Meeting population needs for mental health-the Chinese example.

Moving from an institutional model of mental health care to a community oriented system of care has long been recognized as desirable because of the improved health and social outcomes generally achieved by avoiding institutionalization, and the enhanced stimulation possible in the community. But providing local comprehensive community care is a complex task, and while it is relatively straightforward to plan and implement small-scale demonstration projects, it is very challenging to undertake systematic implementation of such projects across a whole country. National implementation of a community mental health service network across a country as large, populous, and geographically and socially diverse as China is a vast undertaking. The many challenges include political engagement, public and professional support, mobilization of financial and human resources, dedicated training tailored to specific roles, quality assurance, supervision, and monitoring.[1]

One of the key success factors in the 686 Program in China described by Professor Ma[2] was probably the engagement of the government right from the start. The world contains many worthy demonstration projects which are never generalized or rolled out nationally, at least partly because the local government was not engaged at an early stage, did not have a role in designing and planning the project, and, thus, had no ownership of the process.

A further success factor has been the availability of additional funds to cover the double running costs while the transition is made from institutional care to community care. The program has evolved during a time of economic growth for China so it has been possible to continue support for inpatient services while providing new funding for the development of community services. The danger is that the new funding may dry up if the economy slows, which could happen as the population ages and there are fewer young workers to drive economic expansion. This occurred in Tanzania where an excellent collaborative program[3] between the WHO and the ministry of health stalled when the Tanzanian economy weakened in the 1980s; though the program has now been restarted [4] both on the Tanzanian mainland and in Zanzibar.[5]

Yet another important factor in the initial success of the Chinese model is the multifactorial approach that includes targeted training for professionals, patient registration and initial assessment, free medication and regular follow-up in the community, management of community emergencies, and free emergency hospitalization. Moreover, the stated emphasis on individuals' social functioning and recovery will, hopefully, result in enhanced social inclusion and a greater contribution of rehabilitated patients to the economy.[6] A similar mental health reform project in Russia included primary care training, specialist training, multidisciplinary teams, and, most importantly, establishment of municipal and oblast (state) level intersectoral committees to promote service development and interagency collaboration on mental health.[7]

Further questions about China's evolving community mental health program that occur to the interested international reader include:

What proportion of the service providers in the community are newly trained and what proportion are individuals who moved from institutions to the community?

Why does the program only focus on severe mental illness? Why not include common mental disorders such as depression, anxiety and somatization? Other countries have found it crucial to address the common mental disorders as part of comprehensive mental health reform.[8]–[10]

What is the training offered to primary care staff and how do primary care and secondary care services inter-relate?

What data is being collected in the health management information system and how is it used?[11]

How are community mental health teams structured and deployed?

How are the small numbers of individuals who need round-the-clock nursing care looked after in the new system? Are there hostels, supported housing or similar settings to provide services for these individuals? And how is the care of mentally disordered offenders organized?

What prevention programs are being run in the community, in schools, in prisons, and in orphanages?[12]

Are there difficulties in ensuring a consistent supply of needed medications and, if so, how are they being addressed? Some countries still struggle with ensuring a reliable supply chain of basic psychiatric medications.

If the public health burden of mental illness is to be tackled effectively, it is necessary for governments to adopt a strategic approach that encompasses much more than just curative services for acutely ill people.[1] Most countries have historically focussed their policy efforts on the specialist services, a narrow approach that ignores the complexity of the overall mental health care system—a system that encompasses many different agencies which come into contact with people with mental illness. The interconnectedness of these agencies means that any change in the pattern of patient flow through the system will have effects on multiple services providers. For example, it is very difficult to resettle people with severe mental illness in the community if the stigma surrounding people with mental illness is not tackled through public education in schools and communities. Similarly, it is impossible for relatively scarce specialists to focus on people with severe mental illness if they are required to treat the large numbers of individuals with relatively mild conditions because primary care services aren't providing care for these individuals.

The three broad tasks for any country hoping to upgrade their community mental health services are a) community action to promote mental health; b) prevention and prompt and efficient treatment of common mental disorders in primary care settings; and c) specialist services (as local as is affordable) to support those clients in greatest need and to support and sustain expertise in primary care. It looks to this reader as if the China project has undertaken the first and third tasks but is not directly addressing the second task. If this perception is correct, China now needs to promote a rapid expansion of the treatment of common mental disorders in primary care settings. If this does not occur there is a danger that the specialist services will be overwhelmed as increasing numbers of individuals with less severe conditions seek care.

The success or failure of the nation-wide dissemination of this very large demonstration project will depend on several crucial issues. To what extent has the considerable manpower needs of the project been embedded in the planning and development of the human resources in the country? How much have these mental health issues become integrated into the basic and continuing education for mental health staff, primary health care staff, teachers, police and so forth? How invested are professional bodies and educational institutions in the promotion of this new approach to mental health care? Is there a mechanism for quality assurance, accreditation and inspection of the institutions that are providing these community based services? And are there mechanisms for learning from mistakes and successes and, based on these lessons, for fine-tuning the strategy?