Decision Making in Psychiatric Reform: A Case Study of the Czech Experience

A central issue in mental health policy has involved debates over the deinstitutionalization of psychiatric care, about the role of psychiatric inpatient care in the systems of mental health care (Hudson, 2016). These debates have been largely ideological, however, an emerging perspective is that decisions on the deployment of mental health resources should aim at a balanced system of care that is guided by the best available evidence. Despite this, the extensive body of research on policy, administrative, and professional decision making has been largely ignored. This may be because traditional models of decision-making, such as what is known as the rational-comprehensive model, are highly rationalistic, and assume a consensus among stakeholders on goals and an ability to identify alternative means for achieving them and predicting their success, all assumptions that can rarely be met in most fields. For this reason, a variety of alternatives to this baseline rationalistic model have been proposed since the mid-twentieth century. These include Lindlom's incremental decision making model (1959), Simon's bounded-rationality (1991), Etzioni's mixed scanning (1967), and more recently models involving naturalistic decision making on the part of professionals (see Klein, 1997). One of the themes underlying many of these approaches has been the need to expand the range of goals and improve the search for alternative means to be considered, and to introduce appropriate constraints to simplify the search process. Yet, this interest potentially conflicts with the need to base decisions on the best available scientific evidence and professional approaches to decision making. Trade-offs, whether or not they have been necessary, between these considerations have in fact been observed in a variety of studies (Hudson, 1992).

Efforts to improve public health programmes have historically involved a number of strategies that have been extensively reviewed elsewhere. Most notable is the review of Pallasa et al. (2012) of 181 studies that identified seven broad strategic areas of change: standards and guidelines; organizational structure and governance; human resource knowledge and skill; process re-engineering and technology development; use of incentives; organizational culture; and leadership and management. Their identification of the pros and cons of such approaches form the basis for their arguing for a prescriptive model for the selection of optimal strategies that is contingent on the answers to questions involving an analysis of the causes of performance deficits, feasibility and environmental fit, use of best practices, and organizational capability. Several of these involve the decentralization of decision making, which is a strategy that is increasingly used in contexts involving professional services. Decentralization often accompanies psychiatric deinstitutionalization and typically involves an expansion in the range of stakeholders such as community agencies, professionals, consumers, and families of the mentally ill who seek to influence the service delivery system.

In contrast, Bossert (1998) specifically reviewed research on decentralization in health care in developing nations. He draws on the traditional typology of types of decentralization used in public administration, which include deconcentration, delegation, devolution, and privatization, and focuses on the use of principle agent theory from econometrics, most commonly involving the application of financial incentives as a means for central public health administrations to retain some control over peripheral units or organizations within a newly decentralized service system.

Much of the existent theory and research suggests that integrally connected with the success of deinstitutionalization initiatives is the ability of a nation's mental health authority, such as a ministry of health, to navigate the complexities and tradeoffs involved in shared decision making under an increasingly decentralized structure. Within the mental health field, increasing attention has been paid to incorporating various models of shared decision making as a means of assuring maximal responsiveness to the needs of diverse constituencies (see Ramon, Zisman-Ilani, & Kaminskiy, 2017). One such initiative, involving psychiatric reform and shared decision making, is that of the Czech Republic, one that has faced challenges inherent in its transition from communism that began in 1989, a subject to which we will now turn.

In 1989, citizens of the former Czechoslovakian nation mobilized and peacefully overthrew the communist dictatorship in what has come to be known as the Velvet Revolution. Then, in 1993, the Slovakia region of Czechoslovakia formed its own nation, leaving the current state of the Czech Republic. In 1999, the Czech Republic was admitted to NATO, and in 2003, to the European Union. This transition saw the development of a market economy, with the Czech Republic being recognized as one of the most developed industrialized economies among the newer European Union member states (Alexa et al., 2015). Over the succeeding years, the government transitioned to that of a unitary parliamentary constitutional republic, with democratic-socialist leanings, and with a bicameral parliament, independent judiciary, and both a prime minister and president. Reform and modernization of governmental structures led to the Act on Regions 129/2000 that devolved many governmental responsibilities to 14 newly formed regions that have been delegated authority in matters related to health care, social services, and various other areas.

The Czech Republic provides its citizens and residents with a wide range of health and social service benefits (see Nemic, Pavlik, Maly, & Kotherova, 2015). After the Velvet Revolution, the nation reformed the financing of its healthcare system, changing from reliance on taxation to payroll deductions for the funding through seven quasi-public insurance funds which cover virtually all of the population. By 2012, approximately 7.7% of its GDP was devoted to healthcare, below the EU average of 9.6%. This compulsory system, funded from employee deductions and governmental contributions for those not in the labor force, provides for a wide range of inpatient and outpatient benefits, and is overseen by a Ministry of Health. These services are supplemented by various social services, funded through the Act on Social Services in 2006 which was enacted with the aim of enhancing the coordination between the health and social service systems, partly by means of flexible care allowances that permit cross-funding of services between the two systems. Yet, many issues remain in the coordination between these systems, including transfer of patients between social care and healthcare facilities, given significant financial incentives for patients to try to stay in health-care facilities, including psychiatric hospitals, even if it is not required by their medical condition (Alexa et al., 2015).

As a former soviet bloc nation, the development of health and social services in the Czech Republic has also confronted and perhaps been delayed by what has been proposed to be a post-communist syndrome, or a propensity for citizens to excessively rely on central authorities for solutions, a scarcity of community organizations, and a minimally developed civic life. This syndrome has been defined as a lack of concept of the citizenship, a lack of identification with the community and withdrawal into the family (Klicperova, Feierabend, & Hofstetter, 1997). Patients were not encouraged to take responsibility of their own health because a sense of personal responsibility and autonomy was not desirable under a totalitarian regime (Srnec & Klicperova-Baker, 1999). Some have emphasized the potential complications that this syndrome poses for reform efforts that assume active involvement of mental health stakeholders (Klicperová-Baker, 2010). However, there has been another research within the Czech Republic that indicates that as early as the late 1990s, this tendency may not be as strong as some have believed, if even present (Klicperová, Feierabend, & Hofstetter, 1997; Petrescu, 2019).

There is a long-standing recognition within the Czech Republic that its mental health system has been overly reliant on institutional inpatient care (Vevera, 2008; Dlouhy, Cosoveanu, Cizarik, & Hinkov, 2015). It employs a system of 18 public psychiatric hospitals that by 2015 provided 8,833 beds, supplemented by 1,308 acute beds in psychiatric units of general hospitals (see Figure 1). Its psychiatric hospitals are among the largest in Europe, most notably Bohnice Hospital in Prague with 1,360 beds. Between 1990 and 2015, the reduction in inpatient psychiatric beds has been 30%, modest by European standards. Whereas Europe as a whole provided 66.6 beds per 100,000 in 2014, the rate in the Czech Republic that year was 94.1 (computed from WHO Data). This pattern is also supported by a comparative international study that showed that the Czech Republic is one of the few nations that has a significantly higher rate of psychiatric hospitalization than is needed (Hudson, in press). Despite its high rates of hospitalization, the Czech Republic spends only 3.0% of its public health budget on mental health, compared with 6.0% for Europe as a whole (Minutes, Czech Psych Society, Feb. 3, 2016).

Fig. 1

Given the now well established patterns of institutionalization in both psychiatric and social services in the Czech Republic that are largely a relic of the communist era, there have been several initiatives since the Velvet Revolution to reform psychiatric care, ones that the Centre for Mental Health Care Development and the Psychiatric Society of the Czech Medical Association (initially through its Section of Social Psychiatry) have played key leadership roles in. In 1992, an informal working group was created that formulated the Framework of Psychiatry (2000). By 2002 this was adopted as a policy statement by the Scientific Council of the Czech Ministry of Health, and came to be known as the National Health Strategy. In 2004, the Ministry formed an implementation committee which published a new report, Mental Health Care Policy: Roads to Implementation, largely prepared by the Centre for Mental Health Care Development. This report subsequently led to the National Psychiatric Programme, which in 2013 resulted in The Psychiatric Care Reform Strategy. These initial efforts unfortunately never gained traction for a variety of reasons, including lack of specific funding and administrative mechanisms, lack of specified milestones, and inadequate adoption by a broad range of inpatient and community stakeholders.

Current Reform Initiative. The current initiative dates back to October of 2012 when the Czech Minister of Health released the Psychiatric Care Reform Strategy. There had been a widespread recognition that the then current governmental structures, including those for mental health, were overdue for reform (Ochrana, Placek, & Pucek, 2016). The plan proposed at that time emphasized the development of a system of community mental health centers, each which would cover a catchment area of approximately 100,000 persons. It included specific provisions to address the criticisms of the earlier efforts, including lack of financing and administrative plans. The following year, this plan was updated as Strategy for Reform of Mental Health Care in 2013.

Most important, it was announced that the initial implementation of the plans would be funded by the European Union's Structural and Investment Funds (ESIF), which included two major components. The Integrated Regional Operational Programme (IROP) would focus on developing the physical infrastructure for both improved hospitals and community clinics, and this would allow for an investment of 2 billion Czech Crowns ($95,880,000). In addition, the Operational Programme Employment would provide 1.35 billion Crowns ($49,586,850) for various wages and operating expenses involving the reform, specifically, those associated with nine projects involving strategy and methodology; network development; humanization of psychiatric care; destigmatization and communication; education and research; legislative changes; interdepartmental cooperation; and prevention. The plan called for the European Union funding to cover approximately 80% of the costs for the initial four years (2017–2021) of the initiative, which is also scheduled to include a second phase from 2021–2035. While improvements in inpatient care are included in the plan, the major emphasis is on the development of the system of community mental health centers, which will be organized around multi-disciplinary community outreach teams, to be supplemented by outpatient, emergency, daytime services, and mobile services, all provided within the context of a balanced and recovery-oriented system of services.

While the outlines of the plan were announced in 2013, it was not until late 2015 that specific arrangements were finalized to begin the initial implementation over the 2016–2017 period. Despite the earlier abortive reform efforts, the current initiative is beginning to be implemented, with new decision-making structures, more detailed plans, and start-up funding. Perhaps one of the most important developments setting the stage for the current initiative was a policy statement, known as the Platform for Deinstitutionalization, which was formulated by a coalition of community mental health groups, and received endorsement by a Czech municipal court in 2017. This brief policy statement defined overarching principles and mandated the development of a community mental health service system in the Czech Republic.

This study examines the initial period of implementation, 2016–2017. It focuses on changes in decision making during this period, specifically, it addresses the following questions:

How have decisions been made in the allocation of public resources for mental health care, to psychiatric hospitals and community mental health programmes, through planning, budgeting, and other management processes? How has this process changed during the initial period of implementation?

Stakeholders and participants in the psychiatric reform include both individuals and a variety of formal and informal organizations. These can be divided into three categories, depending on the extent of their involvement: (i) a small core group of participants who are investing considerable time and effort into planning and implementation, and who appear to be influential; (ii) a larger group of occasionally involved individuals who mostly receive updates and infrequently pose questions or sometimes take positions; and, (iii) a considerably larger group of individuals who rarely participate or who are completely uninvolved, but who have a stake in the success of the initiative.

The core group that is most active is reported to include the Minister of Health and three to five high level staff advisors; four to six psychiatric hospital administrators and other members of the Psychiatric Society, including a consultant, and three representatives of the Czech NIMH. Also, of some importance are the directors of three key advocacy and/or service NGOs who have actively participated in advisory groups. Although potentially important, virtually no interviewees cited the Minister of Labor and Social Affairs and his advisors as being part of this core group, despite their considerable responsibilities for institutional social care and services.

With the exceptions of a few of their directors, most representatives of community organizations fall into the second group of occasionally involved stakeholders. These include some of the staff and members of organizations such as Sympathea, a family advocacy group; FOKUS, an organization representing service providers; VIDA, an advocacy group of both providers and consumers; and the Dialogos and Kolumbus consumer advocacy groups. One of the consumers interviewed indicated that only two or three other consumers have been occasionally involved in the decision-making for the psychiatric reform initiative, and only a slightly greater number of family members, although these organizations do include a considerably greater number of members. Reports were received of only one elected official, a member of parliament who has been involved. In the various committees, advisory, and work groups, there are reports that up to 200 individuals participated, but whose involvement has been only occasional, ranging from a single to a few monthly meetings per year. One community advocate complained that:

There is a big problem in the Czech Republic and it is that there is no direct leadership considering the reform. There are many subjects connected in between one another but there are none and no one who would lead it. I can only think of ---, who has a clear idea about how it should work and is trying for changing it for many years. But I can't say that the reform is connected to one concrete person or organization.

Regarding the participation of politicians in the reform effort, one active community member stated that,

I have never met any politician. The board for reform consists only of professionals, doctors, social workers, users of the care and their family members. It is probably right to say that the government doesn't really take the interest in the psychiatric reform, but I can't see that far.

Given the aims of the Psychiatric Reform project, there have been a wide variety of decisions and plans that have needed to be worked out. Of central interest are decisions on the goals of the reform initiative. However, other than reducing psychiatric hospitalization and developing community services, informants consistently explained there are no specific goals for how much psychiatric hospitalization should be reduced. One informant explained:

I think that each person understands the goals in a different way, but as it is for us, the main goal is the deinstitutionalization. We want to get the help from the big mental hospitals closer to the clients. It means that if someone would find himself in a critical situation, there will be a team which will work intensively with him so he could stay at home in his natural environment. We also think that it is important to change the approach to the treatment. The current system stands mostly on the medication and hospitalization and we would want to bring there some of the alternative methods successfully working abroad. But it is still early to talk about that. Now we have to focus on the deinstitutionalization. There is a visible progress that can be seen in the hospitals, the care is better, they are more open to the clients and they are there for a shorter period of time than they used to be. On the other hand, there are also negative things that were not [there] 10 years ago. For example and maybe the worst of them is that people are over medicated and the use of medication is abused. People became so accustomed to the accessibility of antidepressants that instead of solving the difficult situation in some natural way, they rather go to the doctor for pills. But it is the problem of psychiatry itself, it is a problem of the society.

These are formed out of a wide variety of formal and informal interactions between the participating organizations and individuals. The complexity of these interactions is amplified not only by the variety of such participants, but by the fact that the initiative has involved a negotiation of new decision-making protocols. The specific decision processes involved with the psychiatric reform are also influenced by, on one hand, the broader societal and policy processes and standards involved with the Czech government, and with the European Union and its judicial system; and on the other hand, the personal decision habits of the many individuals involved.

The decision-making structure that was formalized in May 2017 for the psychiatric reform emerged out of deliberations during both the monthly meetings of the Psychiatric Society and meetings between its core leadership and Ministry of Health officials. At its core is a Scientific Council of three lead psychiatrists: the head of the Czech Psychiatric Association, the director of the National Institute of Mental Health, and the director of the Bohnice Psychiatric Hospital – all of whom were appointed by the Minister of Health, and an Executive Committee, or a working committee, which consists of three representatives of the Ministry, seven leaders of the working projects, and nine other members nominated by the Ministry. It is designated to be a permanent executive body that meets regularly (at least once a month, usually once a week) and operationally addresses the management and coordination of all reform activities.

Also, in mid-2017 the Ministry of Health appointed an Expert Council, consisting of representatives of the Ministry, the Psychiatric Society, and various professional and provider groups. This Council is mandated to be the guarantor of the implementation of the Psychiatric Reform Strategy. It reportably consists of 21 stakeholders and is mandated to meet at least quarterly. Also of some importance is a small international advisory committee consisting of foreign mental health policy experts, including ones from the Netherlands and Italy.

The detailed work of planning the reform process has been divided between seven workgroups: Deinstitutionalization, Mental Health Centers, Multidisciplinary Collaboration, New Service Support, Education, Data and Analytical Support, and Destigmatisation. As of the end of 2017, several of these appeared to be functioning, typically with five to ten members who meet either monthly or every few months, and report to the Executive Committee. For example, the Ministry of Health (MOH), “requested a planning group develop standards, which they worked on for about a year. These ended up being very general, in an effort to gain consensus. They had to first be approved by the Psychiatric Society before the MOH.” There have, however, been concerns voiced that responsibilities of the specialized planning groups may have been taken over by the Executive Committee.

Decision processes within these groups appear, based on available minutes and reports, to be semi-formal. For example, the monthly meetings of the Committee of the Psychiatric Society include a variety of reports, of which psychiatric reform matters are often featured. A moderate degree of discussion takes place, concluding in either a consensus decision, or less frequently, a vote. Only occasionally has it been reported that there is disagreement or even a live debate, for example, on the proper response to stigmatization by the press. Another illustration is criticism that was voiced by a workgroup representative to the Committee of the Psychiatric Society for changes in some of the draft standards for the mental health centers. When votes on decisions have been taken, they have rarely been debated. For example, when a contract to use a consultant in psychiatric reform was debated, the decision was a nominally positive one, with 7 in favor, and 4 abstaining. Often, either the chair or a member of the executive committee has been tasked to follow-up on an action that is decided upon and to report back, for example, through meetings with the Ministry of Health or other relevant groups to obtain support for a preferred course of action.

Less detailed information is available on decision-making within the various workgroups since their processes appear to be even more informal, with the decisions of the chair assuming a particularly central role. One informant explained that, “In the task forces, very little actual decision making [takes place]; the chairs usually dominate. These are mostly conducted for dissemination of information.” It is evident that in most of these groups, there is considerable deference to the leadership, typically to the chair and a few other leading members, several of whom are reported to be private consultants engaged by the Psychiatric Society. To the extent that their chairs represent the workgroup in superordinate decision groups, such as the Executive Committee, and report back, they assume a decidedly influential position within their domain.

An important dimension of mental health decision making considered in this study involves the allocation of resources between psychiatric hospitals and community services. This process generally lacks transparency and is reported by the informants interviewed to be centralized with few officials in the MOH. In addition, because the reform initiative is primarily utilizing funds from the European Union grant, there has been little pressure to re-allocate hospital funding for community services; thus, decision-making in this arena has been largely incremental and disjointed. At this stage of the initiative, the development of new processes and structures for planning and implementing the reform, as is the focus of this section, has been the primary concern of most stakeholders.

A central question is how decision making processes are changing under the Psychiatric Reform initiative. Historically, since the demise of the communist state, there has been minimal national direction or exercise of national administrative authority in respect to the country's mental health policies. The Ministry of Health has no formal mental health division, with reports that they devote only an equivalent of 0.5 full-time equivalent staff to managing the national mental health programme. Regarding key decisions and public announcements, the Minister of Health is reported to rely heavily on the recommendations of his advisors and the Psychiatric Society. As such, the Psychiatric Society, which is heavily representative of the interests of the public psychiatric hospitals, has been the de facto source of mental health policy in respect to inpatient care and some outpatient units in those hospitals. Also, playing an important role are the seven insurance companies that negotiate annual payment agreements with providers, and when necessary, submit these to the MOH for approval. These companies are responsible for a wide range of operational decisions in the approval, allocation, and management of mental health services in the Czech Republic.

Important in operational planning has been the Centre for Mental Health Services Development. With the advent of the massive planning effort for the Psychiatric Reform, the Psychiatric Society, and the various other Councils, committees, and workgroups formed have become active in the development of national mental health policies. In this respect, the national mental health programme has moved from a laissez-faire system, largely reliant on the independent discretion of medical hospital personnel, to a nominally participatory system with elements of representative democratic decision making. As such, this is arguably a needed development, however, one for which it is too early to come to definitive conclusions about its effectiveness. It will be important for all interested parties to monitor the extent to which this trend is broadened and institutionalized with better administrative support in the coming years.

The question of whether mental health decision processes are changing under the reform initiative can be answered in the affirmative, but only provisionally given the early date. While the various informants interviewed routinely noted improvements in the level of community participation, of ex-patients, family members, and service providers, they also emphasized that these are limited. For example, one ex-patient stated,

Well, I think that the most significant thing is the start of psychiatric reform, that the system is already beginning to change and is more patient-friendly then it used to. Another important thing is that the patients, users of psychiatric care are more encouraged to speak out for their needs and rights so them being present at the discussion helps to support the implementation of the reform.

Data on the actual impact of the reform, including the changes in decision making, on the lives of mentally ill persons will not be available for several years. However, important milestones in the implementation of the reform programme are being achieved. These include the establishment of a working decision structure, as described in the preceding section, but very importantly, the establishment of the initial mental health centers. These include two in Prague, one in Preov, and one in Brno, the South Moravian region. The first new center that opened in 2017 was the Centre for Mental Health in the South Moravian Region, which includes a multidisciplinary team that operates a crisis and an outpatient care center. The team includes a psychiatrist, nurse, social worker, clinical psychologist, peer consultant, and job consultant. Five other centers were approved for implementation from July 2018, with another 25 centers to be contracted for in the beginning of 2019. The standards for these centers, developed and approved over several years, were published in 2016, but are yet to be fully implemented in the initial group of centers. These defined general principles, or guiding values, and included specification of a priority group of clients; assertiveness in the case management programme; regionality; collaboration with external agencies; utilization of community resources; collaboration with specific services; multidisciplinarity; use of case management; engaging peer support; work with families; ethics and human rights. Required are field team services, day care, crisis service, psychiatric services, clinical psychologist, psychotherapeutic services, support self-help activities. In addition, many important details of the implementation plans have been worked out, for instance, the support of the new community mental health centers by insurance companies if they adhere to the required standards.