A community-based mental healthcare system

Project completed

With SDC aid, the quality of care is improving in the community mental health centres of Bosnia and Herzegovina. © SDC

In Bosnia and Herzegovina, much of the population is still suffering the consequences of the war which ravaged the Balkans in the 1990s. Since 2010, Switzerland has been helping the country to modernise its mental healthcare system to give patients access to high quality services in their communities.

Country/region	Topic	Period	Budget
Bosnia and Herzegovina	Health nothemedefined Mental health & well-being Primary health care Health systems strengthening	01.03.2014 - 28.02.2018	CHF 5’665’000

The project in brief

Background	A significant progress has been made in mental health care reform in BiH since 1996, focusing on the development of out-patient mental health services at the Community level. However, social exclusion and discrimination still remain key issues affecting the quality of life of people with mental health problems. A stronger focus on preventive care and on identifying early symptoms and preventing mental illness from becoming severe and disabling is necessary. Specific skills of mental health service providers for psychotherapy, occupational therapy, and work with juvenile patients and victims of family violence are lacking.
Objectives	To contribute to an improved general well-being of people with mental disorders and of those at risk of developing mental health problems in BiH.
Target groups	Direct project beneficiaries are about 500 mental health professionals, primarily those working in 68 Community Mental Health Centers throughout the country. The project will support them in gaining required skills and knowledge and in improving their working environments. Beneficiaries of the project are also the health authorities and mental health institutions, whose capacities for effective and efficient management of community-based mental health services will be enhanced. End beneficiaries are persons with mental disorders and their families and those at risk of developing MH problems, belonging to disadvantaged and vulnerable groups.
Medium-term outcomes	Intermediary outcomes: 1. Community-based mental health services are managed more effectively and service quality is continuously improved, based on evidence; 2. Persons with mental disorders and those at risk of developing such disorders have access to mental health services of increased quality and scope in their communities; 3. Discrimination against persons with mental health disorders in the communities has decreased.
Results	Expected results: - Established mental health standards of practice and a quality monitoring system - Established information system for mental health monitoring, data collection and analysis - Improved skills of mental health professionals to provide quality services (case management, occupational and work therapy, psychotherapy) - Enhanced mental health outreach services - Mental health infrastructure improved - Implemented community anti-stigma programs - Increased capacities of user associations for social inclusion interventions Results from previous phases: The policy and regulatory framework for mental healthcare in BiH has been brought in line with European standards. A set of indicators for monitoring the population's mental health was developed. The scope of available mental health services increased: 88% of nurses are now working independently with patients (vs. previous 29%), and the case management approach was introduced in 66% of Community mental healthcare centres, benefiting 1'282 persons with severe mental disorders. Quality of services has been improved and the hospital referrals rate of patients has decreased by 30% (sample of 10 out of 68 Centers).
Directorate/federal office responsible	SDC
Credit area	Swiss cooperation with Eastern Europe
Project partners	Contract partner International or foreign NGO Other partners Entity and cantonal Ministries of Health; Entity Public Health Institutes and Agencies for Accreditation and Quality in Health; professional associations of nurses, psychiatrists, psychologists, and social workers; associations of users of mental health services.
Coordination with other projects and actors	Synergies with other SDC-funded health projects in BiH: Strengthening Nursing Project (continuous education of nurses and nursing standards in mental heaith); Reducing Health Risk Factors Project (reduction of alcohol consumption and promotion of healthy life styles among persons with mental disorders); Promoting Healthy Lifestyles among Young Men and Women (promoting non-violent life styles among youth).The project will also coordinate its efforts with the World Bank, UNICEF, UNFPA, the Government of Denmark and lOM.
Budget	Current phase Swiss budget CHF 5’665’000 Swiss disbursement to date CHF 5’448’179
Project phases	Phase 3 01.03.2018 - 30.06.2023 (Completed) Phase 2 01.03.2014 - 28.02.2018 (Completed) Phase 1 05.06.2009 - 28.02.2014 (Completed)

Further technical details

Sector according to the OECD Developement Assistance Commitiee categorisation	HEALTH HEALTH HEALTH
Sub-Sector according to the OECD Developement Assistance Commitiee categorisation	Promotion of mental health and well-being Basic health care Health policy and administrative management
Cross-cutting topics	The project also supports partner organisation improvements
Aid Type	Mandate with fiduciary funds
Project number	7F06515

In Bosnia and Herzegovina, the number of cases of depression, anxiety and disorders related to stress or domestic violence is rising steadily. Of particular concern is alcohol and substance abuse among young adults suffering from transgenerational trauma, which affects the children of those exposed to conflict. These mental disorders are exacerbated by high unemployment and widespread impoverishment. Mental health problems that affect elderly people, in particular dementia have also risen owing to the ageing population and increased life expectancy.

To meet these challenges, the country embarked on a large-scale reform of its mental health system in 1996. The reform aims to progressively integrate mental health services into basic healthcare infrastructures. The SDC has been supporting the reform in partnership with the cantonal governments of Jura, Fribourg, Bern and Geneva since 2010.

Mental healthcare for all

The project aims to improve the health and well-being of people living with psychological disorders or at risk of mental illness. The project takes a global approach, combining several objectives. These include guaranteeing patients’ access to mental healthcare in their communities, fighting the stigma attached to mental health problems and encouraging better integration of people with a mental illness in communities. So far 74 mental health centres have been established to serve communities nationwide.

The project works with the system already in place and aims to facilitate the reform process while strengthening the capacity of the individuals and organisations involved in the changes. In addition to this, the Swiss cantons are providing valuable technical assistance.

A multidisciplinary approach

The mental health centres set up through the project are fully integrated in primary healthcare services; the high quality services they provide are covered in full by patients’ health insurance. The centres offer new therapeutic options within a reasonable waiting time, made possible by the establishment of multidisciplinary teams of qualified staff comprising a psychiatrist, psychologist, nurse and social worker. This approach has given patients access to more personalised therapies better suited to their specific needs.

The mental health centre teams also run public health and prevention campaigns. Furthermore, a partnership between the public health institutions of the two countries has organised nationwide campaigns to tackle depression and anxiety. Investing in prevention has been proven to be effective and early diagnosis is known to reduce the costs of treating serious psychological disorders and to increase the efficacy of therapies. Together, these activities have reduced hospitalisation by 30% since the start of the project.