Vol. 1, núm. 3 - Noviembre 2002
Revista Internacional On-line / An International On-line Journal
WHO task force on mental health assessment: a reflection on an
experience of three years
José Guimón. M.D (on behalf of the task force)
Professor of Psychiatry, Hôpitaux Universitaires de Genève, Switzerland
Correspondece:
Professor José Guimon
Department of Psychiatry
Hôpitaux Universitaires de Genève
2 ch. du Petit-Bel-Air
CH-1225 Chêne-Bourg
Switzerland
Office +41 22 305 57 77
Fax: +41 22 305 57 99
E-mail: jose.guimon@hcuge.ch
Other members of task force:
Franz.C.J. Baro (CHAIRPERSON), M.D.
Professor f Psychiatry. WHO collaborating center for health and psychosocial and
psychobiological factors, Brussels, Belgium
Thomas Becker, M.D.
Professor of Psychiatry, University Germany
Peter Breier, M.D.
Department of Psychiatry, General Hospital Ruzinov, Bratislava, Slovakia
Jan Czeslaw Czabala, Ph.D.
Institute of Psychiatry and Neurology, Warsaw, Poland
Horst Dilling, M.D.
Professor of Psychiatry, Klinik für Psychiatrie, Medizinische Universität zu Lübeck, Lübeck,
Germany
John H. Henderson, M.D.
Mental Health Europe, Haddington, Scotland, United Kingdom
Leen Meulenbergs, M.A.
WHO collaborating center for health and psychosocial and psychobiological factors, Brussels,
Belgium
Bogdana Tudorache, Ph.D.
Romanian League for Mental Health, Bucharest, Romania
Vassilly .S. Yastrebov
Chief, Mental Health Support Systems Research Center, Mental Health Scientific Center,
Moscow, Russian Federation
Wolfgang Rutz, M.D.
Regional Adviser, Mental Health, WHO Regional Office for Europe, Copenhagen, Denmark
Anke Bramesfeld, M.D.
Short-term technical assistant, WHO Regional Office for Europe, Copenhagen, Denmark
(este texto se publica simultáneamente en el European Journal of Psychiatry)
Resumen
La Oficina Regional para Europa de la Organización Mundial de la Salud (OMS) en Copenhague
estableció un grupo de trabajo sobre evaluación en Salud Mental formado por expertos en
Psiquiatría, los cuales, junto con los centros colaboradores de la OMS, prestan asistencia a una red
Europea de Salud Mental constituido por 47 representantes nacionales para la Salud Mental
nombrados por los diferentes ministerios.
El grupo de trabajo ha respondido a demandas de evaluación mediante visitas a los países y la
elaboración de informes y de recomendaciones. Sin embargo, antes de adquirir cualquier
compromiso, tuvo que clarificar cuáles eran las instancias que pedían una evaluación y cual sería el
alcance y los límites de la intervención que podía ofrecerse. En realidad, una evaluación podía ser
solicitada por organizaciones supranacionales (tales como las Naciones Unidas o la propia OMS), o
por algunas instancias privadas (tales como la Asociación Mundial de Psiquiatría, y organizaciones no
gubernamentales), pero hasta ahora, las consultas han sido requeridas (directa o indirectamente)
por los Estados miembros, que desean cambiar su política en Salud Mental y confían en la OMS
porque tiene el conocimiento y la objetividad requeridos. Obviamente, el tipo de evaluación que ha
de llevarse a cabo depende del origen y de la razón de la demanda.
Sin embargo, el alcance y la metodología de las intervenciones dependen en gran parte de la
definición precisa de la demanda. Así las evaluaciones pueden llevarse a cabo mediante visitas de
evaluación y procedimientos de acreditación; pueden centrarse en una población diana determinada
o en una toda una organización de salud ; pueden utilizar instrumentos de evaluación de
necesidades existentes desde hace tiempo o de reciente creación, manuales operativos e indicadores
de estigma, cuestiones de discriminación y de equidad, etc.
Se han descrito demasiados criterios, demasiadas normas, estándares e indicadores en el campo de
la Salud Mental. La tendencia actual consiste en seleccionar unos pocos " indicadores " factibles, que
son variables medibles y bien definidas en relación con los resultados de las actividades médicas. En
la reunión de los centros europeos colaboradores de la OMS en Lille en 2001, se presentó un amplio
estudio que está siendo llevado a cabo por un equipo de investigadores de Londres con la finalidad
de obtener indicadores simples y fiables. Además, un sub-grupo de nuestro grupo de trabajo de la
OMS está trabajando sobre la selección de cinco indicadores generales de salud mental a añadir a la
base de datos HFA-21 de la OMS. Es de esperar que estos esfuerzos nos conduzcan a disponer de
instrumentos simples y ampliamente aceptados que podamos utilizar en el futuro.
Hasta ahora, el grupo de trabajo ha hecho evaluaciones en Polonia, Kyrgyzstan, Rumania, Lituania y
Eslovenia y visitas cortas a Rusia y Georgia (así como en Malta y ndorra) con la finalidad de
reestablecer los contactos e introducir programas de Salud Mental en el contexto de las políticas reemergentes, explorar la situación actual en Salud Mental y fomentar el interés por encontrar fondos
para los diferentes proyectos. Los limites de tiempo y de presupuesto son proporcionales a la tarea,
y la estrategia varía desde la simple consulta de datos aportados por el cliente hasta costosos
estudios epidemiológicos en profundidad. En Rumania, por ejemplo, se hizo una evaluación bastante
completa que permitió la obtención de datos sobre todos los campos relativos a la salud mental. En
otras evaluaciones, uno o varios miembros (en el caso de Rusia todo el grupo de trabajo) visitaron
los países, en misiones de " hallazgo de hechos " explorando algunas áreas específicas. Se reunieron
con políticos, profesionales de la Salud Mental y representantes de organizaciones activas en el área.
Además visitaron servicios de Salud Mental, principalmente hospitales e instituciones educativas y de
investigación. Por supuesto, el origen de los fondos es una cuestión crítica en términos de
imparcialidad y de eficacia de la tarea. Los resultados de estas evaluaciones se publicarán en otro
lugar en un artículo separado y con más detalle. Un resultado positivo de todas estas actividades ha
sido el poner las cuestiones de salud mental en el corazón de la política. Por lo general se ha logrado
un aumento del interés y de la sensibilidad hacia las cuestiones de Salud Mental lo que ha llevado
algunos países a solicitar evaluaciones más profundas. Otros países, como los siete que componen el
"Pacto de estabilidad" del Sureste Europeo (los países llamados balcánicos) han solicitado una
evaluación y miembros del grupo de trabajo han trabajado ya con representantes de todos los países
para elaborar un cuestionario común de evaluación.
Las visitas que aquí se han mencionado mostraron la existencia de importantes desigualdades entre
estos países y otros más desarrollados, en cuanto a determinantes de salud socioeconómicos, estilos
de vida, recursos en Salud Mental y acceso a los servicios.
Los límites de tiempo y de presupuesto condicionaron en gran medida la tarea solicitada pero en
muchos casos pudo hacerse una estimación global de los modelos de asistencia, del sistema de
cuidados, de sus límites, de las necesidades de la población y de la provisión de cuidados actual. En
algunos casos se hicieron algunas recomendaciones para un plan estratégico de cara a un sistema
local de servicios de Salud Mental. En general, se ha observado tras las visitas un aumento del
interés y una sensibilidad hacia las cuestiones de salud mental por parte de los políticos de los
diferentes países. Algunos han solicitado una evaluación en profundidad de la Salud mental, que
podría llevar a introducir modificaciones en los servicios a nivel local y eventualmente establecer un
ciclo de control y de revisión.
Sin embargo, la mayoría de los políticos y de los administradores se muestran reticentes en cuanto a
cuestiones de Salud Mental porque argumentan que no existe una relación clara entre diagnóstico y
necesidades y que existen dificultades en la evaluación de los resultados. Para mejorar la situación
necesitaríamos proporcionar información simple y relevante a la población general, a los políticos, a
los grupos de riesgo, a los pacientes y a sus familias, a los profesionales de la asistencia primaria, a
los educadores, a los profesionales de la salud mental y a los administradores. Pero por supuesto,
estas son intervenciones costosas y a largo plazo.
En parte debido a las actividades de este grupo de trabajo, la cooperación de la OMS con la UE está
en una fase de desarrollo bilateral en temas psiquiátricos. Por ambos lados se han enfatizado el
deseo de actividades sinérgicas, la coordinación del trabajo y el intercambio de experiencias así
como la asistencia técnica mutua. Como esfuerzos bilaterales conjunto se han realizado un congreso
conjunto, una sesión de brain storming sobre la promoción de la Salud Mental y una conferencia
europea ese tema. Por otro lado, la Oficina Regional ha estrechado los vínculos con los cuarteles
generales de la OMS, con otras redes de la Oficina Regional, con grupos de defensa de los enfermos,
con la Federación Mundial de la Salud Mental (WFMH) y con la Asociación Mundial de Psiquiatría
(WPA).
Summary
The World Health Organization (WHO) Regional Office for Europe in Copenhagen established a task
force on mental health assessment formed by psychiatry experts whom, together with the WHO
collaborating centers, assist a European network on mental health of 47 ministerial-nominated
national counterparts for mental health. This article discuss assessments that have been made in
seven east European and south east European states during the three years of existence of the task
force. Most of the evaluation instruments currently used require costly and lengthy field studies,
which are rarely possible in the context of this kind of assessment. A great effort should be made in
the future to agree on simple and reliable procedures for assessing these parameters and monitoring
evolution. On the whole, the described assessments increased interest and sensitivity for mental
health issues thus putting mental health issues in the focus of policy in most of the countries
concerned.
Key words: National mental health assessment, mental health audit, psychiatric services, East
Europe, South East Europe.
This paper is a summary of the experience obtained over the last three years by the European WHO
Task Force on Mental Health Assessment, its aims, its methodology and the effect that the various
projects already begun have had, both in the respective countries and in the task force itself.
1. The Task Force for Mental Health Assessment
1.1.The creation
The Mental Health program at the WHO European Regional Office identified in 1998 the need to give
its advice about the implementation of new policies in mental health, frequently asked by different
nations (WHO. 1999) mainly by the eastern European countries, which are at present in need of
urgent modification of their mental health services. A task force for mental health assessments was
created including the members authoring this paper. It was decided that the task force, in order to
accomplish its goals, should liaise with WHO headquarters, other networks of the Regional Office,
WHO advocacy groups, other organizations in the European Union, the World Federation of Mental
Health (WFMH) and the World Psychiatric Association (WPA).
The task force meets formally twice a year, always being hosted by one of the members. In this
way, each member and his government has the opportunity to utilize the presence of this
international expert group for his own country through press conferences, ministerial meetings,
consultations, etc.
1.2. The Model for Mental Health
WHO subscribes to a precise model of mental health promotion and mental health care:
a. mental health care should be provided in a participatory approach, involving clients and their
families into decision-making;
b. the size of large mental hospitals should be reduced and inpatient treatment minimalized;
c. whenever possible, inpatient treatment should be provided in general hospitals;
d. in- and outpatient care should be provided as close as possible to the population served,
e.
f.
g.
h.
offered in community-based mental health facilities;
outpatient facilities and day care should be widely available and involve primary health care;
non-medical extramural care by social workers, nurses, etc. should be developed;
the principle of multidisciplinary teamwork should be followed in mental health care;
mental health concerns all parts of society and all parts of society are responsible for it.
1.3.The Goals of the Task Force for Mental Health Assessment
In line with this WHO policy, the task force was assigned the following goals:
a.
b.
c.
d.
collect evidence-based knowledge on the topics;
produce a position paper on the state-of-the-art in Europe;
co-ordinate research to be carried out;
develop evidence-based strategies; implement these strategies in one or two places as "good
examples";
e. prepare and hold a meeting on the topic in the year 2002;
f. develop an action plan on the topic to be presented and adopted at this meeting;
g. integrate the work done by the task force into the preparation of the WHO ministerial
conference on mental health proposed to take place in 2003-4.
2. The activities
2.1. The demands and the methods
The task force has answered assessment requests through evaluative visits to the countries and the
establishment of reports and recommendations. However, before taking any engagement, it has had
to clarify which were the instances asking for an evaluation and what could be the extent and limits
of the assessment that could be offered. An assessment could be, in effect, solicited by supranational
organizations (such as the United Nations or the WHO itself), or some private instances (such as like
the World Psychiatric Association and non-governmental organizations), but until now the
consultancies have been requested (directly or indirectly) by Member States themselves, who wish to
change policies and utilize WHO as having the required knowledge and objectivity. Obviously, the
kind of assessment to be carried out depends on the source and reason of the requirement.
In the accomplishment of its mission the task force has sought the following information:
a.
b.
c.
d.
e.
f.
g.
h.
A panorama of the mental health situation of services in the country,
Needs evaluation of the patient population;
Mental health promotion plans;
Investment in mental health;
Inter-relation of mental and physical components of health;
Evaluation of mental health services;
Evaluation of the quality of management;
Evaluation of equity and human rights legislation.
However the extent and methodology of the interventions depend largely on the precise definition of
the demand. Thus the assessments can be carried out through assessment visits, accreditation
procedures or fact-finding missions; they can be focused on a given target patient population or a
complete health organization; they can use existing or newly created instruments for the evaluation
of needs, operational manuals and indicators of stigma, discrimination and equity issues.
So far the task force has made (or is in process of making) several evaluations and visits to Poland,
Kyrgyzstan, Romania, Lithuania and Slovenia and fact-finding missions were made in Russia and
Georgia (as well to in Malta and Andorra) in order to re-establish contacts and to introduce the reemerged mental health program and its policy, explore the present situation on mental health and
initiate the interest for fundraising regarding the program's different projects. The time and budget
limits are proportional to the task allowed and the strategy varies from simple consultation of data
provided by the client to in-depth and costly epidemiological studies. For example, in Romania a
quite complete evaluation has been made allowing to gain insight into all scopes concerned with
mental health. In other of the audits presented here, one or several members (in the case of Russia
the whole task force itself) visited the countries, in "fact-finding missions" looking at some specific
areas. They met with political and health officials, mental health professionals and representatives of
organizations active in mental health. Furthermore they visited educational and research institutions
and mental health facilities, mostly hospitals. Of course, the origin of funding is a critical issue in
terms of impartiality and efficiency of the task.
Results of these audits will be published in more detail in a separate article elsewhere. A positive
result of all assessments has been to put mental health issues in the focus of policy. On the whole,
an increasing interest and sensitivity for mental health issues has led to the request for a in depth
mental health evaluations in some of the countries. Various other countries have applied for
evaluation and are expected to be visited soon. The seven South East European countries (previously
refereed to as Balkan's countries) having signed the sa called "Stability pact" in 1999 have recently
asked the help of the task force to develop an evaluation instrument on Mental Health in order to
have common data for the reform of Mental Health Services and Plans in the different countries.
2.2. Networking
Continuous and productive exchange in themes of mental planning has taken place with the World
Federation for Mental Health (WFMH) "Mental Health Europe" and the World Psychiatric Association
(WPA). Quite intensive cooperation with the Regional Office has also taken place, for instance, in the
review of data of mental health service provision throughout Europe, collected in 1994. Members of
task forces and networks of the Regional Office are frequently contacted, forming a consistent group
of temporary advisers and experts in different areas of mental health.
The task force has been actively involved in awareness-raising activities specially during the WHO
and the UN "year of mental health 2001" and has engaged all European ministries of health in a panEuropean conference on mental health, held in October 2001 and hosted by the government of
Belgium. At a recent WHO/European Union (EU) meeting, also held in Brussels on the need for
mental health impact assessment, it was decided to spread the task force assessment approach to
other European countries as a joint effort of WHO and EU. Agreements of cooperation has also been
made with the Geneva Initiative on Psychiatry (GIP) to promote mental health reforms in eastern
European countries.
2.3. Enhanced Collaboration between the WHO collaborating centers in Europe
Two collaborating centers meetings have been organized in Copenhagen in 1999 and Lille in 2001
and more than six meetings of this task force have taken place, enhancing the group's cohesion. The
51 EU Member States were asked in 1999 to nominate a national counterpart for the WHO mental
health program at the Regional Office. So far, 47 countries have nominated a counterpart. The
members of these networks and task forces constitute now a highly credible WHO European Network
on Mental Health.
2.4. Compilation of National Data
In September 1998, the Regional Office adopted a new health information system including data
about mortality data, incidence of communicable diseases, international organizations, agencies and
publications and health statistics that can be collected from three databases ( ). A finding was that
insufficient reliable data exist for mental health. The work of this task force is providing valuable
quantitative but mainly qualitative information on the area.
3. Scope and limitations
Three years after the beginning of the assessments and in view of the above-described results, we
can make some comments on the extent and shortages of this kind of endeavor:
3.1. Evaluation of Individual Patient Needs
The trend in mental health services provision is now to make programs, which are "needs-lead"
instead of "service-lead". However, in the process of our audits, when faced with the task of
evaluating the needs of a particular population, we lack a consensus on the instruments for
identifying different types of needs. Existing instruments . focus on individuals in target populations
and the evaluation of the whole groups' needs necessitates costly and lengthy field studies, which
are rarely possible in the context of this kind of audit.
3.2. Evaluation of Mental Health Systems
The evaluation of mental health systems should ideally include the structure (the description of the
different services), the process (technical knowledge and the ethical framework in which the services
are delivered) and the results. The client nations can provide some simple reliable data but more
sophisticated information could only be obtained through ad hoc enquiry. However, time, budget and
sufficient commitment of the clients is rarely assured.
3.3. Indicators
Too many criteria, norms, standards and indicators have been described in mental health. The trend
is to select a few feasible "indicators", which are measurable and well-defined variables in relation to
the results of medical activities. At the above mentioned meeting of WHO European collaborating
centers (Lille, 2001), a large study which is being undertaken by a team of researchers in London in
order to obtain simple and reliable mental health was discussed. Furthermore, a sub-group of our
WHO task force is working on selecting five general indicators on mental health to be added to the
WHO HFA-21 database. These efforts will hopefully lead to the availability of widely accepted, simple
instruments to be used in the future.
3.4..Evaluation of a Psychiatric Service
The task force has eventually to concentrate on the evaluation of a particular psychiatric service. It
has to include the description of the environment, the manual of procedures, the quality of
accommodation provided, the motivation of human resources, etc. All of these aspects can be easily
evaluated with existing tools.
Quantitative clinical indicators (resources, activity,functioning) are easily accessible for the task force
in most countries. However, qualitative indicators are more difficult to obtain without specific
studies. Clinical quality in psychiatric services has, in fact, been studied over the years by many
organizations leading to manuals of accreditation and the creation of commissions on the
accreditation of hospitals. Today existing require energy, skills and adequate budget seldom
available in the usual circumstances of the national evaluations.
3.4. Detection of Clinical Problems
In the course of our audits, several situations have been identified in relation to the clinical quality
that called our attention to some inadequacies of some services or systems throughout the study of
clinical records and could ask for further inquiry. However most of the problems could only be
adequately evaluated through a longer process of in-site evaluation which has not been the case in
our visits until now.
4. Conclusion
During the 3 years of work, the task force following the recommendations of the policy paper of the
Regional Office, HEALTH21 , that stressed the need for inter-sectorial cooperation, was able to
collect evidence-based knowledge on health assessment, produce a position paper on the state-ofthe-art in Europe and develop strategies to carry out a number of assessments and fact-finding
missions in seven east European countries. The assessments described here showed the existence of
important inequities between these and other more developed nations, regarding socioeconomic
determinants of health, lifestyles, mental health resources and access to health services.
The task force has discussed many instruments for the evaluation of the population needs, the
resources and the efficacy of the systems and some were used during the audits but many seemed
inadequate. A great effort should thus be made in the future to agree on simple and reliable
procedures for assessing these parameters and monitoring evolution.
The time and budget limits greatly conditioned the task allowed but an overall appraisal of models of
the system its boundary conditions, the population need and the current provision could be made in
many cases. Some recommendations were made in some cases for a strategic plan for a local
system of mental health services. On the whole, an increasing interest and sensitivity for mental
health issues has put mental health issues in the focus of policy in most of the countries. Some of
them have made the request for a in depth mental health audit that could lead to implementing the
service components at the local level and eventually to Establishing a monitoring and review cycle.
However most politicians and administrators remain reticent about mental health issues and argue
that no clear relation exist between diagnosis and needs and that there are difficulties in evaluation
of the results .To improve the situation we would need to give simple, relevant, information to
general population, employers, groups at risk, patients and families, primary care professionals,
educators, mental health professionals and administrators. But of course these are costly and long
term interventions.
Partially due to the activities of this task force, cooperation with the EU is in a stage of bilateral
development. The wish for synergistic activities, co-ordination of work and exchange of experience
as well as mutual technical assistance has been underlined from both sides. A joint conference and
brainstorming session on mental health promotion and a European conference on mental health
promotion has been presented as a joint effort. On the other hand, the Regional office has
strengthened the links with WHO headquarters, other networks of the Regional Office, WHO
advocacy groups, the World Federation of Mental Health (WFMH) and the World Psychiatric
Association (WPA).
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