The European Journal of Public Health Advance Access originally published online on March 8, 2006
The European Journal of Public Health 2006 16(3):246-251; doi:10.1093/eurpub/cki092
Conflict, Disaster, Homicide |
Mental health reform in post-conflict areas: a policy analysis based on experiences in Bosnia Herzegovina and Kosovo
Albert K. De Vries1 and Niek S. Klazinga2
1 Ministry of Justice, The Hague, The Netherlands
2 Department of Social Medicine, Academic Medical Centre, University of Amsterdam, The Netherlands
Correspondence: Albert K. de Vries, Tweede Boomdwarsstraat 6-E, 1015 LK Amsterdam, The Netherlands, tel: +31 20 3206800, fax: +31 70 3703145, e-mail: albertodevries{at}yahoo.co.uk
Received June 15, 2004, accepted February 28, 2005
This policy analysis provides insight into the ongoing process of mental health reform and the difficulty of sustaining such reform in post-conflict areas. It is based on experiences in Bosnia Herzegovina and Kosovo in the former Yugoslavia.
This could be the first health policy analysis specifically on the subject of mental health reform in post-conflict areas.
Mental health reforms started in 1995 in Bosnia Herzegovina and in Kosovo in 1999, immediately following the end of armed conflict in these regions. As a result, there are now sufficient literature studies and experience available in both areas to make an initial evaluation and policy analysis.
Both areas were studied during various stages of the implementation of mental health reform, and because of this provided insight into the different phases of this ongoing process.
The insights provided by this study could have implications for things such as the development of strategies for improving the sustainability of mental health reform in similar situations in future.
Mental health problems account for five of the 10 leading causes of disability worldwide, which amounts to 12% of the total global burden of disease.1 In general, war-related disabilities (physical injuries) and mental disorders have an increasing impact on the global burden of disease. Projections for 2020 rank unipolar major depression and war-related disabilities in first and eighth place, respectively, in their impact on the global burden of diseases; in 1990 they ranked fourth and sixteenth.1
Mental health reform refers to a shift from institutional mental health care towards community mental health and mental health care. The WHO's World Health Report 2001 showed worldwide interest in community mental health care, considered to be more cost-effective than institutional care. Care of this kind makes it possible to intervene early when mental disorders are developing, and to limit the stigma attached to treatment.2,3 This shift from institutional mental health care towards community mental health and mental health care marks an important change in the whole of Eastern Europe and the former Soviet Union.4,5
Mental health reforms in the post-conflict areas of Bosnia Herzegovina and Kosovo have specific characteristics and dynamics, and are taking place within the context of huge foreign donor influence, overall health care reforms and reform of health care financing systems.
There are many definitions of sustainability.6 Sustainability is defined here as a lasting, successful shift from a system where the main focus is on institutional, clinical mental health care to a system focusing on community mental health and integrated mental health care. The successful continuity of these new services also depends on cultural and financial characteristics.
The following examples illustrate the difficulty of sustaining mental health reform in Bosnia Herzegovina and Kosovo:
- Planned community mental health centres are being implemented slowly.7–10
- The general public is unaware of the mental health reforms and does not understand them.8–10
- There are increasing problems of economic access to mental health care and services.11–14
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Materials and methods |
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Data collection
Literature study of ‘grey’ policy documents and articles on health policy (including mental health policy) in Bosnia Herzegovina and Kosovo was undertaken.
Policy documents were collected from many different actors such as the World Bank, several non-governmental organizations (NGOs) including Médecins Sans Frontières, HealthNet International (HNI) and the International Organization for Migration, the WHO, the United Nations High Commission for Refugees, key mental health and other health professionals and local ministries of health.
Key informant interviews
For Bosnia Herzegovina, key informant interviews took place in August 2001 with:
- Various mental health and other health professionals (psychiatrists, psychologists, nurses and social workers) and patients in 15 mental health institutions, including university hospitals with psychiatric departments, psychiatric clinics, psychiatric wards of general hospitals and community mental health centres all over Bosnia Herzegovina;
- Several NGOs (HNI, Medica Zenica, Vive Zene and War Child);
- WHO office for Bosnia Herzegovina;
- International Committee of the Red Cross;
- Swiss Agency for Development and Cooperation, Coordination office Sarajevo, Embassy of Switzerland;
- Assistant Minister of Human Rights of the state of Bosnia Herzegovina;
- Entity Ministry of Health of the Republika Srpska.
- WHO office for Bosnia Herzegovina;
- Several NGOs (HNI, Medica Zenica, Vive Zene and War Child);
For Kosovo, key informant interviews took place in March 2002 in Geneva with those WHO mental health professionals consulted on mental health reform in Kosovo. In addition, there were email contacts with mental health professionals working in Kosovo (in the Pristina university hospital and in community mental health centres) and with WHO support staff in Kosovo.
Data analysis
Walt's analytical framework15,16 was used here to analyse the data collected in Bosnia Herzegovina and Kosovo. This framework distinguishes context, content and process, and the various actors involved in mental health reform. It is a systematic framework that can broadly analyse the implementation of health policies (involving many disciplines and sectors); such a broad analysis is necessary here for evaluating mental health reform.
For the context analysis, data were collected on political history, the history of mental health services, psychiatric epidemiology, foreign influences, health care financing systems, medical anthropology and societal values.
For the content analysis, data were collected on principles of mental health reform and implementation characteristics (like the establishment of community mental health centres and education of mental health professionals).
For the process analysis, data were collected on the timing and pace of mental health reform.
For the actors (or stakeholders) analysis, Michael Reich's initial political mapping17,18 was used within Walt's framework to show political and other support for and opposition to the various actors in mental health reform in these highly complex, political environments.
Strategies to increase reliability and reduce bias
Data were collected through on-the-spot interviews and literature study. In particular, the interviews with local actors could prevent information bias by the literature, which is mainly oriented towards international donors.
A great deal of grey literature (all types of policy documents) was used, which is common practice for policy analysis. To strive for the maximum degree of reliability, triangulation of this qualitative information was done by double-checking information during the interviews and using information from various local and international sources with different interests. This triangulation resulted in further convergence towards the results.
Meta-analysis of the results detected the most important central theme: the role of foreign influence. This resulted in the main findings on the role of foreign influence in mental health reforms in post-conflict areas.
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Results |
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The collected qualitative and some quantitative data from the interviews and available literature were structured within Walt's framework. Tables 1 and 2 give the most important interview and literature data. The references cited within the tables refer to the relevant literature and Internet sources for each topic.
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Table 1 shows the most important context analysis data for mental health reform in Bosnia Herzegovina and Kosovo.
Table 2 shows the most important content and process analysis data for Bosnia Herzegovina and Kosovo.
Figure 1 is explained more extensively because this figure's characteristics are not as familiar in public health literature. Figure 1 shows political support for and opposition to different actors in mental health reform in Bosnia Herzegovina and Kosovo. The assessment of the amount of power per actor is interpreted from the interviews and policy documents.8–13 The footnotes to this figure explain the characteristics of the relevant health ministries. In general, figure 1 makes clear the processes of decentralization, economic dependency and involvement of professionals in mental health and health policy. Informal networking between the actors and other micropower processes are beyond the scope of this analysis. A more extensive explanation follows to give more specific insights into the interpretation of supporting or opposing power for every actor.
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In-depth explanation of figure 1
In Bosnia Herzegovina, international donors are very powerful because they are funding the reform in an economically unstable country. After decentralization, the National Ministry of Health lost power in terms of responsibility for the health care system (such as financing and determining the essential drug list). On the other hand, the Federation's cantonal ministries and the entity ministry of Republika Srpska gained a great deal of power.
Mental health professionals have a lot of power because they play key roles in implementing this reform and because some health professionals hold key positions in the different ministries. Some key mental health professionals oppose the reform, especially in Republika Srpska's entity ministry and in a number of the Federation's cantonal ministries. They prefer to maintain the pre-war institutional mental health care organization, and support further specialization of mental health care services, such as specialized clinics for patients with post-traumatic stress disorder (PTSD).
The public is not well organized (as in strong patient organizations), is not involved in policy making and so is not very powerful. Still, the public does have some power because they are the actual users of community mental health services.
In Kosovo, international donors are very powerful for the same reason as they are in Bosnia Herzegovina. In 2002, decentralizing health care responsibilities towards the municipalities existed only on paper.
Early in 2001, policy making and financial control of all health care was still a central responsibility of the United Nations (UN) Interim Administration Mission Kosovo Department of Health and Social Welfare. In 2002, this UN Department of Health started to transfer power to Kosovar ministries.
From the beginning, mental health professionals have been heavily involved in drawing up the strategic plan for mental health reform in Kosovo; they reported no opposition to this.
Public power has the same characteristics as those mentioned for Bosnia Herzegovina.
Having all the data available in tables 1 and 2 and figure 1, triangulation and meta-analysis of these data resulted in further convergence towards the most important results on the identified central theme of foreign influence.
Summary of the most important results
The role of foreign influence was a central theme in many of the results.
The context and process analysis showed that both areas became UN international protectorates and financially highly dependent on foreign donor funding. As a result, they became economically and politically dependent on the international community.
The initiation, funding and also part of the operationalization of mental health reform was done by international organizations. For example, during the armed conflicts NGOs started new ambulatory emergency mental health services, and after the end of armed conflicts many NGOs entered the areas with their temporary ambulatory mental health activities focusing mainly on traumatization.
Western health care financing models (mixed public–private insurance models) were quickly introduced in Bosnia Herzegovina, and health care financing became highly dependent on foreign donor funding. Local health administrators had to work according to new Western principles of efficiency and cost-effectiveness.
The content analysis showed that many different mental health professionals were trained by a number of international organizations in the new concept of community mental health and mental health care.
The actors analysis confirmed the power of international organizations to provide political support for mental health reform and also identified the concept of decentralization of political health care responsibilities supported by the international community. Particularly in the Federation of Bosnia Herzegovina, drastic decentralization took place using a Swiss cantonal model, which resulted in many small cantonal ministries of health.19
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Limitations of the method
The input of qualitative data from the literature used was comparable for both Bosnia Herzegovina and Kosovo.
The input of qualitative data from personal interviews differed between Bosnia Herzegovina and Kosovo.
Although extensive personal interviews were held with many actors in Bosnia Herzegovina, owing to practical limitations the same kind of personal interviews were not possible inside Kosovo. This may have affected the input of qualitative data for Kosovo. To reduce this difference, thorough personal interviews took place with those WHO mental health professionals who were consultants on mental health reform there, and e-mail contacts were established with key mental health professionals.
Discussion on the role of foreign influence
All these effects of foreign influence leave us with the following question: do they have a positive effect on mental health reform and its sustainability?
Foreign technical and economic support versus lack of local awareness and lack of local ownership. Clearly, foreign influence, with its technical, political and economic support, pushed the reform forward just after the end of armed conflict. In particular, the foreign training of many different mental health professionals in the new concept of community mental health and mental health care was an important positive contribution to mental health reform. However, many years after the reform's initiation the general public is still not aware of this new concept, and some mental health professionals perceive it as a reform from abroad. This public lack of awareness together with the perception by professionals creates a lack of local ownership for mental health reform. Obviously, this endangers the reform's sustainability. Although it may be very difficult to change local beliefs on mental health-seeking behaviour and professional perceptions, the following two possible strategies could influence these firmly held beliefs and attitudes more successfully.
Possible strategies. First of all, there could be more methodical ‘marketing'. In other words, taking local beliefs into account when developing mental health promotion strategies for the new concept of community mental health and mental health care could result in more successful sustainability of mental health reform. Examples of such marketing within the Bosnian and Kosovar context are mental health promotion within family, school and religious networks, and integrating community mental health services into existing somatic health services. Also, more anthropological research on mental health-seeking behaviour patterns could help tailor mental health promotion strategies.
Secondly, the example of Kosovo showed that immediate involvement of local mental health professionals in strategic plans for mental health reform results in more sustainable reform. This is because local key mental health professionals will not perceive the changes as a reform from abroad, and will therefore be less likely to develop opposition to the reform in a later phase.
Temporary, and chaotic overlapping of, mental health activities
Considering the epidemiology with its high prevalence of PTSD, it was logical for the different NGOs to start mental health programmes that focused on this mental health problem. However, parallel and overlapping mental health activities (‘trauma businesses') appeared that were unmanaged and chaotic. These were temporary, and because of this, endangered the sustainability of overall mental health reform, which includes all mental health problems.
Possible strategies. If NGOs better combined their mental health activities, with PTSD treatment as a first priority, with existing mental health and somatic health services now under reform, sustainable mental health reform would probably stand a better chance.
Privatization and increasing access problems
Introducing Western insurance models and privatization created increasing problems of access to mental and other health care. Private insurance schemes were implemented only by law, not in practise. Bosnia Herzegovina in particular did not seem to be ready for an insurance model. In 2001 Kosovo did not yet have a health care financing system, and even the World Bank suggested reintroducing the old national health insurance or tax model with payroll tax.
Possible strategies. Introducing a financing system closer to the original existing system and taking into account to what extent the area is ready for this could result in increased chances for both sustainable mental health reform and a more sustainable health care system in general.
Rapid, drastic decentralization and increasing access problems
The concept of decentralization promoted by many international organizations aimed at more local involvement was in part counterproductive, especially in Bosnia Herzegovina. It produced microbureaucratic procedures for many health care financing issues like insurance logistics. This created increasing access problems to mental and other health care. Local health care administrators used to centralized bureaucratic principles suddenly had to work from a decentralized, powerful position according to new utilitarian principles like cost-effectiveness and efficiency. One cannot expect a centralized East European post-conflict country to be immediately ready to switch to a decentralized Swiss cantonal model.
Possible strategies. Introducing decentralization less drastically at a local level and at a slower pace by well-trained administrators ready to take over responsibilities would probably reduce the risk of additional access problems and increase local involvement and the chances for sustainability.
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Conclusions |
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As shown by the examples of Bosnia Herzegovina and Kosovo, this policy analysis provides insight into the difficult policy and process of mental health reform in post-conflict areas. These examples show the difficulty of sustaining mental health reform several years after the end of armed conflict and the initiation of such reform.
This insight was gained by collecting all kinds of data (mostly qualitative, some quantitative) on many different topics and themes and from many different sources from various political positions.
The method of analysis used—Walt's framework together with Michael Reich's political mapping—was a useful way to structure all these different and extensive qualitative data. This manner of structuring, along with ongoing triangulation and meta-analysis of the data, resulted in convergence towards the most important results, which follow here.
As illustrated by the examples of Bosnia Herzegovina and Kosovo, foreign influence in post-conflict areas appeared to be a central theme of these results. Foreign influence has the following effects on mental health reform and its sustainability:
Foreign influence has a stimulating effect on the initiation of mental health reforms by introducing this new concept and by technical and economic support along with technical education.
Foreign influence by various actors can threaten the sustainability of mental health reform in the following ways:
- by creating a lack of local ownership of the new concept of community mental health and mental health care;
- by creating chaos with many overlapping short-term mental health programmes (mainly dealing with traumatization);
- by forcing rapid changes in health care financing systems (such as privatization), and introducing new insurance models too rapidly; and
- by forcing rapid decentralization of health care responsibilities.
In conclusion, to achieve sustainable mental health reform, foreign aid provided in these difficult post-conflict situations has to achieve a balance between measured foreign influence and involvement of existing local structures.
Key points
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1 Murray CJL, Lopez AD. The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries and Risk Factors in 1990 and Projected to 2020 (Global Burden of Disease and Injury Series, Vol I.). Cambridge, MA, Harvard School of Public Health (on behalf of WHO and the World Bank).
2 World Health Organization. Mental Health Context (draft document, Mental Health Policy Project). WHO Department of Mental Health and Substance Dependence, 2001.
3 World Health Organization. Organization of Services (draft document, Mental Health Policy Project). WHO Department of Mental Health and Substance Dependence, 2001.
4 Hayward R. Self-help and service users' involvement in Central Eastern Europe and the former Soviet Union (editorial). J Mental Health Reforms Geneva Initiative of Psychiatry 2001;6.
5 Kozaric-Kovacic D, Kocijan-Hercigona D, Jambrocic A. Psychiatric help to psychotraumatized persons during and after war in Croatia. Croat Med J 2002;43:221–8.[Medline]
6 Olsen IT. Sustainability of health care: a framework for analysis. Health Policy Plan 1998;13:287–95.
7 Key informant interviews in Bosnia Herzegovina, August 2001: ministries, NGOs, mental health professionals, hospital directors, self-help groups and patients were interviewed in a semi-structured way.
8 DeClercq L, Lagerkvist B, Kapetanovic T, Puratic V. Assessment of community mental health care in Bosnia Herzegovina after the 1992–1995 war. Internet journal Community Mental Health, in cooperation with HealthNet International. Available online at www.cmhr-bosnia.org (17 September 2001, date accessed).
9 Urbina L.. Topical information fact sheet on mental health programmes in Kosovo. International Centre for Migration Policy Development and International Organization for Migration (= ICMPD and IOM) Kosovo Information Project (updated version, February 2001). Available online on request at: www.kosinfo.org.
10 Agani F, Urbina L. Strategic plan for mental health reforms in Kosovo, 21 December 2000. Elaborated upon by the Mental Health Task Force, with the support of the World Health Organization.
11 World Bank Report. Economic and Social Reforms for Peace and Reconciliation, Kosovo, Federal Republic of Yugoslavia, Vol. 2. 2001.
12 Blatter W. Health care in Bosnia and Herzegovina in the context of the return of refugees and displaced persons. UNHCR report. Sarajevo. 2001.
13 Gashi H. Kosova zur medizinischen Versorgungslage (‘The medical care situation of Kosovo’). Bern, Switzerland, June 2001. Schweizerische Fluchtlingshilfe (Swiss refugee aid organization):1–15. Available online (in German) on request at: www.sfh-osar.ch.
14 Campbell J, Pecival V, Zwi A. Ministerial challenges: Post-conflict, post-election issues in Kosovo's health sector. Eur J Public Health 2003;13:177–81.
15 Walt G. Health Policy: An Introduction to Process and Power. 4th edition. Johannesburg and New York: Zed Books Ltd and Witwatersrand University Press, 1994,1–226.
16 World Health Organization. The process of implementing reform. In: European Health Care Reform, Analysis of current strategies. European Series 1997; no. 72. Copenhagen Copenhagen WHO Regional Publications 1997;47–272.
17 Reich MR. Applied political analysis for health policy reform. From: Current Issues in Public Health 1996. Online: www.polimap.com/applied.html (20 September 2001, date accessed).
18 Figueras J, Saltman R, Mossialos E. Challenges in evaluating health sector reform: an overview. Discussion paper no. 8. London: London School of Economics and Political Science, 1997.
19 Cain J, Duran A, Fortis A, Jacubowski E. Health care systems in transition: Bosnia Herzegovina 2002. The European Observatory on Health Care Systems. 4. See particularly pp. 19–24. World Health Organization Regional Office for Europe and other offices, 2002.
20 http://www.religioustolerance.org/war_koso.htm (January 2002, date accessed).
21 http://www.whokosovoexclusion.net (January 2002, date accessed).
22 Agani F. Mental health challenges in post-war Kosova. JAMA 2001;285:1217.
23 Ceric I. Development of mental health care in the Federation of Bosnia Herzegovina, Psychiatric Clinic, Sarajevo. J Commun Ment Health 2000.
24 Ljubic B, Hrabac B. Priority setting and scarce resources: case of the Federation of Bosnia Herzegovina, Ministry of Health of the Federation of Bosnia Herzegovina. Croat Med J 1998;39:276–80.[Medline]
25 Mollica R, Sarajlic N, Chemoff M et al. Longitudinal study of psychiatric symptoms, disability, mortality and emigration among Bosnian refugees. JAMA 2001;286:546–54.
26 MSF 2000 International Activity Report. Kosovo: The Physical and Psychological Consequences of War. 1 November 2000.
27 Mental health, social functioning, and attitudes of Kosovar Albanians following the war in Kosovo. JAMA 2000;284:569–77.
28 Mental health and nutritional status among the adult Serbian minority in Kosovo. JAMA 2000;284:578–84.
29 Pilav A, Dracic-Purivatra S. Problems in health statistic reporting in Bosnia. Herzegovina. Med Arh 1999;3 (suppl 3) 43–5.
30 Kalinic D. in cooperation with WHO team leaders of the Health Reform and Reconstruction Programme. Strategic Plan for Health System Reform and Reconstruction 1997–2000 for the Republica Srpska. Section VI. 1997:52–60.
31 Ljubic B, Hrabac B, Rebac Z. (Ministry of Health of the Federation of Bosnia Herzegovina). Reform of health insurance in the Federation of Bosnia Herzegovina. Croat Med J 1999;40:1–5.[Medline]
32 Buwalda H. Mental Health Services for Refugees: Understanding the Current Situation to Strategize Change. Chicago, IL: Center for Multicultural and Multilingual Mental Health Services, 1999. Available online: www.mcmlmhs.org/cultures/issueessays/msrefug.htm (15 February 2002, date accessed).
33 Jaranson J, Forbes Martin S, Ekblad S. Status of mental health services at the millennium. Refugee Mental Health: Issues for the New Millennium. The Center for Mental Health Services, United States Department of Health and Human Services Substance Abuse and Mental Health Services Administration, 2000. Available online: www.mentalhealth.org/publications/ (4 February 2002, date accessed).
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