Scientific Justification of the Main Directions for Improving the Regional Mental Health Service (Based on the Example of Sverdlovsk Oblast)

The dissertation is devoted to the scientific justification of the main directions for improving the regional mental health service based on the example of Sverdlovsk Oblast. It examines current problems of psychiatric service development in Russia and abroad, and analyzes the impact of a complex of medical-organizational, socio-economic, and demographic factors on the mental health of the population. An organizational structure and technological model aimed at improving the efficiency and quality of the activities of the regional psychiatric service are developed.

The work conducts a comprehensive analysis of the epidemiological situation, including trends in the spread of mental and narcological diseases, and evaluates the medical-economic efficiency of the activities of major psychiatric institutions. A strategic program for the protection of population mental health at the regional level has been developed, and a system for controlling the quality of medical care has been implemented. The results of the research have been used in the formation of regional target programs and methodological documents in the field of healthcare.

The health of the population, including mental health, is one of the key indicators of the well-being of society and the state. The rapid acceleration of scientific and technological progress characteristic of the late 20th to early 21st century, and the associated changes in living conditions, impose higher demands on the intellectual activity of the individual, thereby elevating the issue of mental health to one of the foremost positions among the factors determining the economic potential of a country and its national security [168].

Data from WHO reports (1996, 1999, 2001) indicate a high burden of mental and narcological diseases in the majority of countries. It has become evident that this problem was previously underestimated and that decisions adopted were not fully implemented [207]. According to WHO experts, more than 40% of countries in the world have no policy whatsoever in the field of mental health care [77].

Radical socio-economic reforms carried out in Russia in the early 1990s contributed to a sharp increase in the incidence of mental disorders, the spread of alcoholism and drug addiction [184, 207], while the social instability and economic crisis characteristic of that period severely reduced the capacity of the psychiatric service. The system of psychiatric care in the USSR was one of the most developed in the world; however, under the new socio-economic conditions, many of its shortcomings became apparent, the principal ones being an extensive development path, an emphasis on inpatient treatment at the expense of outpatient care, low operational efficiency, and others. This led to a reduction in the resources of the psychiatric service, and it became evident that the organizational model created could function successfully only under centralized budget financing [207].

Under conditions of the increasing development of market mechanisms in the national economy, the paradigm shift in the delivery of psychiatric care makes it an urgent task to justify, develop, and practically implement new models of organizing psychiatric service that take into account the specific features existing in different regions of the country and make it possible to ensure accessibility and quality of the services provided [55, 207].

An important instrument for addressing this task is strategic planning [116]; however, in Russian healthcare and the psychiatric service, which remains the most difficult subsector to reform, this management system has not received adequate development. There are also very few studies devoted to the development of technologies for preparing strategic plans to address large-scale medical and social problems at the level of a region and a large municipal entity [139, 185].

One of the principal tasks facing the psychiatric service is the optimization of its financial support and the improvement of the efficiency of utilizing available resources [96, 122–159, 197, 207]. This task becomes especially acute as a result of the emerging course of healthcare system reforms aimed at enhancing the legal and economic independence of medical and preventive care institutions [161]. Despite a large number of studies on various aspects of this problem in healthcare, it remains very poorly developed, including in the field of psychiatry.

A similar situation is observed with respect to improving the quality of medical care. The development and active implementation of a quality control system in healthcare is still poorly utilized by psychiatric service institutions.

Thus, the problem of justifying and developing organizational models of regional mental health services that are adequate to the socio-economic conditions existing in the country and correspond to the modern doctrine of organizing psychiatric care is urgent, and its resolution should be based on a systemic approach and rely on the methodological base of such scientific disciplines as healthcare organization, economics, mathematics, and others.

The objective of the research is the scientific justification of the main directions for optimizing the activities of mental health care provision in a subject of the Russian Federation through the development of an organizational structure and technological model for improving the efficiency and quality of the activities of the regional psychiatric service.

The objective of the research is the scientific justification and development of the main directions for optimizing the regional psychiatric service based on the principles of strategic planning and inter-agency cooperation.

To achieve the stated objective, the following research tasks were set and resolved:

1. To study and summarize the experience of psychiatric service development in Russia and abroad.

2. To conduct a comprehensive analysis of the main indicators of mental health among various population groups in Sverdlovsk Oblast and to develop a forecast of their change over the next five years.

3. To study the network, structure, and medical technologies of municipal and oblast psychiatric and narcological institutions in Sverdlovsk Oblast.

4. To conduct a systemic analysis of the impact of a complex of socio-economic, demographic, and medical-organizational factors on the mental health of the population of Sverdlovsk Oblast. To provide a forecast of the effectiveness of various management interventions through a mathematical model.

5. To analyze trends in the financial support of the regional psychiatric service.

6. To investigate and conduct an expert evaluation of the medical-economic efficiency of activities of major psychiatric institutions in the region and the structural units of the oblast hospital.

7. To develop and implement a system for assessing the quality of medical care in the oblast psychiatric hospital.

8. To justify and develop the main directions for improving the regional mental health service and to evaluate the effectiveness of implementing programmatic measures.

Scientific Novelty of the Research

A methodology for a systemic approach to justifying the management of population mental health at the level of a federal subject has been developed and piloted.

A comprehensive characterization of the mental health status of the population of an industrial region of the country has been obtained for the first time, along with forecasts of its change through 2005. A typology of municipal entities in Sverdlovsk Oblast by level of mental health and by factors influencing it has been developed.

It has been demonstrated that the use of "integral" indicators makes it possible to obtain a generalized picture of the health status of the population of municipal entities, the potential of the psychiatric service, and the level of socio-economic development of territories.

For the first time, through the methods of multivariate analysis, it has been established that the level of mental health of the population of municipal entities in the region depends on a complex set of causes of a socio-economic, medical-organizational, and demographic nature. The most significant among them is the level of development of the psychiatric service. A forecast of the effectiveness of various measures aimed at improving mental health has been provided through a mathematical model.

A comprehensive analysis of organizational and economic problems arising in the sphere of management at the current stage of healthcare development has been conducted using the example of the psychiatric service of Sverdlovsk Oblast. For the first time, a comprehensive study of the efficiency of medical-economic activities of major psychiatric hospitals in Sverdlovsk Oblast and the inpatient departments of the oblast hospital has been carried out.

The possibilities of the developed quality control system for psychiatric care have been investigated.

A strategic program for the protection of population mental health at the regional level has been developed, and an assessment of the medical-social effectiveness of its first stage of implementation has been made.

Practical Value and Implementation of Research Results

On the basis of the conducted research, a scientific justification has been provided for the main directions of the strategic program for the development of the psychiatric service of Sverdlovsk Oblast.

Technologies for evaluating the efficiency of medical and economic activities of psychiatric hospitals and their structural units have been piloted and implemented in practice. A computerized quality control system for medical care has been introduced in the oblast hospital.

Materials of the dissertation have been used:

• in methodological letters of the Ministry of Health of the Russian Federation;

• in methodological recommendations for administrations of municipal entities in Sverdlovsk Oblast;

• in methodological recommendations of the Ministry of Health of Sverdlovsk Oblast;

• in methodological guidelines for extramural preparation for practical classes for students of the general medical faculty of the Ural State Medical Academy;

• in the formation of the "Territorial Program of State Guarantees for Providing Free Medical Care to Citizens of the Russian Federation Residing in the Territory of Sverdlovsk Oblast" for 2001, 2002, and 2003;

• in the development of the oblast state target program "Healthcare Development in Sverdlovsk Oblast for 2002" (Resolution of the Government of Sverdlovsk Oblast dated 05.07.2001 No. 470-pp) and "Healthcare Development in Sverdlovsk Oblast for 2003" (Resolution of the Government of Sverdlovsk Oblast dated 31.07.2002 No. 1125-pp);

• in the formation of the oblast state target comprehensive program "Counteracting Drug Abuse and Their Illegal Circulation in Sverdlovsk Oblast for 2002–2004" (Resolution of the Government of Sverdlovsk Oblast dated 28.08.2001 No. 594-pp); in the development of the "Concept for Healthcare Development in Sverdlovsk Oblast for 2003–2010," approved by Resolution of the Government of Sverdlovsk Oblast dated 03.04.2003 No. 179-pp; in the development of measures for Stage 2, "Development of the Structural Model of Psychiatric Care," of the regional target program of Sverdlovsk Oblast "Mental Health" (Resolution of the Government of Sverdlovsk Oblast No. 1016-pp); in the preparation of Order No. 15-pp of the Ministry of Health of Sverdlovsk Oblast dated 16.01.2003, "On the Organization of Work on Fulfilling the State Order by Municipal Medical and Preventive Care Institutions Performing the Functions of Inter-District Specialized Centers for Providing Medical Assistance to Non-Resident Patients for Socially Significant and Costly Types of Care"; in the preparation of Order No. 86-pp of the Ministry of Health of Sverdlovsk Oblast dated 26.02.2002, "On Measures to Improve the Organization and Raise the Quality of Psychiatric Care for the Population of Sverdlovsk Oblast"; in the preparation of Order No. 83-pp of the Ministry of Health of Sverdlovsk Oblast dated 17 February 2003, "On Measures to Improve the Organization and Raise the Quality of Narcological Care for the Population of Sverdlovsk Oblast";

• in the formation of the program for providing medicinal substances to citizens suffering from socially significant diseases at the outpatient stage;

• in the development by the Ministry of Health of Sverdlovsk Oblast and the Territorial Fund of OMS of the oblast target program "Reforming Outpatient and Polyclinic Care."

Dissemination of Dissertation Results

Materials of the dissertation were presented and discussed at international symposia, seminars, and conferences devoted to issues of psychiatric and narcological care: "Harm Reduction Programs" (England, Jersey Island, 2000); "Organization of Psychiatric and Narcological Care" (Luxembourg, 2001), "Rehabilitation in Psychiatry" (Czech Republic, Prague, 2002); the oblast scientific-practical conference "Modern Methods of HIV Infection and Drug Addiction Prevention" (Yekaterinburg, 2001); the Russian scientific-practical conference "On Measures to Improve Medical Care for Patients with Acute Poisonings" (Yekaterinburg, 2002); the XII All-Russian Working Meeting on Forensic Psychiatry "Practical Questions of Organizing the Forensic Psychiatric Service of the Country" (Yoshkar-Ola, 2003); the All-Russian meeting of leaders of healthcare management bodies of subjects of the Russian Federation "Current Questions of Organizing Outpatient and Polyclinic Care for the Population of the Russian Federation" (Yekaterinburg, 2003); the V All-Russian Conference on Emergency Medical Care "Problems of Interaction Between Pre-Hospital and In-Hospital Stages of Emergency Medical Care and Their Resolution in a Large City" (Yekaterinburg, 2003); the symposium "First Psychotic Episode: Organizational and Clinical-Therapeutic Problems" within the framework of the All-Russian Conference "Affective and Schizoaffective Disorders" (Moscow, 2003); the Regional Medical Association "Healthcare of the Urals" (Shadrinsk, 2001; Tyumen, 2002); the Association of Psychiatric and Narcological Institutions of the Urals (Nizhny Tagil, 2003; Miass, 2003); sessions of the Oblast Duma, Government of Sverdlovsk Oblast, collegiums, and medical councils of the Ministry of Health of Sverdlovsk Oblast; academic councils of the Ural State Medical Academy (2001, 2002).

The dissertation defense took place at a joint scientific conference of the departments of public health and healthcare with a course in economics of the Medical Faculty, healthcare organization with a course of medical statistics and informatics of the Faculty of Advanced Training, healthcare management of the Faculty of Advanced Training, the laboratory of functions and methods of healthcare management, the laboratory of standardization, licensing, and accreditation issues of the Research Institute of Public Health and Healthcare Management of the I.M. Sechenov Moscow Medical Academy (protocol No. 24 dated 19 May 2004).

Thirty works have been published on the subject of the research, including two monographs, four methodological letters of the Ministry of Health of the Russian Federation, and four publications in central Russian publications.

Positions for Defense

1. Socio-economic transformations in the country have contributed to the deterioration of the mental health of the population, which has been expressed in an increase in the prevalence indicators of mental disorders, primarily of non-psychotic origin.

2. The level of mental health of the population is formed under the influence of a complex set of medical-organizational, demographic, and socio-economic factors, among which the most important role belongs to the organization of the psychiatric service.

3. The medical and economic efficiency of the activities of psychiatric hospitals in Sverdlovsk Oblast and their structural units is directly dependent on the level of resource provision and the degree of preparation of management personnel on issues of management and economics in healthcare.

4. A multi-level system of quality control for psychiatric care makes it possible to ensure the rights of patients and reduce the number of defects in the provision of medical and diagnostic services.

5. The most important principles of reforming the regional psychiatric service are: a systemic approach and inter-agency cooperation; the combination of organizational, economic, and technological changes; monitoring at each stage of implementation. The main directions for improvement are ensuring the accessibility and quality of medical and medical-social care, and improving the efficiency of managing the primary resources of the psychiatric service.