Problem: Increasing national burden of mental health disorders; mental health care model focused on institutionalization and lacked community-based treatment alternatives; access inequities for mental health services existed between urban and rural populations.
Solution highlights: New political commitments to mental health reform led the government to pass the Mental Health Act in 1997 to promote community-based mental health care; a wide variety of community-based mental health services have been made available, with emphasis on services for prevention, early treatment, rehabilitation and home care; advocacy from the health workforce motivated reforms and helped define the vision for care transformations; strategic timing was an important contributing factor in achieving political support for mental health reform; partnerships with NGOs and volunteer organizations helped expand the continuum of mental health care.
Description of practice
Prior to the late 1990s, mental health services in Cyprus were heavily institutionalized, and few community partners provided care outside of hospital settings. Limited availability of community treatment options contributed to inequitable service access between rural and urban populations. Of further concern, mental health needs were increasing. Between 1990 and 2000, the number of disability-adjusted life years attributable to mental health disorders increased from 15 000 to 17 000. In the context of increasing needs, the shortcomings of the acute model for mental health services, which included lengthy hospitalizations and high levels of stigma, became increasingly apparent. Action promoting a more sustainable care model was needed.
National advocacy, backed by international recommendations, proved successful in persuading the government to back mental health reform in 1991. Changes to the Mental Health Act in 1997, along with the design of a strategic plan for shifting services into the community, provided the framework from which the Mental Health Services Department within the Ministry of Health worked to deinstitutionalize mental health services. During the next decade, a network of community clinics and centres was established, offering a wide range of services to people with mental health needs, including counselling, support groups, detoxification, substitution therapy, rehabilitation programmes and employment assistance. Providers were reorganized into multidisciplinary teams to promote coordinated delivery of the holistic care package to patients. Coordination mechanisms like weekly team meetings and dedicated liaison officers helped to ensure effective collaboration and communication among professionals. Several training opportunities for health professionals accompanied changes to cultivate professional competencies for community-based care, and a committee for lifelong learning was established to facilitate continuing education for professionals. Partnerships with NGOs supported efforts and extended services to include rehabilitation. As a result of reforms, the majority of care is now delivered in community settings, with community-related expenditures accounting for 73% of the annual mental health services budget in 2013, compared to only 20% in 1997. The Mental Health Services Department continues to encourage growth of community-based mental health services, and reforms to increase the role of primary care in delivering mental health services are currently under consideration.
Implementation of practice
What stage is the practice currently in?
Who was/is responsible for the implementation of the practice?
Mental health reforms in Cyprus were first initiated by four NGOs that formed throughout the 1990s as a result of patient and provider dissatisfaction with the status quo of service delivery. After many years of advocacy, backed by international recommendations for mental health reform, these NGOs were successful in convincing the government to support mental health reform and adopt a national mental health strategy. During the next two decades, experts were consulted to provide guidance on implementing reforms. A management committee, composed of division heads within the Mental Health Services Department at the Ministry of Health, was established and tasked with informing the design, development and implementation of reforms. Continuous cooperation among representatives of the Ministry of Health, the Mental Health Services Department and WHO eventually led to the strategic plans for reform.
The initiative reports improving the availability of community-based services for patients with mental health needs. The number of inpatients at Athalassa Mental Hospital has declined and outpatient services, including home visits and vocational programmes, have increased.
This case was prepared as part of a larger effort by the WHO Regional Office for Europe and published (2016) in the document, "Lessons from transforming health services delivery: Compendium of initiatives in the WHO European Region".
© Copyright World Health Organization (WHO), 2016
The methodology used for the development of this case is slightly different from the templates used on the IntegratedCare4People web platform, in particular in the analysis of enabling factors and barriers to change.
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- Irene Georghiou
- Ministry of Health