Approaching Mental Health Care Reform Regionally: The Mental Health Project for South-eastern Europe This report was produced for the SEE Mental Health Project, a programme of the SEE Health Network sup- ported by the WHO Regional Office for Europe. The editors and main writers were Desmond Maurer and Melita Murko, while the text was reviewed by Ms Vesna Purati}, Regional Project Manager of the SEE Mental Health Project, Dr Matthijs Muijen, Regional Adviser, Mental Health, WHO Regional Office for Europe, Dr Maria Haralanova, Regional Adviser, Public Health Services, SEE Health Network Secretariat, WHO Regional Office for Europe. Special thanks for their contributions are due to the nine Country Project Managers, Dr Zana Kokomani, Albania, Dr Joka Blagov~anin Simi}, Bosnia and Herzegovina, Dr Hristo Hinkov, Bulgaria, Dr Neven Henigsberg, Croatia, Ms Tatijana Mandi} \uri{i}, Montenegro, Dr Larisa Boderskova, Republic of Moldova, Ms Raluca Nica, Romania, Dr Vladimir Jovi}, Serbia, and Dr Vladimir Ortakov, The former Yugoslav Republic of Macedonia. We would also like to acknowledge the use in the text of materials provided for various train- ing seminars and workshops by, amongst others, Dr Carlos Artundo, Mr Ray Baird, Professor Athanassios Constantopoulos, Dr Michelle Funk, Dr Margaret Grigg, Dr Paul O'Halloran, Dr Sla|ana [trkalj Ivezi}, Dr Matthijs Muijen, Dr Mario Reali, Dr Colin Rickard, and Professor Peter Ryan. Finally, we are grateful to Dr Judit Csiszar, Regional Director of Project HOPE Central and Eastern Europe, who provided the personnel and ad- ministrative support required for the production of this report. Design and layout were done by Graphic Studio Oskar. The report was printed in Sarajevo, Bosnia and Herzegovina. Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe Scherfigsvej 8 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the WHO/Europe web site at http://www.euro.who.int/pubrequest. © World Health Organization 2009 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 ex- pression of any opinion whatsoever on the part of the World Health Organization concerning the legal sta- tus of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. 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 en- dorsed 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. All reasonable precautions have been taken by the World Health Organization to verify the informa- tion contained in this publication. 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Approaching Mental Health Care Reform Regionally: The Mental Health Project for South-eastern Europe Report on the Implementation of the SEE Health Network's “Enhancing Social Cohesion through Strengthening Community Mental Health Services in South-eastern Europe” Project Sarajevo, December 2008 TABLE OF CONTENTS Foreword 5 Acknowledgement 7 Introduction: A Model Approach to Mental Health Reform 9 Mental Health as a Public Health Issue 13 Three Decades of Advocacy and Political Progress on Mental Health 14 Mental Health in South-eastern Europe 17 Relevant Recent History of the SEE Region 17 The Path towards Regional Cooperation 18 The Benefits of Approaching Mental Health Care Reform Regionally 22 The Mental Health Project for South-eastern Europe 25 Funding 27 Stepping Stones: A Coordinated Approach to Mental Health Reform 29 Component One: The Development of National Mental Health Policies and Legislation 31 Lessons learned from Component One 38 Component Two: Establishment of Pilot Community Mental Health Centres 43 Review of Key Concepts of Community Mental Health Care 47 Lessons Learned from Component Two 49 Component Three: Training of Mental Health Professionals and Primary Health Care Practitioners in Community Mental Health 51 Review of Main Training Programmes 52 Country Profiles 61 Albania 62 Bosnia and Herzegovina 64 Bulgaria 68 Croatia 70 Montenegro 72 Republic of Moldova 74 Romania 76 Serbia 78 The former Yugoslav Republic of Macedonia 80 Concluding remarks 83 Annexes 1. The Dubrovnik Pledge 84 2. The Skopje Pledge 87 3. The Declaration on a long-term programme for regional cooperation and development on mental health 91 4. List of Participants 96 FOREWORD It was with great pleasure that we accepted the invitation to introduce this final report on the Mental Health Proj- ect for South-eastern Europe. It offers a clear and detailed account of the impressive and fruitful efforts made over the past six years by the nine countries of South-eastern Europe under the Stability Pact's Social Cohesion Initiative, with the aim of developing modern and socially responsible mental health services that respect the needs and the rights of service users, and that fully recognize the community's duty to offer care in and as part of the community. To sum up the achievement is not difficult: in six years the countries have converted an aspiration into a reality, formulating a vision for the humane treatment of those suffering from mental disorders, developing new policies and mental health legislation, elaborating mental health reform strategies, and beginning the transition to com- munity-based care by the creation of one or more pilot community mental health centres. These community cen- tres are now centres of excellence which showcase best practice. They also provide the focus for programmes of professional training for mental health and primary health care professionals, public awareness raising, and advocacy. Given the excellent results attained by these centres, the stage has been well and truly set for the par- ticipating countries to roll out the next phase, the generalization of the pilot model as the way forward for men- tal health care in South-eastern Europe. After the long years of development and achievement, it is easy to forget the starting point. Mental well-being and psychiatric services had been severely affected by war, economic turbulence, and humanitarian disaster. To many it must have seemed that the human rights, social inclusion, and modern evidence-based treatment of those suffering from mental disorders and their carers would be a low priority for the exhausted and insolvent countries of the region, with their traumatized populations and outmoded services concentrated in stigmatizing mental hospitals, rife with neglect and abuse. Securing political support was therefore essential to the success of the process, as was the recognition that social reconstruction, peace, and democracy all depend on the mental well-being and solidarity of the population. Nor was such political support lacking for the creation of commu- nity mental health centres that would place mental well-being symbolically at the heart of the community by of- fering support to the most vulnerable members of society, resulting in a powerful message that stigma, exclusion and neglect would no longer be accepted. This new political and social solidarity has nowhere been more clearly expressed than through the internation- al partnership that created the Mental Health Project of the Stability Pact for SEE. The nine countries that signed the Dubrovnik Pledge offered their contributions enthusiastically at every level, political, managerial and clinical, throughout the duration of the project, while the WHO Regional Office for Europe and the Council of Europe were equally unwavering in their support. Generous funding from many countries, with Greece and Belgium in the forefront, but also including Italy, Switzerland, Slovenia, Sweden, and Hungary, facilitated the honest shar- ing of ideas and experiences and the gradual implementation of good practice at a series of extremely fruitful seminars and workshops, which resulted in an effective model of community-based care, based on a shared vi- sion, but sensitive to local needs and resources. The high-political nature of the policy and strategic components of this project should not be allowed to obscure the equally crucial and effective steps taken by participants on the ground to establish community services. Effec- tive reforms require both good policy and consistent implementation. This report describes the process very well, but cannot possibly do justice to the many coordinators, professionals, representatives, and experts involved at the various stages. Those involved will join us in remembering the emotional exchanges on vision and values, as 6 The Mental