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One of the most important developments in the last decade in the field of mental health in Turkey has been the adoption of a community-based approach toward mental health by official circles. The Republic of Turkey National Mental Health Policy published in 2006 by the Ministry of Health covers issues such as the shift of mental health services to a community-based system; their integration into general health services and primary health care services; efforts to establish community-based rehabilitation programs; the improvement of the quality of mental health services; the enactment of laws concerning mental health; the protection of patients’ rights against stigmatization; and the improvement of training, research and human resources in the field of mental health (1). Following the publication of the mental health policy, a National Mental Health Action Plan (2011) (Ulusal Ruh Sağlığı Eylem Planı) was developed which stated that community-based mental health services were to be implemented (2). In April 2009, the decision to establish Community Mental Health Centers (CMHCs) (in Turkish Toplum Ruh Sağlığı Merkezleri - TRSM) was made by the Ministry of Health. In the same year, the Convention on the Rights of Persons with Disabilities (CRPD) was signed (3). Following pilot projects conducted for CMHCs, the relevant directive was issued and initiated in February 2011 (4). By signing the CRPD, the Republic of Turkey has undertaken to ensure that individuals with mental impairments have equal access to mental health services as available for full-fledged citizens and that they lead their lives with dignity. As of October 2015, the number of CMHCs that were promptly licensed and opened had reached 86. The present paper critically examines the situation of CMHCs in Turkey and focuses on the associated problems and solutions.
By signing the National Mental Health Policy, the National Mental Health Action Plan, and the CRPD (1, 2, 4), the Republic of Turkey has undertaken that the human rights of individuals with mental illness in Turkey would not be ignored or violated; however, neither have they established a genuine collaboration with professional organizations, patients, patient relatives, and nongovernmental organizations nor, to the best of our knowledge, has any official inspection been performed. Furthermore, no serious efforts have been made during this time to raise awareness regarding the human rights of individuals with mental illness in the community. Similarly, one observes that no actions have been taken to fight against stigmatization, exclusion, or discrimination on the basis of mental illness in the community and that the efforts of nongovernmental organizations in this area have been ignored.
A study published in 2004 in Turkey (5) reveals that despite the fact that mental disorders pose a serious burden to public health, the necessary financial resources are not allocated to mental care. Indeed, to implement community-based mental health services in any country, high priority should be given to mental health by the government (6). The budget share allocated to all health services in Turkey is very low; therefore, it is expected that the share of mental health in the forthcoming budget will be very small. Furthermore, according to the results from the Mental Health Economics European Network (7), the percentage of total health services allocated to mental health services in Turkey remains unknown. Since 2013, the budget of the Ministry of Health is drawn up in the following three parts: The Ministry of Health, the Turkish Public Hospitals Institution, and the Turkish Public Health Institution. They aimed to raise the total health budget from 18 billion 422 million TL in 2014 to 20 billion 214 million TL in 2015. A total health budget of 20 billion TL accounts for 4.2% of the central budget. The Public Health Institution’s investment allowance has been set at 80 million. This means that no share has been allocated to preventive healthcare services. On the other hand, with a share of 5 billion 743 million TL in the 2013 budget, the Presidency of Religious Affairs has outstripped the budgets of 11 Ministries (8).
The budget and financing of mental health services are not presented transparently enough and the allocation of resources is unclear. Financing of mental health services worldwide is predominantly funded through the general tax system. Studies emphasize that if payments for mental health care are directly made by patients, this will prevent their access to services and will lead to a two-tiered system, dividing patients into higher and lower economic statuses (9). No country in Western Europe uses a method in which the people pay for mental health care themselves. Financing is predominantly covered by general taxes or the social insurance system (9–11).
In addition to this grim picture regarding economic resources, because of the lack of adequate and reliable data, our knowledge of the prevalence and impact of mental disorders in Turkey remains uncertain (8, 10).
The fact that it was possible to publish a National Mental Health Policy in Turkey, even under these circumstances, should be considered an important acquisition. Nevertheless, even though the document does emphasize the importance of community mental health, one observes that not enough space was given to all stakeholders in the production of the policy and that the views of those who were given that space were not sufficiently taken into account. Although attention is drawn to the central role the patients and their relatives currently play in mental health policy-making (12) and although this is emphasized many times in the document itself (1), it can be observed that such organizations are not consulted in Turkey. As one of the main objectives covering the structure of the National Mental Health Policy, the document states that “there is a need to integrate the best practices model to improve mental health services within the important network of primary health care centers in the provinces” and that the primary focus would be preventive mental health services; however, there has been no notable improvement in the action plan on this issue either. Furthermore, this “great” document has no legal standing; therefore, a Mental Health Law must be enacted as soon as possible. Rather than merely being a legal document covering only the involuntary hospitalization of people with serious mental disorders, this Mental Health Law should be the source of policy-making (13).
Our final criticism in terms of community and government is the linking of “the reform of mental health care with narrow ideological or party political interests” (6)–one of the most striking mistakes noted by prominent experts in community psychiatry–has unfortunately reached alarming proportions.
We noted earlier that following the publication of the mental health policy, a National Mental Health Action Plan was developed. The plan stated that, because of the lack of adequate human resources, a “balanced care model” would be implemented in the short term before fully shifting to the community-based mental health model. In this balanced care model, emphasis would be placed on the establishment of psychiatric clinics within general hospitals, and the community psychiatry model would be simultaneously set up with an original restructuring in which the treatment and rehabilitation of people with severe mental illness would be provided within the community. This would integrate services for mild mental illnesses into the family doctor system (2).
As clearly stated in the plan, one of the main problems is that the number of psychiatrists and other mental health professionals per capita and the number of psychiatric beds are far below the European Union averages. Besides, much more important than numerical inferiority is the quality of the staff, which is the only way to ensure adequate and competent workforce (14, 15). Despite the fact that the action plan draws attention to the increase in the number of psychiatrists in recent years, there is no mention of quality. Trained Ministry personnel who could be involved in education and training are generously cast out of the Ministry. Not only have no steps been taken to fight against stigmatization and discrimination as stated in the action plan, the efforts of nongovernmental organizations in this area have also been ignored. Similarly, in the context of mental rehabilitation and supported employment, the Mavi At Café, which employs schizophrenic patients and was established by the Federation of Schizophrenia Associations using independent and limited resources, has been virtually ignored when it should have been taken into account and supported (16).
At the local level, community-based mental health services will essentially be organized through CMHCs. Despite numerous disadvantages, a large number of CMHCs were promptly opened. Although it is evident that great care should be taken in the processes of designing, monitoring, and organizing a community-based mental health system. Such a system must first be internalized and absorbed by mental health professionals. One observes that this issue is still not given sufficient space in the curricula of training programs in medicine, psychiatry, psychology, clinical psychology, and social services. Despite the fact that the integration of CMHCs into primary health care services is a matter that has been repeatedly written about, the awareness, education, and cooperation of family doctors in this area could not be achieved. The Directive on CMHCs (4) states that these centers would be established so as to operate within inpatient care facilities affiliated with the Turkish Public Hospitals Institution. The fact that a community-based practice is affiliated with an institution that is administratively and financially related to hospitals is contradictory in principle and also gives rise to many problems in practice, particularly financial issues.
It can be observed that current implementations of CMHCs do not meet the minimum standard, either in terms of service delivery or equipment and number of personnel, and that no concrete step has been taken toward the Measurement and Evaluation Processes in Mental Health Services that are highlighted in the Mental Health Action Plan; at least there is no written report to which we had access. With regard to CMHC staff, lack of training, inadequate salaries, high staff turnover and burnout, and low morale are issues that need to be seriously addressed (6).
At CMHCs, the directive is not sufficiently clear about staff training. Starting out with an inadequately trained CMHC staff can lead to irreparable problems (13). Furthermore, training programs initiated belatedly with the support of the World Health Organization seem to have come to a standstill. One observes that existing training programs do not make sufficient use of the knowledge and experience of human resources in Turkey who are trained in this field. Structured training programs must be provided to CMHC personnel as soon as possible.
The high turnover of CMHC personnel is an important problem that deteriorates the quality of services. Because of the insufficient number of psychiatrists and other mental health professionals in Turkey, medical specialists either cannot work, at least full-time, in the CMHC staff, or serve on a rotating basis. Beyond limited resources, this kind of a high turnover sometimes happens for entirely arbitrary and political reasons, and trained personnel end up leaving their jobs. High turnover or impermanence of staff leaders and members is one of the important obstacles to the system’s sustainability (6).
The way CMHC personnel are paid leaves doctors and other mental health professionals in financial difficulties, and some positive initiatives that were attempted within the existing system after receiving criticism have had consequences that would disturb the peace among the staff and degrade the quality of services. From the outset, other mental health professionals have been receiving smaller salaries than their colleagues who work in hospitals.
It is evident that CMHCs should collaborate with other disciplines and institutions (13). However, for this collaboration to take place promptly and efficiently, the Ministry of Health must establish enforceable protocols with other institutions. Otherwise, even a competent, motivated, energetic, and innovative CMHC professional will rapidly fall into burnout after facing the incompetent indifference of other institutions.
CMHC staff is still far from embracing a recovery-oriented approach that is patient-centered rather than hospital-centered. A recovery-oriented and person-centered approach to health care is only possible with the involvement, at all levels of health care, of patients, patient relatives, and nongovernmental organizations active in this field (6). The system’s valuing of the goals of patients and their families and the sharing of decision-making processes will ensure that person-centered care becomes a key value in the assessment of services provided and their outcome.
In conclusion, CMHCs can only survive and provide the desired services if authorities in this field create, with the active participation of all stakeholders, a platform for discussion to critically examine the process thus far and, in line with the feedback obtained, take action and not just talk.