Ukrainian mental health services and World Psychiatric Association Expert Committee recommendations

On Oct 19, 2017, the Parliament of Ukraine initiated health reform by adopting the Law of Ukraine on government financial guarantees of public medical services.¹ The first phase of the reform, in 2018, focused on primary health care, the eHealth system, and creation of the National Health Service of Ukraine. The second phase, addressing secondary and tertiary care, was launched on April 1, 2020. Before the reform, regional health departments could decide how much funding from the state health budget should go to mental health services in each region. From April, 2020, mental health services entered into an agreement with the National Health Service individually.² The changes resulted in severe budget cuts for most of the state psychiatric hospitals. Ukraine has a population of about 44·6 million, of whom 1 847 113 (4%) received mental health care in 2018. 1 499 239 patients attended outpatient services, 308 735 patients were treated in psychiatric hospitals, and 39 139 attended day hospitals.³

To study the emerging difficulties in mental health-care service delivery related to these changes, the Ukrainian Psychiatric Association did a survey. Invitations were sent by email to all 25 regional health departments, except the Crimea and parts of the Lugansk region, because they are not under control of the Ukrainian authorities. Regional health departments were asked to forward the invitation to directors of mental health services (including inpatients, outpatients, and day-care services) in their region. Non-responders were followed up by telephone call.

From April 8–16, 2020, representatives of 53 mental health services from 21 regions of Ukraine completed the online survey. No information was received from four regions (Chernivtsi, Lugansk, Poltava, and Sumy). The results of the survey indicated that funding for psychiatric hospitals provided by the National Health Service for the period from April 1 to Dec 31, 2020, was reduced by 50·25% compared with the same period in 2019. Service providers estimated that these financial cuts could lead to the loss of 3164 full-time equivalent positions, of whom 2485 would be health-care specialists (197 doctors, 661 nurses, 1237 nurse assistants, and 390 other specialists, including psychologists and social workers). In addition, 785 workers had already been shifted from full-time to part-time employment, including 169 doctors, 188 nurses, 309 nurse assistants, and 119 other specialists.

In May, 2020, the Ukrainian Psychiatric Association (UPA) and the Association of Neurologists, Psychiatrists and Narcologists of Ukraine (ANPNU) approached the World Psychiatric Association (WPA) with a request for assistance. The WPA, in collaboration with the Federation Global Initiative on Psychiatry, established a WPA Expert Committee to provide recommendations. The members of the committee were selected on the basis of their expertise and knowledge of the situation in Ukraine. The Expert Committee met weekly for 5 weeks using online conferences.

The WPA Expert Committee noted that the second phase of the health reform had not been properly prepared and implemented when the COVID-19 pandemic reached Ukraine. The first case of COVID-19 in Ukraine was recorded on Feb 29, 2020, and by July 3, there were 46 763 confirmed cases and more than 90 000 suspected cases, with 6874 confirmed cases among health-care workers.

The WPA Expert Committee made six recommendations.

First, a regular consultation process between the Ministry of Health and the professional psychiatric associations (UPA and ANPNU) should be initiated.

Second, Ukraine adopted the concept for the development of mental health for the period up to 2030 on Dec 27, 2017.⁴ The concept proposed a national mental health action plan. This plan has been developed but not yet approved by the Government of Ukraine.⁵ The national mental health action plan needs to be adopted and used as a basis for future consultations to support implementation and commitment by all stakeholders, including representatives of all mental health-care professions, as well as consumers and their relatives and care providers.

Third, a financing mechanism should be put in place that allows the continuation of in-patient care while community services are being developed (twin-track approach). A gradual reduction or phasing out of beds would result in a step-by-step transfer of finances to these newly established services.

Fourth, specialist multidisciplinary teams should be set up to form the backbone of community-based mental health-care services. These teams need to be properly trained and resourced before the process of deinstitutionalisation is rolled out nationally.

Fifth, international guidelines and obligations and human rights commitments need to be adhered to.

Sixth, independent advocacy for each service user should be established and available to ensure that their interests are meaningfully represented by someone who is impartial to both the institution and the person's social circle, yet is fully committed to their wellbeing and the upholding of their right to liberty at all times.

Seventh, phasing in of modern technology—eg, e-health and m-health applications, easily accessible mental health websites for the general public, and e-learning materials in the context of sustainable training programmes—should be considered.

Furthermore, the WPA Expert Committee suggests that both Ukrainian member associations should keep the WPA informed and request specific follow-up advice when necessary to monitor the provision of treatment and care for people with mental illness in Ukraine.