Background
Methods
Type of need [26] | Method(s) | Data source(s) | Inclusion and exclusion criteria |
---|---|---|---|
(1) Comparative need (gap between what services exist in one area and what services exist in another) | (1) Country comparison between Moldova, the South-Eastern European Health Network (SEEHN) countries and the EU 15 average on mental health system indicators | Indicators inform on the mental health system and data is available from 2014/2011 from Moldova, (some of) the SEEHN countries and the EU15 average | |
(2) Normative need (what the expert or professional, administrator or social scientist defines as need) | (2.1) Document review providing an overview of the existing mental health services structure in Moldova in comparison with the norms on the optimal mix of services described by the WHO in the ‘pyramid framework’ | (2.1) National policy documents (n = 5), reports (n = 6), international reports (n = 10), and service provision- and usage data from the Moldovan National Health Management Centre (NHMC) from 2014 | Documents inform on the mental health services structure in Moldova and are written in English between 2007 and 2015 |
(2.2) Content analysis using ‘a priori’ and open coding of interview (n = 23) and qualitative survey data and descriptive analysis of 5-point Likert scale question (n = 70) from professionals involved in the mental health services reform (n = 93) | (2.2) Semi-structured interviews (n = 23) with implementation team members (ITM) (n = 11), health care managers (HCM) (n = 12), and surveys with predominantly open-ended questions among health care practitioners (HCP) (n = 70) collected between May and October 2017 | Professionals involved in the reform as ITM, HCM or HCP1. ITM if they were part of the international MENSANA project team or the local project implementation unit (PIU). HCM and HCP if they worked in their position for at least 3 months in the pilot districts (Soroca, Orhei, Cimislia and Cahul), or in one of Moldova’s three psychiatric hospitals (Chisinau, Balti and Orhei) | |
(3) Felt need (what the population feel they need) | (3) Content analysis using ‘a priori’ and open coding of qualitative survey data and descriptive analysis of 5-point Likert scale question from service users and carers who use the services part of the in the mental health services reform (n = 52) | (3) Surveys with predominantly open-ended questions among service users (n = 23) and carers (n = 23) collected in July 2017 | Service users and carers older than 18 who received care from community mental health care centres (CMHC’s) in the pilot districts (Soroca, Orhei, Cimislia and Cahul), or in one of Moldova’s three psychiatric hospitals (Chisinau, Balti and Orhei) |
Comparative need based on a country comparison
Normative need based on WHO norms and the perspective of professionals
Soroca (%) | Orhei (%) | Cimislia (%) | Cahul (%) | Balti (%) | Chisinau (%) | Total (%) | Male (%) | Average age | |
---|---|---|---|---|---|---|---|---|---|
Surveys | |||||||||
(1) Health care practitioners (HCP) | |||||||||
District HC’s | 5 | 5 | 4 | 5 | 5 | 24 | 2 | ||
CMHC’s | 7 | 6 | 6 | 4 | 23 | 2 | |||
Mental hospitals | 3 | 10 | 10 | 23 | 6 | ||||
Total | 12 | 14 | 10 | 9 | 10 | 15 | 70 (48.27) | 10 (14.28) | 44 |
(2) Service users | |||||||||
CHMC level | 6 | 3 | 5 | 5 | 19 | 9 | |||
Mental hospital level | 3 | 3 | 4 | 10 | 4 | ||||
Total | 6 | 6 | 5 | 5 | 3 | 4 | 29 (20) | 13 (44.82) | 45 |
(3) Carers | |||||||||
CMHC level | 4 | 3 | 5 | 2 | 14 | 3 | |||
Mental hospital level | 2 | 2 | 5 | 9 | 3 | ||||
Total | 4 | 5 | 5 | 2 | 2 | 5 | 23 (15.86) | 6 (26.08) | 53 |
Total surveys | 22 | 25 | 20 | 16 | 15 | 24 | 122 (84.13) | 29 (23.77) | 47 |
Interviews | |||||||||
(4) Implementation team members (ITM) | |||||||||
International | 7 | 4 | |||||||
Local | 4 | 1 | |||||||
Total | 11 (7.58) | 5 (45.45) | 49 | ||||||
(5) Health care managers (HCM) | |||||||||
District HC’s | 1 | 1 | 1 | 1 | 4 | 2 | |||
CMHC’s | 1 | 1 | 1 | 1 | 4 | 2 | |||
Mental hospitals | 1 | 2 | 1 | 4 | 2 | ||||
Total | 3 | 2 | 2 | 2 | 2 | 1 | 12 (8.27) | 6 (50) | 47 |
Total Interviews | 6 | 4 | 4 | 4 | 4 | 2 | 23 (15.86) | 11 (47.82) | 48 |
Total participants | 28 (19.31) | 29 (20) | 24 (16.55) | 20 (13.76) | 19 (13.1) | 26 (17.93) | 145 (100) | 40 (27.58) | 48 |
Felt need based on the perspective of service users and carers
Results
Comparative need emerging from a country comparison
Moldova | Albania | Bosnia and Herzegovina | Bulgaria | Croatia | Macedonia | Monte-negro | Romania | Serbia | SEEHN Average | EU 15 average | |
---|---|---|---|---|---|---|---|---|---|---|---|
General information | |||||||||||
% Disability adjusted life years accounted for mental disorders* | 8.03 | 6.82 | 6.68 | 5.06 | 6.72 | 5.92 | 6.99 | 5.43 | 5.9 | 6.39 | 10.25 |
% Prevalence mental disorders* | 17.34 | 14.38 | 15.81 | 14.79 | 15.46 | 14.61 | 14.76 | 14.28 | 14.89 | 15.15 | 18.04 |
Suicide (age-standardized rate per 100,000) ** | 13.8 | NR | 6.2 | 6.9 | 12.3 | 6.8 | NR | 8.8 | 10.6 | 9.34 | 8.94 |
Existence of mental health policy | Yes | Yes | Yes | Yes *** | Yes | Yes | Yes | Yes | Yes | 100% | 93% |
Implementation status | Partial | Partial | Partial | Partial *** | Partial | Partial | Partial | Partial | Partial | None, 0%; Partial, 100%; full 0% | None, 0%; Partial, 46.6%; full 53.5% |
Resources for mental health | |||||||||||
Total health expenditure as % of the GDP (WHO Estimates)**** | 10.3 | 5.9 | 9.6 | 8.4 | 7.8 | 6.5 | 6.4 | 5.6 | 10.4 | 7.87 | 9.83 |
Mental health spending per capita (US$) | 4.77 | NA | 1.89 | NR | NA | NA | NA | NA | NA | 3.33 | 293.72 |
Total no of mental health workers per 100,000 | 65.2 | 13.5 | 23.4 | NR | NR | NR | 35.2 | 36.3 | 21.8 | 32.57 | 127.2 |
No of psychiatrists per 100,000 | 5.92 | 1.32 | 4.00 | NR | NR | NR | 8.69 | 5.97 | 7.35 | 5.54 | 14.1 |
Institutional care | |||||||||||
Total no. of mental hospitals in 2011 (per 100,000)*** | 3 (0.08) | 2 (0.06) | 6 (0.16) | 12 (0.16) | 7 (0.16) | 4 (0.2) | 3 (0.48) | 39 (0.18) | 5 (0.05) | 9 (0.17) | 73.62 (0.27) |
Total no. of beds in mental hospitals in 2011 (per 100,000)*** | 2080 (58.17) | 520 (16.41) | 467 (12.42) | 2705 (36.08) | 3353 (76.04) | 1150 (56.28) | 332 (53.08) | 8107 (38.26) | 3880 (39.37) | 2510.44 (42.90) | 11,021.54 (44.72) |
No. of beds per mental hospital in 2011 *** | 693.3 | 260 | 77.83 | 224.41 | 479 | 287.5 | 110.67 | 207.87 | 776 | 346.40 | 198.2 |
Total no. of mental hospitals in 2014 (per 100,000) | 3 (0.08) | 2 (0.06) | 3 (0.08) | NR | 8 (0.19) | 4 (0.2) | 2 (0.32) | 35 (0.16) | 8 (0.08) | 8.13 (0.15) | 102 (0.21) |
Total no. of beds in mental hospitals in 2014 (per 100,000) | 2070 (59.8) | 490 (15.4) | NR | NR | 3375 (79.0) | NR | 261 (42.0) | 10 950 (50.6) | 3692.67 (39.0) | 3473.12 (47.63) | 13 373.3 (36.61) |
No. of beds per mental hospital in 2014 | 690 | 245 | NR | NR | 421.87 | NR | 130.5 | 312.86 | 461.58 | 376.97 | 184.6 |
Changes (%) in total no. of mental hospitals 2011–2014 (% per 100 000)***** | 0% (0%) | 0% (0%) | − 50% (− 50%) | NR | 14.28% (18.75%) | 0% (0%) | − 33.34% (− 33.34%) | − 10.26% (− 11.12%) | 60% (60%) | − 9.67% (− 11.77%) | 38.5% (− 23.31%) |
Changes (%) in total no. of beds in mental hospitals 2014–2011 (% per 100,000)***** | − 0.49% (2.8%) | − 5.77% (− 6.22%) | NR | NR | 0.65% (3.89%) | NR | − 21.34% (− 20.88%) | 35.06% (32.35%) | − 4.83% (− 0.94%) | 38.34% (11.02%) | 21.33% (− 18.14%) |
Changes (%) in total no. of beds per mental hospital 2014–2011***** | − 0.48% | − 5.77% | NR | NR | − 11.93% | NR | 17.91% | 50.5% | − 40.52% | 8.82% | − 6.8% |
Normative need emerging from a comparison between the existing and ideal mix of services
Long stay facilities and specialist psychiatric services
Community mental health services
Psychiatric inpatient services in general hospitals
Mental health services in PHC
Informal services
Normative need emerging from the perspective of professionals
Deinstitutionalisation and implementation of CBMHS
ITM 6: “Care was mainly offered in the three main hospitals of Moldova in Orhei, Balti and Chisinau. People were institutionalized for long periods of time and there is no service to continue the care in the community. That’s why that after a longer period in the hospital they relapse and come back in a short time because there is nothing to support them in the community.”
HCP 4112: “Cooperation between diverse institutions and social actors will contribute to the multidimensional approach of the beneficiary, a continuation of not only of medical care, but also social and psychological care”.
Re-integration in society, community and family
HCM 11: “People with a mental illness had a lot of different problems and they were marginalized. All problems were more pronounced as result of migration. There are children and parents left who cannot self-manage their money and properties and were at risk of being deprived from what they had.”
HCM 12: “The mental health patients were institutionalized so they spent most of their time in the hospital and nobody wanted to deal with them at home. After hospitalization they went nowhere. Taking into account the difficult economic situation in the country and the attitude of the local government they were in a very poor position (…) Frankly speaking they were not considered as human beings. They were considered as a burden to the society, as if the society did not need them.”
HCP 4262: “(It is needed) to be involved in the beneficiary’s problems such as their living conditions, family and work place”.
Accessibility and quality of services
Governance and finance
ITM 4: “In Moldova the government is responsible for buying medication. They buy a bulk amount and distribute it to the clinics. They have to use that, even if they don’t need to. The government bought a lot of lithium and the expert told me that nobody knew how to use it. Which means that it wasn’t used and as a consequence the government didn’t buy it anymore. So now there is no lithium available in Moldova to treat bipolar patients. Of course, you can argue there are other medications that can be used to do the job, but they won’t be “state of the art”. It also illustrates that the mental health system it is still organized very top down, and the people who are responsible for the decisions, the policymakers and the decision-makers, are often not that medically well informed.”
Health workforce
HCM 9: “Staff problem remain. (…) It is a problem not only faced by the CMHC’s but also by the medical institutions. This problem is different in each institution. One institution faces the shortage of doctors, another institution has a shortage of nurses”.
Felt need emerging from the perspective of service users and cares
Accessibility and quality of services
Service user 7141: “There should be community services because when you feel depressed there should be someone who listens to you, encourages you and helps you.”
Service user 7251: “Of course it is better to stay at home without problems with her son, so she does not have to stay in the hospital. The conditions in hospital are very good, they feed them well, they take them out for walks, the attitude of the doctors and nurses is very good.”
Reintegration in society, community and family
Carer 8124: “People think they will get sick from her daughter. If people come to visit them (at home), they will be rewarded well”.
Carer 8142: “There should be the possibility to have a workplace for patients”.
Deinstitutionalisation and implementation of CBMHS
Carer 8272: “It would be perfect if ambulatory treatment (at home) will be developed because not every case of mental illness needs to be hospitalized. Periodic follow-up of the patient would prevent from worsening situation that leads to hospitalization.”
Medicines and technology
Carer 8251: “They should have the last generation equipment and medicines.”
Health workforce
Carer 8265: “The attitude should change. They should understand that the relatives are not their patients. They (the doctors), consider that only they are right. Also, we don’t have always enough money to give them.”
Overview results comparative, normative and felt need
Type of need [26] | Informed by | Main outcomes |
---|---|---|
(1) Comparative need (gap between what services exist in one area and what services exist in another) | (1) Country comparison | Mental health care remains largely institutionalized evidenced by a far higher number of beds per mental hospital (690) and a higher number of mental hospital beds per 100,000 population (59.8) in 2014 than both the SEEHN (376.97 and 47.63) and EU15 average (184.6 and 36.6). In contrast with an average decline of the number of mental hospitals per 100.000 population both in the SEEHN (− 11.77%) and the EU15 countries (− 23.31%) Moldova has shown no decline in number of mental hospitals between 2011 and 2014 |
(2) Normative need (what the expert or professional, administrator or social scientist defines as need) | (2.1) Comparison Moldovan mental health services structure with norms WHO | The Moldovan mental health services structure shows an inversion of the WHO ‘Pyramid Framework’. In other words, long-stay facilities and specialist services provide the bulk of care, followed by traditional outpatient services, with limited services offered in the community by primary care-, social care- or mental health care professionals. Informal services seem underdeveloped with little to no involvement of community stakeholders |
(2.2) Perspective of professionals involved in the reform including health care practitioners, health care managers and implementation team members | The majority of professionals (82.8%) were in favour of a mental health services reform. A number of issues and reform needs were expressed by the professionals with the most mentioned being the need to (1) deinstitutionalise and implement a CBMHS model with integrated services; (2) reintegrate service users in society, community and family; (3) improve access and quality of services; (4) improve governance and finance; and (5) address health workforce issues | |
(3) Felt need (what the population feel they need) | (3) Perspective of care recipients of services involved in the reform including service users and carers | Almost all care recipients (92.3%) were in favour of a mental health services reform. A number of issues and reform needs were expressed largely in line with the responses of the professionals, but in a different order based on their frequency mentioned with the need to (1) improve the access and quality of services; (2) reintegrate in society, community and family; (3) deinstitutionalise and implement CBMHS; (4) address problems with medicines and technology and (5) address health workforce issues |