I paesi dell’Asia centrale cercano a Trieste i segreti del successo della riforma della salute mentale basata sulla comunità
In the 1970s, Trieste forever changed mental health care in Italy by closing its mental hospital and shifting to a community-based care model, fully centred on its users. Within a few years, the rest of Italy followed.
The city continued this history of innovation by hosting, on 17–19 October, the first-ever study visit of representatives from 4 central Asian countries, eager to learn the secrets to its success in mental health reform and what it would take to put these into practice in their respective contexts.
Health ministry representatives and mental health professionals from Kazakhstan, Kyrgyzstan, Turkmenistan and Uzbekistan spent 3 days in the small city in north-eastern Italy, hosted by the WHO Collaborating Centre for Research and Training in Mental Health at the Mental Health Department of Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI).
ASUGI has shaped community-based mental health services worldwide through promoting the Trieste model, which helps people to live as a part of their community, rather than just trying to cure their illness.
“Rehabilitation is the master project for the user. We must do everything we can to support it,” says Dr Pierfranco Trincas, director of the Mental Health Department of ASUGI.
The study visit follows from a policy dialogue held on 24–25 April 2023 in Tashkent, where moving towards community-based care was high on the agenda.
“They treat me as a peer”
“Our responsibility as mental health professionals is to both meet the person’s care needs and protect their rights and responsibilities as a citizen,” says Dr Tommaso Bonavigo, a psychiatrist working at one of Trieste’s 4 community mental health centres.
These centres do far more than merely provide psychiatric crisis care – they offer a suite of services focused on supporting users’ recovery and resilience.
“A mental health crisis does not happen just because the person has a mental health problem. It is caused by factors in the users themselves, as well as their family, work, neighbourhood and more,” says Dr Bonavigo.
For that reason, community mental health centres focus on identifying factors in users’ environments that contributed to their crises, and finding solutions appropriate for them. This can mean working with family members, housing support, further training or education, and work placements. All this is done in collaboration with users themselves.
“The mental health professionals in Trieste are a part of my family. They take care of me as a person, make me feel valued,” says Elena Cerkvenič, a service user. “They treat me as a peer – there are no white coats, no hierarchy.”
“Promoting mental health is not the specific project of psychiatrists, nurses, and educators,” says Morena Furlan, a psychiatric rehabilitation technician. “You have to take a multilevel approach, engaging users and all public and private agencies in the community network. The best setting to promote mental health is the community, not a single place or service.”
The personalized project
“How is this all financed?” asked one delegate from Uzbekistan – a common refrain throughout the study visit.
How to finance community-based mental health reforms is a perennial question. While early advocates emphasized that community-based care is cheaper than facility-based care, a 2014 WHO expert survey indicated that they cost roughly the same. In fact, the gradual scaling down of facility-based care and reallocation of resources to community-based care – a process known as deinstitutionalization – is more costly in the short term, as both old and new models must be financed in parallel.
Current evidence indicates that community-based services are more effective at promoting recovery. Because they actually see a return on investment, they are considered more cost–effective.
Italy invests about as much as the rest of the WHO European Region in its mental health services, at 3.5% of the total health-care budget. However, Italy’s model allows much more flexibility in how this 3.5% is spent. Through a system known as the “personalized project,” funds are budgeted for individual users to promote overall recovery, not just treatment – this can mean subsidizing their housing or education costs, investing in training or helping them to find work.
“About a quarter of the community mental health service budget is allocated for personalized projects,” says Sari Massiotta, manager of administrative area coordination and development at ASUGI.
Personalized projects are supported by a network of 11 social cooperatives – for-profit companies that work closely with ASUGI to support service users in earning an income. Initially, users’ salaries are funded by their personalized project budget, but they are often hired full-time afterwards.
Accustomed to working with service users, social cooperatives are willing to accommodate users’ needs.
“People may relapse,” says Stefania Grimaldi of the social cooperative La Collina, which offers administrative and cultural services to the city. “It’s not a dramatic situation for us – we decide with the person and community mental health service to use sick leave, so nobody loses their job.”
A service user, Tamara Lipovec, found this essential for her own recovery: “Work is one of the main pillars for rebuilding yourself after a crisis”.
“I never thought I’d be inside the system as a worker, not only as a user,” said Michele Sipala, another service user.
“Our public institutions are not trying to minimize costs, but maximize the benefits and impact on the community,” says Massiotta, “That’s why it is so important to work with local organizations, ones that are trying to improve the well-being of the whole community,” she adds.
“It is truly amazing,” said one delegate from Kazakhstan. “They really do everything with the user at the centre.”
What next?
The study visit closed with a sense of optimism among the delegates from the central Asian countries.
“Mental health is society health,” said a delegate from Uzbekistan. “It was very important to see all those aspects – social aspects, legal aspects, gender aspects – considered.”
“We learned so much,” said a delegate from Kyrgyzstan. “The main thing is that we need to have a strategy. We need to have people tell their stories, really create a collection of successful stories of people who have used our mental health services.”
A delegate from Turkmenistan acknowledged that while there were major differences between the situation in Trieste and that in her country, there was definite scope for improvement. “We do include various groups in decision-making, but not people with mental illnesses. We must start to engage these people as well.”
“We want to apply everything we can – but how do we go about it?” she added.
“I don’t agree that we cannot apply this in our countries; you should never say never. We can always change things,” said a delegate from Kazakhstan.
WHO is planning follow-up sessions with each country to see how these lessons may be applied in practice. It is also organizing other study visits to Trieste, including one from Ukraine in December 2023.
Per saperne di più: https://www.who.int/europe/news/item/19-12-2023-central-asian-countries-seek-secrets-to-success-in-community-based-mental-health-reform-from-trieste–italy