Developing a capacity-building programme to support a mental health service modernisation pilot project in Lviv region of Western Ukraine

Abstract

This paper reflects on the development of a capacity-building programme to support a mental health service modernisation pilot project based in the Lviv region of Western Ukraine. National programmes that aim to modernise mental health services now have the experience of other countries on which to draw. The challenges faced by such modernisers have much in common. Nevertheless, although there are lessons to be learned from what has worked well elsewhere, we caution that the local context can have a profound effect on the successful implementation of plans based on best practice.

Ukraine is currently carrying out a significant reform of its healthcare services. Reorganisation of the mental health system is one of the key components. Overarching aims include improving access to and availability of evidence-based care, developing and delivering modern health workforce plans, and enhancing transparency and accountability in the system.

The government is committed to making changes to both the structure of the health system and how providers are funded. Primary care developments based on the principle of ‘funding following the patient’ are promising. Legislative change is underway; a concept note on mental healthcare development was approved in 2017¹ and a draft action plan for the reform of the mental health system was produced. The social care system has also been subject to review, with the aim of shifting mental healthcare into community-based services.

The proposed changes to the mental health system will see the introduction of a defined package of care options, in which the patient will have a choice about where to be treated. Hospital providers will become ‘communal non- commercial enterprises’ (similar to National Health Service foundation trusts in the UK) with the freedom and flexibility to operate with more autonomy. The proposed reforms will also encourage a multiplicity of new providers (such as not-for-profit non-governmental organisations and private providers) to improve patient choice, care quality and outcomes.

Delivery challenges

The challenges to delivering these aspirations are many.² Gaining independence from the Soviet Union in 1991 led to economic growth until Ukraine faced political turbulence and conflict in the East (including the annexation of Crimea by Russia in 2014) and occupation of two Eastern regions. Economic challenges led to a significant reduction in the national health budget. Continuing political turbulence has had an influence on both the development of policy and implementation plans.

Until recently, Ukraine operated a centralised model of healthcare that did not address the needs of its diverse population. In common with many other Eastern European countries, reforms must take into account an ageing population, rapid urbanisation and the expanding adoption of an unhealthy lifestyle. However, an additional challenge for Ukraine is the war in the East. There are 1.5 million officially registered internally displaced persons who lack access to basic services, including healthcare and psychosocial support.^{3, 4} There is therefore a pressing need to develop regional plans and local approaches to models of care and support.

Risk factors for poor mental health are present across Ukraine, including relatively high levels of poverty and unemployment, which militate against the affordability of care and medical treatment. There are additional risks associated with the conflict in the East. Stigma associated with mental health problems is profound in this culture and has been compounded by a lack of trust in state institutions. There have been no systematically organised information campaigns to promote public awareness of mental health issues.

Against this backdrop, there are also a significant number of international organisations working in Ukraine to share knowledge and expertise. These include a review carried out by the World Bank in 2017;⁵ the support of the World Health Organization (WHO) for a local adaptation of the mhGAP Intervention Guide ⁶ and the mhGAP Humanitarian Intervention Guide;⁷ the work of the International Medical Corps with conflict-affected communities;⁸ and the Human Rights in Mental Health – FGIP federation, which has been supporting deinstitutionalisation and the provision of social care homes.⁹ The WHO Europe policy of 2007¹⁰ and the Geneva initiative of 1980¹¹ have also been taken into consideration. A major challenge for the government of Ukraine is how to coordinate efforts across myriad partners, especially in the East; a further challenge is how to ensure, given the constraints on government funding for health and social care, that these efforts are sustainable with stable state support.

Mental Health for Ukraine pilot project

The Mental Health for Ukraine (MH4U) project is financed by the Swiss Agency for Development and Cooperation. The commission for the implementation of the project, following a competitive tender, was assigned to a consortium, led by GFA Consulting Group GmbH, together with their international partners. These include Implemental Worldwide CIC (previously Maudsley International), the Zurich University Hospital of Psychiatry and the Ukrainian Catholic University of Lviv. The aims of the consortium are to support policy makers, healthcare professionals, and people who live with mental health problems and their families, and to build a mental health system that is more available and accessible, providing better quality of care and supporting people in the community. Prior to the MH4U programme there was an ‘inception’ phase. This identified priorities for capacity-building by government agencies which could complement and link with those funded and delivered by other international partners. The aim was to identify best practice and opportunities to build on existing local innovations.

Views of stakeholders

The issues and concerns raised with the MH4U team would be common to many, if not most, mental health system reforms. They include the following needs: to identify governmental funding; to implement decentralisation and local planning; to coordinate and integrate care across organisational boundaries; and to integrate health and social care. Models of care should be based on evidence of best practice and should recognise the needs of vulnerable groups, especially children and young people and the ageing population. Patients and carers should be empowered. There is a need for leadership and strengthening of the mental health workforce.

There were also important considerations to take into account concerning the cultural context of post-totalitarian Ukrainian society. A pervasive legacy of Soviet era rule is a general feeling of disempowerment, which manifests in an unwillingness to take the initiative and accept responsibility for finding local solutions ‘outside’ established practice. Unfortunately, this attitude is compounded by the fact that professionals have had little experience of team and multidisciplinary working in the public sector; previously, the emphasis was on individual accountability. There has been insufficient development of professional roles. Nurses have been working as basic carers, and doctors tend to choose personally preferred interventions. Practitioners tend to work in organisational silos, and there are few examples of stakeholder involvement in service planning. Patients and their families are not consulted, and there are high levels of stigma. There are also tensions between the government and professional bodies and within government, between health and social care.

Implementation

Moving forward into the implementation of the pilot phase, there is to be an emphasis on leadership training to support the implementation of legislative changes. There should be practical examples of multisector collaboration and interdisciplinary team working. MH4U will facilitate the development of local implementation teams and provide capacity-building for family doctors (via mhGAP). There will be a small grant programme and support for the new Center for Mental Health, as well as for reforms to legislation, accrediting providers and coordinating stakeholders. A communication campaign has begun to address the deeply engrained cultural stigma about mental health disorders. The project will prioritise developments for children, young people and their families, where an integrated approach to service delivery is crucial for early intervention and preventative approaches.

Genuinely respectful relationships among collaborators that are nurtured over time will be necessary, but success can be achieved, as has been demonstrated by an earlier project in Sverdlovosk oblast.¹² Assessing the success of the pilot activities will be the first step before widening the scope of capacity-building support across the country. The process we have described has relevance for similar mental health developments in other parts of the world.