One issue of mental health care, as important in the past as at present, was already mentioned as one of the reasons why mental illness is not always treated adequately or it is treated with a delay. According to Pirisi , mental illness has sat on the back burner around the globe in terms of medical and public attention and resources____[That] has kept mental illness from getting its due recognition as a costly, disabling form of disease____Social stigma has been foremost in contributing to the long silence that has kept mental illness locked away in asylums, and harboured as dirty family secrets not to be mentioned to neighbours or employers.
For this reason, the enormous public health relevance of mental disorders did not receive the attention it deserved for a long time.
It is also one of the reasons why psychiatry was comparatively late to develop into a scientific and therapeutic discipline and why the integration of mental health care in the general health care system has been slow in almost all countries.
The widespread ignorance of the high frequency of mental disorders and of their social and economic implications was not overcome until trans-nationally comparable population surveys were conducted in different countries and progress was made in assessing life years lost through disability . According to the World Health Report 1999 , neuropsychiatric conditions make up an estimated 11.5% of the global burden of disease. They globally account for 28% of the total years lived in disability (except for sub-Saharan Africa where they account for 16%). A large proportion of the burden of disease is attributable to major depression, also linked to increased mortality by making up the majority of about 800000 suicides per year [21, 22]. Wells et al.  "have shown that the effects of major depression . . . on . . . quality of life outcome are comparable to, and in some respects greater than, the effects of such chronic physical disorders as hypertension, diabetes and arthritis, to name but a few" . Due to their low age of onset and chronicity, severe mental disorders frequently have "powerful adverse effects on critical life course transitions, such as educational attainment, teenage childbearing , and marital instability and violence " . These facts indisputably show the necessity for any society to provide for a mental health care system quantitatively and qualitatively of the same standard as the general health care system.
Most mental disorders differ from most physical diseases in their ratio of cure and care not only quantitatively, but also qualitatively. In many physical diseases inpatient care is closely associated with medical treatment both temporally and functionally and is usually provided at the same location, such as a hospital. But this is only rarely the case with mental disorders and disabilities. Just consider dementia, a frequent disorder of old age: instead of inpatient treatment, rarely necessary, long-term support in activities of daily living and, at more advanced stages of the illness, comprehensive care are needed. Consider the social disabilities and occupational impairment of chronic schizophrenic patients, and the need for psychosocial training, and social and occupational rehabilitation becomes evident. In chronic schizophrenia, the need for psychosocial care, if available, exceeds that for inpatient and outpatient medical care to a considerable extent. A similar pattern of need can also exist in some physical diseases, but clearly more rarely.
"The universe of mental health is vast and multidimensional," says Ustun . Given its psychosocial dimension, the universe of mental health care clearly exceeds that of general health care. To accomplish its tasks, a mental health care system at any rate must offer not only medical and psychiatric, but also a wide range of psychosocial services. Psychosocial care and occupational rehabilitation are in part provided by the mental health care system alone, mostly, however, in cooperation or competition with the existing social services.
In this context, the contribution of families, especially in the case of the socially disabled chronically ill, must be borne in mind. Particularly in countries with predominantly extended families, family care plays an important role. When adequate social care systems are lacking, families are more or less compelled to care for their ill members irrespective of whether they are capable of doing so or not. Hence, an essential indicator of the goodness of a mental health system is whether and to what extent the needs of the chronically mentally ill and disabled for non-medical and social care are met.
FAIRNESS IN HEALTH CARE: HOW TO PROTECT AGAINST THE FINANCIAL RISK OF ILL HEALTH
The requirement of fairness in national health care systems was fulfilled very late and in only a few countries. For most people in any country, "until well into the 19th century... little protection from financial risk [existed] apart from that offered by charity or by [the described] small-scale pooling of contributions among workers in the same occupation" .
The early forms of mental health care, knowledge of the nature of illnesses and their prevention and treatment, as well as the systems of protecting against financial risks, did not evolve homogeneously. On the basis of their observations of workers in silver mines, the Swiss physician Paracelsus as early as 1535 and later, in 1614, Martin Pansa in Germany described acute quicksilver intoxications and chronic heavy-metal encephalopathies and proposed preventive security measures. Reports of the fates of affected miners, their widows and orphaned children gave rise to the formation of the first miners' societies based on the principle of solidarity. Their aim was to help all disabled miners and their families. In this way small-scale systems sprang up out of a feeling of solidarity fairly early to provide protection against the financial risk of ill health and its consequences. These core systems, founded in Europe in the 19th century in other occupations as well, were the forerunners of the modern solidarity-based health insurance systems.
Towards the end of the 19th century, the time was ripe for first steps towards the establishment of health and social security systems. In 1883 the German chancellor Bismarck enacted a law requiring employer contributions to health benefits for low-wage workers in certain occupations, adding other classes of workers in subsequent years. The contributions to this preliminary, state-mandated social insurance scheme, which covered illness costs first for employees, and later also for their families, were shared by employers and employees. The benefits that these laws brought to the working class and the step that it took towards establishing social justice led to the adoption of similar legislation in Belgium in 1894, in Norway in 1909 and later in many other industrialized countries. After World War I the German model also began to spread outside Europe, to Japan, Chile, etc. [1, 5].
An alternative model, a state-run health service, was first established in Russia in the late 19th century, when a huge network of provincial medical stations, local dispensaries and hospitals were founded to offer treatment free of charge. The system was financed from tax funds. After the Russian Revolution in 1917, free medical care was provided for the entire population in a completely centralized and state-controlled system.
In 1948 Britain, as already mentioned, replaced its mostly private health insurance system, which left a large proportion of the mostly poorer section of the population unprotected against the financial risk, by the National Health Service. Previously, New Zealand had introduced a similar system in 1938. The 1944 British government's White Paper stated the policy as follows: "Everybody irrespective of means, age, sex or occupation shall have equal opportunity to benefit from the best and most up to date medical and allied services available . . . those services should be comprehensive and free of charge and should promote good health as well as treating sickness and disease'' . Many other countries, such as the Scandinavian, followed suit.
"In a third model state involvement is more limited ... sometimes providing coverage only for the most under-privileged population groups in giving way for the rest of the populace to largely private finance, provision and ownership of facilities'' . This is the case in some high-income countries, such as the USA, and naturally also in many medium- and low-income countries that lack the resources to finance health care for their entire population. As a result, deficits in fairness are widespread. In many of the poorest countries only a few rich people can afford to pay for their health care costs, while the majority cannot.
In the last two decades the question of which of these systems is the best and least expensive, was discussed with great intensity and controversy. Due to soaring health costs and increasing economic constraints in the late 20th century, economic aspects moved to the foreground. Health expenditures can be more easily controlled in tax-funded state-run health care systems. However, the advantage of achieving a maximum balance between rich and poor, ill and healthy, in protecting against the financial risk and the advantage of an optimal regulation of health care are diminished by the fact that such systems discourage the initiative of the health care personnel and, as a result, lead to a low efficiency at the micro-level . Frequent consequences are as follows: (a) reduced productivity and quality of health services; (b) rationing of cost-intensive services (e.g., surgery), usually to the disadvantage of certain at-risk groups (e.g., the elderly, people with diabetes, and the mentally ill, a further at-risk group, but apparently not in the British national health service—whether and to what extent the mentally ill are disadvantaged, is primarily a question of a political decision in a centralized health care system); (c) lengthy waiting lists; (d) limited autonomy of users to choose physicians and hospitals; and (e) growing dissatisfaction among users .
Contribution-based systems have the advantage that both employers and employees pay their share. In these systems, usually also family members are insured and the financial costs of ill health and disability are covered. Their innate weakness is that only the working population makes a financial contribution. In countries with declining working populations and increasing numbers of the elderly and the unemployed with greater needs for health care, these systems are pushed to the limits of their financial capacity. In this context the World Bank speaks of from-hand-to-mouth systems that will inevitably lead to intergenerational conflict .
Table 2.1 shows three basic systems that have been adopted to provide protection against the financial risk of ill health. The state-managed, centralist type of a national health care system is divided into a socialist type, currently under reform in many countries to make it more democratic, and a democratic type, such as the National Health Service of Great Britain. In addition, there are various private (or mixed) systems of health insurance and health care.
Private health care systems based on either direct payment or private insurance place the less well-off sections of the population at a disadvantage. Governments aiming at fairness in their social policy actions are compelled to find ways of financing health care from tax funds for certain underprivileged groups. Such government subsidies, as in the USA and Switzerland, enhance fairness.
In many countries, mental health care—as far as it consists of the therapy traditionally supplied by psychiatrists and medical services, as in private practice or the hospital—has been included, step by step, in the benefits provided by state-run or contribution-based systems. Where this is the case, there has been—and still is—a tendency to exclude from coverage—or set temporal limits to the coverage of—expensive long-term care for chronic psychiatric disorders involving multisectoral services. This will be discussed in greater detail in the context of managed care.
Another problem of health-insurance systems rather specific to mental health care has been the financing of long-term care of the disabled mentally ill either in institutions or in the community. Most health-insurance systems cover only treatment costs, but not social and occupational rehabilitation or long-term care for disability, which in many cultures is traditionally the duty of families. In some high-income countries where coverage was expanded in periods of economic growth, a considerable proportion of the costs of utilizing the services for the disabled has been financed by the social security system.
But the mentally ill are still at risk of being disadvantaged compared with the physically ill. For example, in Germany, until 1980, 50% of the costs of inpatient care in a mental hospital had to be paid by the patients themselves or their families, provided they were not incapable of doing so and thus eligible for tax-funded welfare. In most low-income countries, mental patients in need of treatment and their families receive no financial support to pay for treatment and to cover the loss of income during illness- or disability-related incapacity to work. The only coverage the mentally ill in many of
Table 2.1 Mental health care systems and their structure. From Schneider , modified
Financed by Controlled by
Insurance provided by Services provided by
Centralist national health care systems
Socialist health State State care system National health State State
State State service
Contribution (solidarity)-based insurance schemes—only health insurance
Social (solidarity-based) insurance scheme
- physicians in private practice
- health insurance organizations
Mandatory health insurance Organizations under state control
State hospitals and clinics State hospitals Specialists
Hospitals Physicians in private practice, etc.
Private (mixed) systems comprising only health insurance or health insurance and managed care
Managed care system
Private insurance schemes
Employers State Users Users
Hospitals Physicians Health insurance organizations
Health insurance organizations
Hospitals Physicians Laboratories, etc. Hospitals Physicians, etc.
Users assigned to services Users enrolled
Free choice of physicians
Free choice of physicians
HMOs: health maintenance organizations. Reproduced by permission.
these countries receive is limited to inpatient treatment in state mental hospitals, of which usually very few exist. Until recently, the costs of treating alcohol and drug abuse and related health risks were excluded from coverage in some countries, because these conditions were regarded as self-inflicted and, hence, as the patient's own responsibility.
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