China's National Comprehensive Management Pilot Project for Mental Health.

The National Continuing Management and Intervention Programme for Psychoses, also known as the 686 Programme, was launched in China in 2004, marking a shift to a hospital-and-community collaborative model of care for patients with psychoses. An updated programme, the National Comprehensive Management Pilot Project for Mental Health, was launched in 2015 with the cooperation of six government ministries and bodies, including the China Disabled Persons Federation. Mechanisms for multi-sector cooperation in mental health services are being put in place in China.

Historical background: the 686 Programme

In 2004, the Ministry of Health and Ministry of Finance of the People’s Republic of China launched the National Continuing Management and Intervention Programme for Psychoses, also known as the 686 Programme, with an initial annual funding of ¥6.86 million (Liu et al, 2011), which signified the official inclusion of mental health services in the public health system. The 686 Programme aims to address the current problems of discontinuous care and lack of cooperation between hospital and community services in terms of the management, treatment and rehabilitation of patients with psychoses. In 2005, 60 demonstration pilot sites (one urban site and one rural site in each of 30 provinces, municipalities and autonomous regions) around the country were selected to initiate the 686 Programme. Psychiatric hospitals provided outreach services for patients with psychoses who lived in the community. Before 2004, China’s community-based mental health system had been largely eliminated with the introduction of the market economy. Mental health service provision became primarily hospital based (Liu et al, 2011).

At that stage, the running of the 686 Programme was the responsibility at all levels of health administrative departments and psychiatric hospitals or centres of disease control and prevention. Generally, though, psychiatric hospitals provided follow-up services and guidance on treatment and rehabilitation for patients in the community. However, in some demonstration pilot sites with limited resources, community physicians were trained to take on that responsibility.

By the end of 2008, about 100 000 patients had benefited from the 686 Programme and experience had been accumulated on how primary healthcare facilities can provide community-based services to patients with psychoses. In 2009, this service for patients with psychoses was included in the National Basic Public Health Services Project, which aims to provide basic public health services for every citizen. Basic public health services cover the management and treatment of only a few diseases that are prioritised by the government (e.g. hypertension). In terms of services for patients with psychoses, primary healthcare facilities were responsible for screening, registration, information filing and follow-up. Psychiatrists usually provide technical guidance to community physicians and emergency treatment for patients, instead of following up patients in the community personally. With that, a shift to a hospital–community collaborative model of care delivery has been realised.

Such a collaborative model re-establishes the roles of the mental health specialists as trainers, supervisors and tertiary-care providers, while transferring the responsibility for direct service delivery to community health workers or primary-care professionals, who are trained and supervised for mental healthcare.

Since then (2010–2011), healthcare coverage for patients with psychoses has increased rapidly (Ma, 2012). By the end of 2011, over 1.87 million patients had been included in the 686 Programme. Huge progress was made in promoting the Programme. It has managed to speed up the implementation of relevant health policies, especially policies on medication, insurance or medical aid, in different provinces and districts. For example, patients with psychoses in Beijing and Changsha were able to get free medication in clinics (Good & Good, 2012).

Challenges

Over 4.3 million patients with psychoses had been registered in the 686 Programme by the end of 2014. However, a number of challenges that are difficult for the health sector to handle alone also surfaced. For example, ‘relocking’ of patients at home (meaning that patients were held at home behind locked doors) happened because of ‘the unavailability of [a] capable care-giver and financial difficulties’ (Guan et al, 2015). Moreover, community rehabilitation agencies established by the China Disabled Persons Federation (CDPF) generally provide rehabilitation services only for patients with physical disabilities. Community rehabilitation services for patients with psychoses in most provinces, especially in areas with limited healthcare resources, are very scarce. Driven by 686 Programme, there was a variety of medical care and living assistance services for poor patients. However, since these policies spread across multiple sectors (such as health, civil affairs and the CDPF), and the procedures for cross-departmental collaboration are complicated, it was hard for patients to get medical care and living assistance from all the related sectors.

National Comprehensive Management Pilot Project for Mental Health

To address the current challenges of China’s mental health services, an updated programme, named the National Comprehensive Management Pilot Project for Mental Health, was launched in 2015 with the cooperation of six national government ministries and bodies: the Central Comprehensive Management Office; the Ministry of Civil Affairs; the Ministry of Public Security; the Ministry of Human Resources and Social Security; the National Health and Family Planning Commission; and the CDPF. Each of the 30 provinces (except Tibet) in mainland China was asked to select one city to carry out the programme, with extra funds from central government.

The National Comprehensive Management Pilot Project for Mental Health has seven goals:

improving service delivery mechanisms

increasing rates of treatment

establishing and improving the rehabilitation system

improving medical insurance and medical assistance

strengthening the mental health workforce

improving services for people with common mental disorders

actively supporting and guiding civil organisations to participate in mental health services.

The significance of the Project lies in the key elements of ‘comprehensiveness’ and ‘innovation’. ‘Comprehensive’ has two aspects in dealing with mental health: first, it means providing comprehensive services for patients with mental illness, including diagnosis, treatment, rehabilitation and life assistance; second, it also refers to the provision of multi-sectoral services. Under the Project, for the first time six sections at national, provincial, municipal, county and township levels are actually working together as a team for patients with psychoses.

One of the most important objectives is to improve the mechanisms of service delivery. The Project aims to establish an integrated services delivery mechanism for the comprehensive management of mental health at municipal and county level, with the government playing the leading role, different departments cooperating and society participating. Each municipal and county government that is selected as a pilot site will establish a coordinating group, whose key tasks are to devise a cooperating mechanism and to identify the core responsibilities and tasks of each ministry or sector. At least 70% of the townships should establish a community care support team (CCST), including officers from the community committee, civil affairs, the CDPF, police and primary healthcare facilities. Each of these CCSTs is responsible for developing a specific management process to enhance the mental healthcare coverage for patients, identifying their responsibilities and holding a regular meeting at least every 3 months. After getting consent from the patient and the family, the CCST members at the township level meet together to discuss the whole family situation, including the patient’s health condition, rehabilitation situation, the family’s economic status, the difficulties the family has encountered and insurance coverage. Through discussion, the team jointly provides different aspects of assistance for patients, such as healthcare, financial support and employment. The CCST provides multi-sector services based on the needs of patients and their families. The regular meetings will promote cooperation among different departments and help them tailor and improve their management and service delivery mechanisms for patients with psychoses.

Another important goal of the Project is to reduce patients’ out-of-pocket medical expenses. It presents a clear vision to keep the out-of-pocket medical payment for both out-patients and inpatients under 10%. The selected cities need to strengthen the convergence of basic medical insurance and various types of medical aid. Departments related to medical insurance cover should communicate and cooperate to ensure that patients with psychoses can be reimbursed in a convenient and effective way. For example, Ningbo, an economically developed city of Zhejiang Province, integrates the policy resources between civil affairs, human resources and social security, the Health and Family Planning Commission and the CDPF through an electronic information system. Patients can obtain real-time reimbursement of medical expenses by using an electronic card. By way of another example, Tianshui, an economically less developed city of Gansu Province, integrates the various policy resources of different sectors, so that medical expenses are reimbursed in the psychiatric hospitals. Patients do not need to go to separate departments to get medical aid, as was the case before. Staff at the psychiatric hospitals will regularly go to different departments to reimburse hospital costs.

There are some limitations to the Project. For example, it only suggested some measures and has not fully explored concrete measures to complete each goal effectively; further, it does not take into account the disparities in mental health management between city and rural areas.

Conclusion

In recent years, by the endeavours of central and local governments in China and mental health professionals, access to, and the quality of, the mental health system have been improved gradually (Xiang et al, 2012). The National Comprehensive Management Pilot Project for Mental Health is one of these continuing efforts. It will improve the multi-sector planning and resource allocation with local priorities; and enhance the political will to support policy making, training and infrastructure development as explicit priorities at the national and regional levels.

Mental health services in China prioritise two main objectives: (1) the care of patients and (2) social harmony. For patient care, we still need to improve services related to identification, assessment, treatment and rehabilitation. In terms of maintaining social harmony, it will be more conducive for the health sector to work with other sectors. It will urge local government to devote more resources to mental health services.

China’s National Mental Health Working Plan (2015–2020) is a major public health initiative to address vital social issues affecting the economic and social development of the country. Strengthening mental healthcare is important for the development of the health system, the maintenance and promotion of people’s physical health and mental health, and the promotion of social harmony and stability. For various historical reasons, mental health services had been a low priority in China (Xiang et al, 2012). However, the situation is changing. Strengthening mental health services and focusing on the prevention and control of mental disorders was proposed in China’s National Economic and Social Development Plan (the 13th 5-year plan, 2016–2020) for the first time. Although there are still many challenges to be addressed, China’s mental healthcare has ushered in its spring.