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A Cross-National Analysis of Mental Health System Reform Gordon C Shen1* and Lonnie R Snowden2

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A Cross-National Analysis of Mental Health System Reform Gordon C Shen1* and Lonnie R Snowden2 Shen and Snowden International Journal of Mental Health Systems 2014, 8:47 http://www.ijmhs.com/content/8/1/47 RESEARCH Open Access Institutionalization of deinstitutionalization: a cross-national analysis of mental health system reform Gordon C Shen1* and Lonnie R Snowden2 Abstract Background: Policies generate accountability in that they offer a standard against which government performance can be assessed. A central question of this study is whether ideological imprint left by policy is realized in the time following its adoption. National mental health policy expressly promotes the notion of deinstitutionalization, which mandates that individuals be cared for in the community rather than in institutional environments. Methods: We investigate whether mental health policy adoption induced a transformation in the structure of mental health systems, namely psychiatric beds, using panel data on 193 countries between 2001 and 2011. Results: Our striking regression results demonstrate that late-adopters of mental health policy are more likely to reduce psychiatric beds in mental hospitals and other biomedical settings than innovators, whereas they are less likely than non-adopters to reduce psychiatric beds in general hospitals. Conclusions: It can be inferred late adopters are motivated to implement deinstitutionalization for technical efficiency rather than social legitimacy reasons. Keywords: Diffusion of innovation, Institutional theory, Governance, Mental health policy Background mental illness from institutional environments to the Countries that subscribe to international norms and community. Institutionalization is a social process by ideas of progress and advancement uphold them in na- which structures, policies, practices, and programs are tional health policies. Even when policies are ratified, instilled with enough value such that they first acquire national governments frequently fail to implement their social legitimacy, are normatively and cognitively held terms and conditions. Why? Problems with implementing in place by members of the world society, become policies are especially pronounced due to institutional taken-for-granted by the collective, and ultimately achieve inertia, which is manifested in heated parliamentary deli- a “rule-like” status ([1-3]: 25, [4]). We argue that the berations and legislative proceedings. A whole host of institutionalization of deinstitutionalization policy is a other sociopolitical forces are at play during the im- two-fold process: isomorphism may be observed in the plementation of health reform, such as cultural cleavages, adoption of mental health policy across countries (first resource availability, and the extent of political or legal stage), but not necessarily in the make-up of state infrastructure development. In this study, we are inte- administrative apparatus and health care infrastructure rested in whether deinstitutionalization policy galvanizes a (second stage) [5,6]. Thus, the objective of this study is revolution in the organization of national mental heath to empirically examine whether the institutionalization systems. Deinstitutionalization policy is a policy that man- of deinstitutionalization policy changed the supply of dates a shift in practice of caring for individuals with psychiatric beds in 193 countries from 2001 to 2011a. Public policies are broad statements of intentions and general directions their writers wish to undertake. They * Correspondence: [email protected] 1School of Public Health, Yale University, 60 College Street, P.O. Box 208034, may also outline methods and principles that politicians, New Haven, CT 06520, USA professional and industry groups, and other constituencies Full list of author information is available at the end of the article © 2014 Shen and Snowden; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Shen and Snowden International Journal of Mental Health Systems 2014, 8:47 Page 2 of 23 http://www.ijmhs.com/content/8/1/47 plan to use to achieve their directives. Policy statements, implications. We will conclude with a brief discussion of however, are not always complemented with local catch- the policy implications. ment area and organization plans, funding, programs, personnel, and regulations. Deinstitutionalization is a Theoretical background major, yet broad component of national mental health Internal efficiency policies. The United Nations [7] and WHO [8] have Are mental health systems designed for efficiency or le- both declared that mental health care should be shifted gitimacy reasons? Realists believe behavioral consisten- from hospital- to community-based treatment facilities. cies reflect inherent needs and interests. Rational choice Deinstitutionalization is fundamentally an administrative theorists, in particular, consider nation-states as rational, philosophy rather than a technical advancement, so va- unitary actors who are actualizing fixed preferences riances found in its implementation among countries [18-20]. As such, there is a distinct economic rationale invoke social legitimacy and cost-effectiveness impetuses underlying policy adoption lag: policymakers valorize behind policy change [9-11]. We test both the external deinstitutionalization because it is instrumental in cut- legitimacy and internal efficiency hypotheses using the ting the exorbitant cost of delivering mental health care World Health Organization’s(WHO)Mental Health Atlas, in residential facilities and hospitals. a country-level panel dataset of mental health systems. The mechanisms underlying policy adoption and imple- The pattern of policy diffusion reflets countries’ readiness mentation differ for early- versus late-adopters. Countries for change and propensity to take political risks. Tracing that are innovators in mental health care tend to face two the sigma-curve of innovation diffusion, a few early- dilemmas. Early on in the diffusion process, they face a adopters (“innovators”) are followed by a critical mass of lack of information: not all policy alternatives are known late-adopters (“laggards”) and non-adopters (“resisters”) and the merits of the ones known are uncertain. The gen- [12]. The phase of policy adoption lends itself as a pre- eral lack of information about the cost of all policy options dictor of mental health system change. Laggards are of and the benefits of their concomitant solutions hampers particular interest to us because it is equally plausible for governments’ ability to make rational decisions. Govern- such countries to hold either a legitimacy or efficiency ments can only make predictions on the equity, quality, motivation in adopting deinstitutionalization. Institutional and efficiency implications of deinstitutionalization policy theorists assert that early adopters assume a certain based on their own experience with reforming the general organizational form because they are motivated by eco- health sector. nomic and technical needs, whereas late adopters conform Alternatively, early adopters with slack resources may because they are chiefly concerned with status enhance- invest them in experiments involving the reorganization ment [3,13]. As such, actions of late-adopting countries of mental health system on a trial and error basis reinforce the bandwagon effect because they are sus- [21,22]. Government stakeholders and special interest ceptible to norms institutionalized in the world society groups associated with the experiments have a large [14-16]. Proponents of the legitimacy side, however, often stake in their outcomes, so therein lies a chance that the fail to recognize bureaucrats and technocrats’ ability to test population of citizens are exploited in the process of purposefully and creatively applying knowledge gained carrying out the experiments [23,24]. Another trade-off from earlier adopters [17]. With sufficient resources and earlyadoptersmakeoncetheyembarkonsuchanirre- stewardship, late adopters have the potential to implement versible course of action is surrendering option value, a policy innovation such that efficiency gains are rea- or the benefit that incurs from delaying a decision to lized from policy adoption opportunities. Late-adopting conduct experiments. High sunk costs are incurred if countries could customize off the shelf policies so that deinstitutionalization proves to be a failure because the treatment, preventive, and rehabilitation services can political or financial price of reversing it is exceedingly eventually be delivered at the mental health system’s high,orbecausethepolicyitselfcannotbeeasilyun- optimal capacity. done once enacted. On the upside, investment in pilots This article is organized as follows. In the Theoretical could pay off in dividends if pilot results are used to in- background section we will review the relevant literature crementally improve mental health systems. Pioneers in that support our interpretation of late-adopting nation- mental health care stand to reap the benefits of discov- states’ behavior as being driven by internal efficiency or ering new norms and practices in the form of increased external
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