................................................................11 Initial findings of the Monitoring of Mental Health Systems and Services survey – the case of Albania ..............................................................................................................................................12 Group work on the selection of mental health domains....................................................................13 WHO task forces and networks – an update (part 2)...................................................................................15 Task Force on Stigma and Discrimination........................................................................................15 Task Force on Helplessness and Stress-related Disorders ................................................................16 Feedback from the Conference Secretariat..................................................................................................16 The way forward .........................................................................................................................................17 Feedback from the counterparts ........................................................................................................17 Closing the meeting.....................................................................................................................................18 Annex 1. List of participants .......................................................................................................................19

EUR/03/5035055 page 1 Official opening Wolfgang Rutz, WHO Regional Office for Europe Wolfgang Rutz welcomed the participants and extended his greetings to the newly appointed national counterparts. He then explained the aims of the meeting: exchanging knowledge and experience among counterparts, discussing the WHO headquarters project Monitoring Mental Health Systems and Services and focusing on preparing the WHO European Ministerial Conference on Mental Health: Facing the Challenges, Building Solutions to be held in Helsinki in 2005. He also said that an evaluation team was present at the meeting and that interviews would be carried out with some of the participants to evaluate the activities of the WHO European mental health programme. Mental health in Europe: problems, processes and challenges Wolfgang Rutz, WHO Regional Office for Europe A panorama of trends and problems across the European Region was described, emphasizing stress-related morbidity, especially in countries in transition, attention and conduct disorders among children and adolescents and the mental health problems occurring outside mental health services. Other issues addressed were the increasing importance of values and human rights to integrity and health and the tendency of psychiatry to focus on research and to ignore or neglect the real problems. Wolfgang Rutz also highlighted the need to meet the problems where they are – workplaces, schools, communities and networks – and called for considering the accessibility and allocation of resources and ways of involving primary health care in community-based mental health services. The WHO report evaluating the effectiveness of mental health services (What are the arguments for community-based mental health care?1) indicated this perspective. Regarding challenges for the future, several issues were emphasized: the quality and quantity of evidence and cost–benefit evaluation of evidence, challenges arising from the regionalization of Europe, accessibility and allocation of resources for community-based mental health care and challenges related to terrorism and threats. Wolfgang Rutz concluded by highlighting the importance of partnerships and cooperation with other government organizations, such as the European Union and the Council of Europe, with Member States, with WHO headquarters, within the WHO Regional Office for Europe and with other WHO regions. He also pointed out that the network of counterparts would be continuously involved in preparing the WHO European Ministerial Conference on Mental Health: Facing the Challenges, Building Solutions and related pre-conferences. 1 Thornicroft G, Tansella M. What are the arguments for community-based mental health care? Copenhagen, WHO Regional Office for Europe, 2003 (http://www.euro.who.int/eprise/main/WHO/Progs/HEN/Syntheses/mentalhealth/ 20030822_1, accessed 4 May 2004). EUR/03/5035055 page 2 Mental health policy and service development – the WHO strategy Michelle Funk, WHO headquarters Michelle Funk introduced the WHO mental health policy and service strategy and explained the reasons for embarking on this project: countries needed to reform mental health services, the economic costs of mental health problems were high and mental health resources were lacking or, if available, were improperly used. She underlined that, when organizing services, priority should be given to shifting care away from mental hospitals and to developing community mental health services and integrating mental health into general health care systems. Past experience demonstrated that developing groups of users and families and actively involving them in reform improved the quality of services. Seven principles of service reform were then highlighted: accessibility, continuity, comprehensiveness, needs-led, effectiveness, equity and respect for human rights. Regarding financing of mental health care, the level of resources being invested is disproportionately low compared with the disease burden and that considerations related to equity, efficiency and reform should influence financing decisions. Although the workforce is the most valuable asset in mental health care, countries have difficulty in developing and maintaining the workforce. From this perspective, several courses of action have been taken: developing human resources policy; planning for numbers, skill mix and competencies; continuing education, training and supervision; and management strategies. Michelle Funk emphasized that quality is an essential requirement of any mental health service, ensuring that resources are used properly and building trust in the effectiveness of the system. Further, the WHO Mental Health Policy and Service Guidance Package2 developed by WHO headquarters to assist countries with technical guidance was presented briefly. The following modules were approached: • the mental health context; • mental health policy, plans and programmes; • mental health financing; • mental health legislation and human rights; • advocacy for mental health; • organization of services for mental health; • planning and budgeting to deliver services for mental health; and • quality improvement for mental health. Michelle Funk said that modules on other topics were being prepared: • improving access to and use of psychotropic medicines; • mental health information systems; 2 For more information and to download the modules, see http://www.who.int/mental_health/policy/en. EUR/03/5035055 page 3 • human resources and training for mental health; • mental health of children and adolescents; • research and evaluation of mental health policy and services; and • mental health policies and programmes in the workplace. In conclusion, the modules can be used for training forums and workshops, for country technical assistance in partnership with regional and country offices and for developing a faculty of consultants to provide technical assistance in mental health reforms. Group work on the WHO strategy for mental health policy and services development Workshop 1: Quality improvement and organization of services Anastas Suli (Albania), Isidore Pelc (Belgium), Cyril Höschl (Czech Republic), Anna Brockmann (Germany), Jan Czeslaw Czabala (Poland), Maria João Heitor dos Santos (Portugal), Aleksandra Milicevic Kalasic (Serbia and Montenegro), Herbert Heise (Switzerland), Nargiza Khodjaeva (Uzbekistan) and Franz Baro (WHO Collaborating Centre on Health and Psychosocial Factors) Facilitator: Jan Czeslaw Czabala Rapporteur: Aleksandra Milicevic Kalasic The group had a short briefing on the WHO module Quality improvement for mental health and discussed in detail the involvement of general practitioners in treating mental disorders and in the process of deinstitutionalization. Although the experience from countries was diverse, the conclusion was that disseminating knowledge is essential as well as being willing to make partnerships and set conditions for intersectoral collaboration. It was commonly agreed that awareness on the identification and treatment of mental disorders still needs to be raised among general practitioners and other primary health care staff and training is needed on this. Various countries described experience and practices related to deinstitutionalization. It was suggested that some facilities be kept and used for some special treatment and care; a small proportion of patients needs long-stay facilities. It was also pointed out that time will be needed for this process. Comments The need to share experience on how mental health care could be coordinated and how responsibilities should be distributed was strongly emphasized. Attention was drawn to the fear of mental health care staff of losing their jobs and to the paradox of psychiatrists sometimes abandoning their social responsibilities and, subsequently, to the need to build incentives for staff. EUR/03/5035055 page 4 In the ensuing discussion, the topic of the social consequences of deinstitutionalization was debated, and representatives of various countries pointed out the lack of logistics to prepare the community to integrate former mental hospital patients. Other concerns expressed from a management perspective were avoiding duplicating resources and trying to build strong alliances (such as with the police and the education sector). An experience from Finland was shared regarding coordination, and information was given on the existence of a common health record in Finland accessible to all departments and functioning as a vehicle by which continuity can be assured. Workshop 2: Financing, planning and budgeting for service delivery Samvel Torosyan (Armenia), Ismet Ceric (Bosnia and Herzegovina), Helja Eomois (Estonia), Laszlo Tringer (Hungary), Maris Taube (Latvia), Ray G. Xerri (Malta), Bogdana Tudorache (Romania), Peter Breier (Slovakia), Vitomir Micev (The former Yugoslav Republic of Macedonia) Facilitator: Ray G. Xerri Rapporteur: Peter Breier A common trait among the countries participating in the workshop is an unstable political situation with frequent changes of ministers and a need to have a vision for long-term programmes, with consistent political commitment. Other issues discussed were: • the role and position of psychiatrists in influencing changes in general health care and in improving the financing of mental health care; • the importance of effective strategic planning with the need for a ring-fenced mental health budget with incentives; • the need for a national policy with one management structure for both hospitals and community care; and • the need for technical management and an efficient operational system. This group believed that continuing communication on new policies upwards and downwards and building alliances with all stakeholders and donor organizations is crucial. Building alliances with some politicians and increasing their recognition of the burden of mental health problems was given as an example of successful practice that helps to move things forward. Comments A comment was made that budgets should be decentralized and that financial data should be linked to performance. It was stressed that attempting to exercise very effective management by simply using financial data would not provide enough information. However, attention was drawn to the fact that decentralization in many countries places mental health care and service providers at risk. EUR/03/5035055 page 5 Further, it was pointed out that more information and research is needed on mental health expenditure, since most of the information currently available is on salaries and not on the real social and economic costs. Workshop 3: Legislation, human rights and service delivery Agabey Sultanov (Azerbaijan), Joka Simic Blagovcanin (Bosnia and Herzegovina), Kristian Wahlbeck (Finland), Baibre Nic Aongusa (Ireland), Ona Davidoniene (Lithuania), Alexander S. Karpov (Russian Federation), Helena Silfverhielm (Sweden), Valery N. Kuznetsov (Ukraine) Facilitator: Helena Silfverhielm Rapporteur: Kristian Wahlbeck The group discussed the influence of advocacy groups on legislation, starting from the example of the Compulsory Care Act from 1992 in Sweden. Issues debated were ways of promoting respect for patients’ dignity not only through legislation but also through financial incentives or testimonies and reports of ex-patients about their experiences. Minimizing the use of general restrictions on individuals was also discussed as well as various related topics such as: involuntary admission versus treatment, restriction on the use of antipsychotic drugs during the observation phase, a code of ethics, informed consent for treatment, the role and set of powers given to the family, confidentiality and access to information. Workshop 4: Policy and planning Heinz Katschnig (Austria), Pavel Rynkov (Belarus), George B. Naneishvili (Georgia), Roberto Cardea (Italy), Frans Clabbers (Netherlands), Sebastiano Bastianelli (San Marino), Juan López- Ibor (Spain) Facilitator: Heinz Katschnig Rapporteur: Juan López-Ibor The discussions were based on the presentation of two examples of two large mental hospitals that closed in the Federal State of Lower Austria: a success (Donauklinikum Gugging) and a failure (Ostarrichiklinikum Amstetten). The Austrian experience had shown some patterns of resistance to changes such as: lack of knowledge about mental health and mental disorders among people working outside the mental health sector (such as politicians, the general public and others), stigma and fear of stigma, a fragmented system for financing mental health care, poor data on the total costs of mental health care, poor management and professional rivalry. The group also analysed the experience in Italy and the Netherlands and underlined the danger of splitting services, which consisted of difficulty in quality assurance and coordination with social services and responsibilities split between curative services (municipalities responsible) and care services (central government responsible). Attention was drawn also to the lack of coordination due to professional rivalry and to the need to clearly define the responsibilities of the staff. EUR/03/5035055 page 6 Country updates The counterparts split into four groups and gave an update on the situation in their countries. Workshop 1: Western Europe Heinz Katschnig (Austria), Isidore Pelc (Belgium), Kristian Wahlbeck (Finland), Anna Brockmann (Germany), Baibre Nic Aongusa (Ireland), Frans Clabbers (Netherlands), Helena Silfverhielm (Sweden) and Herbert Heise (Switzerland) Facilitator: Heinz Katschnig Rapporteur: Anna Brockmann This workshop reflected on the content and constitution of country reports and proposed a new structure for these reports, which should contain the following items: • background information about the country; • mental health legislation; • responsibilities for financing mental health care and for providing services; • mental health plans and policies; • community-based mental health and deinstitutionalization; • preventing common mental disorders and promoting mental health; • advocacy and empowerment of service users and their families; • the strengths and weaknesses of mental health systems; and • any other issue considered important. The length of the report was proposed to be about 900 words, with an average of 90–100 words per section. It was also highlighted that each country should take responsibility for improving the update for reports, and it was felt that it would be much more useful to concentrate on processes and structures than on figures and data. Comments It was signalled that including figures and evidence-based information is important but that the report should have a certain limitation. The information was given that an electronic board would be created under the auspices of the Mental Health Unit of the WHO Regional Office for Europe, to offer the counterparts the possibility to raise questions and comment on matters of interest. Workshop 2: Southern Europe Roberto Cardea (Italy), Ray G. Xerri (Malta), Maria João Heitor dos Santos (Portugal), Sebastiano Bastianelli (San Marino) and Juan López-Ibor (Spain) Facilitator: Maria João Heitor dos Santos Rapporteur: Juan López-Ibor EUR/03/5035055 page 7 The group indicated several matters of common concern in southern Europe despite the specific characteristics of individual countries: insufficient programmes for promoting mental health and preventing mental disorders; poor mental health information systems; lack of human resources in mental health services for children and adolescents; predominance of the “medical model”; need for the development of transcultural psychiatry on a country basis due to the mobility of users; creation of crisis intervention teams for disasters; continuity of care in areas dealing with alcohol-related problems and drug dependence and coordination with other sectors; development of action in the fields of education, social security, justice and environment; and stigma and its consequences. Attention was also drawn to several areas of progress: the growing visibility of mental health, following the efforts of WHO and the European Union and growing political involvement; existence of a legal framework for mental health national policy in many countries; increasing interest for mental health programmes and their implementation at all levels; and increasing involvement and empowerment of users’ associations and users’ families. Five future targets were highlighted as issues of priority: • reducing waste in budgets and in human resources; • improving the quality of services; • focusing more on evidence-based policies and practices; • creating assessment tools that can be easily and regularly used in each of the countries; and • improving management structures and systems. Workshop 3: Central Europe Anastas Suli (Albania), Ismet Ceric and Joka Simic Blagovcanin (Bosnia and Herzegovina), Cyril Höschl (Czech Republic), Helja Eomois (Estonia), Laszlo Tringer (Hungary), Maris Taube (Latvia), Ona Davidoniene (Lithuania), Jan Czeslaw Czabala (Poland), Bogdana Tudorache (Romania), Aleksandra Milicevic Kalasic (Serbia and Montenegro), Peter Breier (Slovakia), Andrej Marusic (Slovenia), Vitomir Micev (The former Yugoslav Republic of Macedonia) Facilitator: Laszlo Tringer Rapporteur: Ona Davidoniene It was first highlighted that countries in central Europe were in continuous development and some still in an uncertain period of transition. Several countries reported on the steps taken towards establishing community mental health structures, especially implementing small psychiatric wards in general hospitals and intensive training for professionals working in mental health. Attention was drawn to the conservatism of stakeholders and to the need to disseminate information and to train managers, policy-makers, general practitioners, psychiatrists and other health care staff. Information was given also on efforts to implement the recommendations of various meetings under the European Union, WHO and the Council of Europe. EUR/03/5035055 page 8 Other countries informed about the work that had been carried out on mental health strategies (Estonia), on positive developments for a health education programme in schools especially emphasizing mental health (Hungary) and the work to set up a state alcohol programme and a suicide prevention programme (Lithuania). Several counterparts mentioned the establishment and role of a national body for mental health in their countries. Several countries reported concern about a lack of professionals, both physicians and others, and a gap between health and social care and lack of continuity in activities because projects are long-term and governments short-term. Workshop 4: Eastern Europe Samvel Torosyan (Armenia), Agabey Sultanov (Azerbaijan), Pavel Rynkov (Belarus), George B. Naneishvili (Georgia), Valery Solojenkin (Kyrgyzstan), Alexander S. Karpov (Russian Federation), Valery N. Kuznetsov (Ukraine), Nargiza Khodjaeva (Uzbekistan) Facilitator: Valery N. Kuznetsov Rapporteur: George B. Naneishvili The group informed about the existence of state programmes on psychiatric care in Georgia, the Russian Federation and Ukraine but pointed out that these programmes cannot cover all needs. Armenia, Azerbaijan, Belarus and Uzbekistan have no such programmes. Other difficulties pointed out were: no system of social care for people with mental health problems; few, if any epidemiological investigations on the increase in mental disorders in the country; and an urgent need for training psychiatric staff. Deficits in health budgets as a percentage of total expenditure across the countries were also reported: Belarus 40%, Russian Federation, Ukraine and Uzbekistan 60% and Azerbaijan 70%. Progress was noted in Georgia, which had implemented a programme for the psychosocial rehabilitation of children and adolescents and had set up a Mental Health Coordination Council gathering various stakeholders from government structures and nongovernmental organizations. However, it was stressed that nongovernmental organizations were local in character and had little power and worked on limited projects related to the psychosocial rehabilitation of various risk groups. A common challenge was outlined: working towards deinstitutionalizing mental health care services and creating a system of psychosocial rehabilitation for people with mental health problems. EUR/03/5035055 page 9 WHO task forces and networks3 – an update (part 1) Task Force on National Assessments Franz Baro, WHO Collaborating Centre on Health and Psychosocial Factors, Brussels, Belgium Franz Baro informed that the Task Force on National Assessments worked on policy development and carried out mental health assessments at the national or regional level at the invitation of health ministers or other authorities and provided recommendations for action. The assessments consisted of visits to mental health services and facilities and meetings and interviews with various stakeholders such as professional associations, policy-makers, families and users’ associations. The data collected were both quantitative and qualitative, but information was also gathered on political issues related to the nature of mental health reform in the countries. It was highlighted that the data collected were always the property of the country but that analysing and comparing data to illustrate some basic general mechanisms would be useful. The problem of finding funds for these activities was especially stressed. Franz Baro then invited the counterparts from Lithuania, Malta, Romania, Serbia and Montenegro and Slovakia to give more information on the assessments that had been carried out in their countries. The main issues emerging from these experiences were that recommendations still needed support from the WHO Regional Office for Europe to be put into practice, that having international experts, and thus an independent review, helped to make links between psychiatrists and that these assessments contributed to increasing the understanding of politicians of the need to develop outpatient care. Comments A suggestion was made that the results of these experiences should be shared with other countries and possibly published in reports or international journals. Task Force on Child and Adolescent Mental Health Wolfgang Rutz, WHO Regional Office for Europe Wolfgang Rutz noted that the Task Force on Child and Adolescent Mental Health was established in January 2003 to work on the mental health of children and adolescents in Europe and to make recommendations for countries. He took this opportunity to mention the names of the members of the Task Force. He also provided information on the first meeting of the Task Force in July 2003, at which the Task Force worked on the clinical implications of crisis management in adolescence and 3 The names and contact details of the members of the task forces are listed at: http://www.euro.who.int/mentalhealth. EUR/03/5035055 page 10 discussed evaluation of the quality of psychiatric services in European countries and the quality of education and training in child and adolescent psychiatry in various European countries. WHO European Ministerial Conference on Mental Health: Facing the Challenges, Building Solutions, Helsinki, Finland, 12–15 January 2005 Simo Kokko, WHO Regional Office for Europe Simo Kokko introduced the general principles related to the programme of the WHO European Ministerial Conference on Mental Health and explained that a series of pre-conferences would precede the main Conference and address selected themes. Although the Conference would be a political meeting of the ministers responsible for health and their delegations composed of policy-makers, the target audience of the pre-conferences would be mental health professionals, policy-makers and administrators knowledgeable on mental health. The content and dates of the pre-conferences were described briefly: • pre-conference on Suicide Prevention Strategies, Brussels, Belgium, 11–12 March 2004; • pre-conference on Societal Stress, Moscow, Russian Federation, 3–5 June 2004; • pre-conference on the Mental Health of Children and Adolescents, Luxembourg, 20–21 September 2004; and • pre-conference on Mental Health and the Working Life, Tallinn, Estonia, 4–5 October 2004. It was emphasized that all these dates would be confirmed in a second announcement. The draft programme of the Conference was then explained in detail. The plenary session was to have the following main topics: • introduction to the challenges of mental health and ill health in Europe; • mental health of children and adolescents; • mental health of people of working age; • mental health of elderly people; • mental health services; • implementing national mental health policies; • health ministers challenged at the round table – building solutions; • round table discussion on stigma; and • inclusion and human rights. Parallel workshops would be organized for each plenary session. Simo Kokko invited the counterparts to think, from the perspective of their countries, about what the outcome of the main Conference should be. He also informed about the WHO proposal to EUR/03/5035055 page 11 have a declaration that would include recommendations for an action plan for both Member States and WHO. Gudjon Magnusson, WHO Regional Office for Europe Gudjon Magnusson emphasized the complex work that had been done in countries and the huge diversity of initiatives that had been taken to promote raising the profile of mental health on the political agenda. Progress had been made, but collaboration between mental health and public health needs to be increased. He also pointed out the need to consult widely the Member States on the outcome of the Ministerial Conference and stressed that the Regional Office was relying on the counterparts’ assistance to ensure that an appropriate balance of represented parties participates in the Conference. He concluded by encouraging the counterparts to provide feedback on the Conference themes and outcomes and to share information and experience on the developments in their countries. Group work on the Conference themes The counterparts split into three working groups and debated the proposal of conference themes and outcomes. The main issues emerging from discussions were the following. • It was commonly agreed that the outcome of the Conference should be an action plan. • It was suggested to take into account the new challenges linked with social changes and the mobility of individuals. • It was proposed to include the topic of value-based medicine and research-based medicine in the Conference themes. • Three topics were pointed out as important: preventing suicide, restructuring mental health services to community care and integrating mental health services in primary care. • It was suggested that each country present a policy paper at a pre-conference and that overlap in Helsinki be minimized. • Suggestions were made to give more attention to slogans to send clear messages not only to ministers but also to administrators. Finally, the counterparts expressed the need for more information on the role they would have in contributing to preparing these documents. Monitoring of Mental Health Systems and Services project Shekhar Saxena, WHO headquarters Shekhar Saxena introduced the Monitoring Mental Health Systems and Services project, which had been developed by WHO headquarters during 2003 with the aim of assisting countries in enhancing mental health systems and services by developing a set of indicators to monitor mental health systems and services. The starting-point of the project was the ten recommendations of The world health report 2001: mental health: new understanding, new hope that suggested action from treatment to prevention EUR/03/5035055 page 12 and promotion, and to monitoring and research. It was highlighted that this was in accordance with the WHO Global Action Programme for mental health, the Ministerial Round Tables on mental health of the Fifty-fourth World Health Assembly4 and the project Atlas – Mental Health Resources in the World (http://www.who.int/mental_health/media/en/244.pdf, accessed 4 May 2004). Shekhar Saxena explained that 10 domains had been set up and that the facets of each domain represented the content that should be assessed to monitor the domain. Qualitative and quantitative indicators had been derived from these facets, after consultation with experts and key focal points in developing countries. The 10 domains were then presented, with the proposed facets and indicators. 1. Mental health in primary health care – Example of a facet – training of primary care staff: initial and refresher training of primary care staff, including physicians, nurses and health care workers, in mental health care; – Example of an indicator – percentage of training hours devoted to psychiatry or mental health during the specialization in primary care, family medicine or general practice for general practitioners and nurses; 2. Availability of psychotropic medicines 3. Mental health services in the community 4. Public education 5. Involvement of communities, families and consumers 6. National policies, plans and legislation 7. Human resources 8. Link with other sectors 9. Monitoring 10. Research. In conclusion, it was emphasized that implementing the indicators could lead to substantial gains. Thus, countries would be able to monitor the progress in implementing their reform polices, in providing community services and in the activities of the communities and associations of users and families. Moreover, it was stressed that indicators might prompt governments and health system managers to build a data infrastructure, to implement an information system and to foster the use of surveys of mental health disorders. Initial findings of the Monitoring of Mental Health Systems and Services survey – the case of Albania Anastas Suli, National Hospital and University Centre, Tirana Anastas Suli informed that a National Steering Committee for Mental Health had been set up with the technical support of WHO and that the Minister for Health had approved a national 4 Mental health: a call for action by world health ministers. Geneva, World Health Organization, 2001 (http://whqlibdoc.who.int/hq/2001/WHO_NMH_MSD_WHA_01.1.pdf, accessed 4 May 2004). EUR/03/5035055 page 13 mental health policy document containing the main guidelines and recommendations for the reform process. Based on this policy document, a national implementation plan was being developed. In addition, the mental health situation in Albania was presented briefly. The main issues put forward were the following. • Indicators related to mental health were integrated in the general health information system and were mainly related to mental hospital care. • Data about mental health and education and family involvement were difficult to collect, but data existed if sentinel sites were reached. • Data were mainly collected manually; no information technology was used. Detailed information was also given on the main findings in domains 1 and 7. Comments Several speakers pointed out the variety of existing data across the regions and stressed that some countries had a large proportion of data available, whereas others had very few. Attention was also drawn to avoiding duplication and to the need to improve collaboration and coordination. A few examples of data collection exercises in the European Region were given: • Eurostat – Statistical Office of the European Communities (http://europa.eu.int/comm/ eurostat/Public/datashop/print-catalogue/EN?catalogue=Eurostat, accessed 4 May 2004); • OECD (Organisation for Economic Co-operation and Development) databases (http://www.sourceoecd.org/content/html/index.htm, accessed 4 May 2004); • the European Union funded project Minimum Data Set of European Mental Health Indicators;5 • the EHDP (Expert Health Data Programming) database for European hospital data (http://www.ehdp.com/index.htm, accessed 4 May 2004); and • the EUROHIS project.6 Group work on the selection of mental health domains Group 1 Anastas Suli (Albania), Isidore Pelc (Belgium), Cyril Höschl (Czech Republic), Anna Brockmann (Germany), Aleksandra Milicevic Kalasic (Serbia and Montenegro) and Liliana Urbina (WHO Regional Office for Europe) Facilitator: Anastas Suli Rapporteur: Cyril Höschl 5 Minimum data set of European mental health indicators. Proposed set of mental health indicators: definitions, description and sources. Helsinki, National Research and Development Centre for Welfare and Health – STAKES, 2001 (http://www.stakes.fi/verkkojulk/pdf/minimum.pdf, accessed 4 May 2004). 6 Nossikov A, Gudex C, eds. EUROHIS – developing common instruments for health surveys. Amsterdam, IOS Press, 2003 (Biomedical and Health Research, No. 57). EUR/03/5035055 page 14 The group reported on the heterogeneity of existing data across Europe but also within countries and regions. It was highlighted that data might not be comparable since there were different ways of collecting data. Attention was also drawn to the workload related to collecting the data and to the minimal output related to it as well as to the fact that some items mentioned were impossible to collect at the regional level. Another issue of crucial importance was the need to have a reliable system of statistics from which to extract data. Suggestions were made to clarify or further define the terms (such as the list of essential drugs and refresher training) and to add qualitative information on the decrease in the number of beds. Group 2 Heinz Katschnig (Austria), Ismet Ceric (Bosnia and Herzegovina), Helja Eomois (Estonia) George B. Naneishvili (Georgia), Laszlo Tringer (Hungary), Roberto Cardea (Italy), Maris Taube (Latvia), Bogdana Tudorache (Romania), Sebastiano Bastianelli (San Marino) and Peter Breier (Slovakia) Facilitator: Peter Breier Rapporteur: Heinz Katschnig The group equally pointed out the difficulties in collecting data because of the variety of administrative structures and procedures across countries and regions. Some domains were considered more useful than others such as: domains 3 (mental health services in the community) and 6 (national policies, plans and legislation). The group also discussed the new structure of country reports from the perspective of the mental health domains presented previously. Group 3 Agabey Sultanov (Azerbaijan), Joka Simic Blagovcanin (Bosnia and Herzegovina), Kristian Wahlbeck (Finland), Ona Davidoniene (Lithuania), Alexander S. Karpov (Russian Federation), Andrej Marusic (Slovenia) and Valery N. Kuznetsov (Ukraine) Facilitator: Kristian Wahlbeck Rapporteur: Andrej Marusic It was pointed out that all countries were able to provide data on several domains: domain 2 (availability of psychotropic medicines), 3 (mental health services in the community), 6 (national policies, plans and legislation) and 7 (human resources). It was also stressed that the counterparts should not have sole responsibility for collecting data but that a letter should be sent to health ministers requesting their support in completing the questionnaire. The letter should highlight the objectives and outcomes of this exercise. The suggestion was made to specify which questions should be answered in more detail and which questions could be answered “yes”, “no” or “not applicable”. EUR/03/5035055 page 15 Comments Shekhar Saxena thanked the counterparts for their comments and suggestions. He emphasized that the project was meant to be an action-oriented exercise and that the aim was to offer assistance to countries if and when this was needed. He also pointed out that the counterparts could decide whether to reply to the questionnaires. He also acknowledged that gathering data was more feasible at the regional level than at the country level and suggested that a benefit of this exercise could be networking with other sectors, such as education and social care. It was reiterated that counterparts would be invited to provide the information available and to indicate what data could be obtained without spending too much time. A booklet would be distributed explaining the terms used and providing clear definitions. In conclusion, Shekhar Saxena suggested that counterparts should give priority to some domains and stressed that this would provide evaluation of different domains. WHO task forces and networks – an update (part 2) Task Force on Stigma and Discrimination Lars Jacobsson, University of Umeå, Sweden Lars Jacobsson informed that the Task Force on Stigma and Discrimination had been working for several years on preparing a number of reports and materials due to be ready for the Ministerial Conference in 2005. A first report of the Task Force, in which the counterparts had been involved by means of a questionnaire, focused on stigma and discrimination, looking at activities in countries and issues that were considered problematic. A second report looked at the mental health situation of children and adolescents, comparing the resources allocated to children and adolescents with those allocated to adults. A third activity mentioned was preparing a book on good examples of combating stigma and discrimination, including recommendations on action to be undertaken to raise awareness of these problems. Other activities included finalizing several articles for various international journals. Information was given also on the work of the Trimbos Institute (Netherlands Institute of Mental Health and Addiction) group that gathers people from different disciplines working with stigma and discrimination (such areas as eating disorders, leprosy and HIV/AIDS). Comments It was suggested to look for more interaction with other task force activities and to join efforts in sharing information, knowledge and methods. EUR/03/5035055 page 16 Task Force on Helplessness and Stress-related Disorders Per Bech, WHO Collaborating Centre on Quality of Life Studies, Hillerød, Denmark Per Bech informed the participants about the main activities of the Task Force on Helplessness and Stress-related Disorders, which is investigating the treatment of depression in primary care, depression among men (in collaboration with the German Research Network on Depression and Suicidality) and the relationship between cardiovascular diseases and depression. He then briefly presented the European Alliance against Depression (led by Ulrich Hegerl in Munich), which has received funding from the European Commission. The project focuses on awareness-raising campaigns on depression and suicide in various European countries. The objectives are to collect epidemiological, psychosocial and biological data on stress-related disorders, especially depression and suicidal behaviour. Another achievement presented was the second edition of the book How to cope with stress by Peter Tyrer. Feedback from the Conference Secretariat Liliana Urbina, WHO Regional Office for Europe Liliana Urbina thanked the counterparts for their valuable comments and suggestions regarding the preparation of the Ministerial Conference and summarized the feedback from the Conference Secretariat. • The suggestions to emphasize evidence-based mental health and to introduce value-based mental health were welcomed. • The proposal to have a new structure of country reports was considered a positive point. However, it was pointed out that a decision on the future of the country reports needed to be made first. • The proposal from Austria to hold a pre-conference on the mental health of elderly people was also welcomed as well as the idea of using new slogans. • The suggestion to have an action plan with clear steps, responsibilities and timetable was widely supported. • Regarding the comments on the survey Monitoring Mental Health Systems and Services, it was proposed to conduct a feasibility study (by e-mail or by fax) with the counterparts and incorporating the following ratings in the questionnaires: A = readily available B = available after some searching C = only though a study or survey D = only through a sentinel collection E = not available. The next steps after this feasibility study would be to develop a proposal based on the results and to send the new version of the questionnaires to the counterparts. EUR/03/5035055 page 17 Comments A suggestion was made to possibly merge points C and D and to leave more space for narrative comments and explanations. The way forward Wolfgang Rutz, WHO Regional Office for Europe Picking up the suggestion to have new slogans for the Conference, Wolfgang Rutz initiated a discussion on various existing and possible slogans. Several examples were debated. • No health without mental health. • No mental health without human rights and no human rights without mental health. • No peace without mental health; no mental health without peace. • Mental health is public health. • No environment and health without mental health. • No health impact awareness and assessment without mental health. • No health investment without mental health. • Good psychiatrists should have the team within themselves. He also took the opportunity to announce that he would be leaving his position as Regional Adviser for Mental Health. Feedback from the counterparts Responding to Wolfgang Rutz’s address, a number of counterparts pointed out the benefits of creating this network and the advantages of these meetings: sharing experiences and information, having a reliable back-up and a reference point from which to ask for information and support and having the network’s international background while elaborating strategies to promote mental health. The importance and benefits of the work of task forces were also highlighted, and it was suggested that they should be more engaged in future meetings of the counterparts. The need to receive support from the WHO European mental health programme to continue the activities was reiterated. Suggestions were made to concentrate on more country-action plans and on effective ways of disseminating information and of influencing professionals and policy-makers. Another suggestion regarding the slogans presented before was to avoid “no”-type slogans, taking into consideration that “no” indicated absence, and to put more emphasis on the positive work that had been done. Peer review, peer support and peer development were underlined as highly important, as the experience of the Balkan countries involved in the mental health project of the Stability Pact for South-Eastern Europe had demonstrated. The suggestion was made to discuss in the future ways of getting countries together, grouping them by subregions or by other criteria. EUR/03/5035055 page 18 A number of counterparts highlighted Wolfgang Rutz’s contribution to strengthening the work on mental health policy at the country level and emphasized his role in coordinating activities, mobilizing resources and creating partnerships. Closing the meeting Wolfgang Rutz thanked the participants for an intensive and enriching meeting and informed about the intention of the Government of Finland to host the Eighth Meeting of the European National Counterparts for the WHO European Mental Health Programme in Helsinki in 2004. He concluded by thanking the counterparts for their collaboration and commitment and invited them to make every effort to ensure that the spirit of the meetings would continue with the same dedication and professionalism. EUR/03/5035055 page 19 Annex 1 LIST OF PARTICIPANTS Albania Anastas Suli, Chief, Department of Neurology, Neurosurgery and Psychiatry, National Hospital and University Centre, Tirana Armenia Samvel Torosyan, Chief Psychiatrist, c/o Ministry of Health, Yerevan Austria Heinz Katschnig, Professor, Ludwig-Boltzmann Institute for Social Psychiatry, Vienna Azerbaijan Agabey Sultanov, Professor, Chief Specialist, c/o Ministry of Health, Baku Belarus Pavel Rynkov, Professor, Chief Psychiatrist, Ministry of Health, Minsk Belgium Isidore Pelc, Professor, Institut de Psychiatrie et de Psychologie Médicale, CHU Brugmann, Brussels Bosnia and Herzegovina Ismet Ceric, Professor, Clinical Center, University of Sarajevo, Sarajevo Joka Simic Blagovcanin, Ministry of Health and Social Protection, Banja Luka (Republica Srpska) Czech Republic Cyril Höschl, Director, Prague Psychiatric Centre, Prague Estonia Helja Eomois, Chief Specialist, Public Health, Ministry of Health, Tallinn Finland Kristian Wahlbeck, Research Professor, Mental Health, National Research and Development Centre for Welfare and Health – STAKES, Helsinki Georgia George B. Naneishvili, Professor, M. Asatiani Research Institute of Psychiatry, Tbilisi Germany Anna Brockmann, Federal Ministry of Health, Bonn Hungary Laszlo Tringer, Professor, Department of Psychiatry, Semmelweiss Medical School, Budapest EUR/03/5035055 page 20 Ireland Baibre Nic Aongusa, Department of Health and Children, Dublin Italy Roberto Cardea, Senior Medical Officer, Ministry of Health, Rome Kyrgyzstan Valery Solojenkin, Professor, Head, Department of Psychiatry, Drug Medical Academy, Bishkek Latvia Maris Taube, Psychiatry Centre, Riga Lithuania Ona Davidoniene, Director, State Mental Health Centre, Vilnius Malta Ray G. Xerri, Director, Department of Health Policy and Planning, Floriana Netherlands Frans Clabbers, Directorate for Mental Health and Addiction Policy, Ministry of Health, Welfare and Sport, The Hague Poland Jan Czeslaw Czabala, Deputy Director for Research, Institute of Psychiatry and Neurology, Warsaw Portugal Maria João Heitor dos Santos, Direcção-Geral da Saúde, Lisbon Romania Bogdana Tudorache, President, Romanian League for Mental Health, Bucharest Russian Federation Alexander S. Karpov, Head, Division of Psychiatric and Neurological Care, Ministry of Health of the Russian Federation, Moscow San Marino Sebastiano Bastianelli, State Hospital, Neuropsychiatric Services, San Marino Serbia and Montenegro Aleksandra Milicevic Kalasic, City Institute of Gerontology and Home Care, Belgrade Slovakia Peter Breier, Head, Department of Psychiatry, General Hospital Ruzinov, Bratislava Slovenia Andrej Marusic, Director, Institute of Public Health of the Republic of Slovenia, Ljubljana Spain Juan López-Ibor, Professor, Clinica López-Ibor, Madrid EUR/03/5035055 page 21 Sweden Helena Silfverhielm, Medical Adviser, National Board of Health and Welfare, Stockholm Switzerland Herbert Heise, Deputy Director, Universitäre Psychiatrische Dienste, Berne The former Yugoslav Republic of Macedonia Vitomir Micev, Macedonian Medical Association, Skopje Ukraine Valery N. Kuznetsov, Professor, Medical Academy of Postgraduate Training, Kiev United Kingdom John Mahoney, National Institute for Mental Health Eastern Region, Colchester Uzbekistan Nargiza Khodjaeva, Ministry of Health, Tashkent Rapporteur Roxana Radulescu, Mental Health Europe, Brussels, Belgium WHO European task forces Franz Baro, Professor, WHO Collaborating Centre on Health and Psychosocial Factors, Brussels, Belgium Per Bech, Professor, WHO Collaborating Centre on Quality of Life Studies, Frederiksborg General Hospital, Hillerød, Denmark Lars Jacobsson, Professor, University of Umeå, Sweden Steering Committee of the WHO European Ministerial Conference on Mental Health (participated only 12 December) John Henderson, Senior Policy Adviser, Mental Health Europe, Brussels, Belgium Eero Lahtinen, Ministry of Social Affairs and Health, Helsinki, Finland Leen Meulenbergs, Federal Public Service of Health, Food Safety and Environment, Brussels, Belgium Organization team, WHO European Ministerial Conference on Mental Health Merja Paimensaari, Project Assistant, WHO European Ministerial Conference on Mental Health, National Research and Development Centre for Welfare and Health – STAKES, Helsinki Evaluation Team José Miguel Caldas de Almeida, Chief, Mental Health Programme Unit, Pan American Health Organization, Washington, DC, United States of America EUR/03/5035055 page 22 John Mahoney, National Institute for Mental Health, London, United Kingdom José L. Vazquez-Barquero, Professor, University of Cantabria, Santander, Spain World Health Organization WHO Regional Office for Europe Frances Ingels, Programme Assistant, Mental Health Unit Johanna Kehler, Programme Assistant, Mental Health Unit Simo Kokko, Mental Health Conference Coordinator Gudjon Magnusson, Director, Division of Technical Support – Reducing Disease Burden Wolfgang Rutz, Regional Adviser for Mental Health Liliana Urbina, Desk Officer for Mental Health Activities Headquarters Michelle Funk, Coordinator, Mental Health Policy and Service Development Shekhar Saxena, Coordinator, Mental Health: Evidence and Research SEVENTH MEETING OF THE EUROPEAN NATIONAL COUNTERPARTS FOR THE WHO MENTAL HEALTH PROGRAMME Seventh Meeting of the European National Counterparts for the WHO Mental Health Programme Report on a WHO meeting Copenhagen, Denmark 11–13 December 2003 EUR/03/5035055 E82939 Original: English