Providing free treatment for severe mental disorders in China.

Following the SARS outbreak in 2003 the Chinese government substantially strengthened its public health infrastructure. One of the new programs was the ‘Central Government Support for the Local Management and Treatment of Severe Mental Illnesses Project’. Initially funded in December 2004 with 6.86 million Renminbi (829,000 in 2004 US$), the ongoing project has subsequently been referred to as the ‘686 Project’. The aims of the project include establishing an effective system to control and prevent violent behaviors by individuals with severe mental disorder, increasing care-seeking by persons with severe mental illnesses and disseminating knowledge about mental health. The main activities conducted under the auspices of the program are: a) the registration and evaluation of individuals with severe mental disorders, b) the identification and follow-up of persons with severe mental disorders who are considered at risk of violence, and c) the provision of free outpatient, inpatient and emergency treatment to persons with severe mental disorders who are living in poverty. In most locations the program is coordinated by the local public health department with varying levels of participation by mental health institutions.[1]

This project has played an important role in the transformation of mental health services in China. It has moved China closer to the long-term goals of reducing the financial burden to individuals and families of severe mental disorders, of increasing care-seeking and treatment adherence, and – ultimately – of decreasing the relapses and chronic disability associated with severe mental disorders.[2] By the end of 2012 the program had expanded to cover approximately 60% of the population in 1578 districts and counties around China. Three million people with severe mental disorders had been registered, among whom 249,000 had received free treatment and over 41,000 had received free inpatient care. Over this period the reimbursement limit of medications has increased from 500 to 700 Renminbi per person per year (about 110 US$) and the reimbursement limit for inpatient treatment has increased from 1,500 to 2,000 Renminbi per hospitalization (about 330 US$).

Despite these considerable achievements, there is still a huge unmet need for services among persons with severe mental illnesses. Given the size of the population and the rapidly rising cost of health services the 686 project is only dealing with a small part of the problem. According to data from the Chinese Center for Disease Control and Prevention, there are more than 16 million people with severe mental disorders in China and the majority of them (57%) live under the official poverty line, primarily because of the disability and subsequent poverty that is associated with chronic mental disorders. The need for long-term treatment, the frequent relapses, and the high costs of medications impose a tremendous financial burden on individuals with serious mental disorders and their families. In many cases these cost limit care-seeking and treatment adherence.[3] A secondary burden associated with under-treatment of individuals with serious mental disorders is the greatly increased risk of harm to self or others among untreated individuals, problems that can undermine social stability and harmony.

The public health system – which runs the 686 program – does not identify all individuals who need free treatment and, in any case, the 686 project does not have the funds to provide free treatment to all such individuals. To address this unmet need, national and local governments need to substantially increase financial support for the 686 program and more effectively integrate the program with other mental health services. For example, in Shanghai mental health facilities have integrated the ‘686’ project into the regular mental health service system. This has made it possible to institute standard protocols for the evaluation of patients, the determination of eligibility for free treatment, and the regular follow-up of patients to monitor safety and medication adherence. This has resulted in a steady increase in the provision of free treatment. By the end of 2013, almost 11,000 individuals with severe mental disorders had received free medication in Shanghai; 70% of them were being regularly followed up and 98% were clinically stable.

The provision of free treatment to all individuals with severe mental disorders is an important policy goal that would significantly benefit society. Severe mental disorders have serious negative consequences for individuals, families and the society at large. The prevention and management of these conditions requires the coordinated effort of the individuals, their family members and their communities. But, given the severity of the behavioral disturbances and disability associated with severe mental disorders, the high level of chronicity of these conditions, and the high costs associated with their treatment, it is not realistic to believe that disabled individuals or their family members can assume full financial responsibility for providing these services. Unable to pay for services, their conditions are either inadequately managed or not managed at all. Gradual deterioration in their condition leads to social disability, an inability to work, self-neglect and self-harm, and, in some cases, harm to others or to public order.

One important function of government is to maintain social equity and justice. One core component of this function is to guarantee equal access to basic medical care. The provision of essential medical care to vulnerable groups is also vital to maintain social welfare and sustainable growth. Thus, in addition to being the ethical thing to do, providing appropriate long-term treatment to individuals with serious mental disorder is advantageous for the community at large. Paying for these essential services should be a responsibility of the government. China does not yet have a comprehensive universal health care system, so a special medical aid system should be established to ensure basic medical services are provided to all persons with serious mental disorders. This medical aid system for individuals with serious mental disorders should be one component of a comprehensive mental health service network that also includes a public health education component (to educate the communities about mental health issues and, thus, reduce stigma), community-based services (in general medical institutions) for common mental disorders, specialized treatment centers for severe mental disorder, and community-based follow-up networks for persons with serious mental disorders to monitor rehabilitation and medication adherence.

In summary, the Chinese government has the responsibility to provide free treatment to individuals with severe mental disorders. This is one essential component of a universal social welfare system. The rapid expansion of the 686 project is an indication that the government sees the importance of moving in this direction. However, organizing a targeted medical aid system for mentally ill individuals and integrating this system with the overall mental health services network will be complicated and, given the economic differences between different provinces, will probably progress at different speeds in different parts of the country. In moving towards this goal, China can learn from the experiences of other countries that are already providing free services to mentally ill individuals, though the unique aspects of mental illnesses and of the health care system in China will necessitate adaptation of foreign-based models. At the same time, it is likely that the experiences China accrues as it moves towards universal free services for mentally ill individuals will provide models of service provision that may be useful to other low- and middle-income countries.