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DOI: 10.1515/cejpp-2016-0022
2015 licensee De Gruyter Open. This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 License.
Dobiášová Karolína1
,Tušková Eva1
, Hanušová Pavla1
, Angelovská Olga1
, Ježková Monika2
The Development of Mental Health Policies in the
Czech Republic and Slovak Republic since 1989
ABSTRACT: The article aims to describe the key events in the development of mental health care policies after 1990 in the two countries
and identify the main reasons for stagnation or incremental changes to the institutional setting in the field of mental health care. The process
of mental health care reform is explained using the framework of historical institutionalism. The explanation shows that the lack of political
interest in combination with the tradition of institutional care resulted in poor availability of psychiatric care, outdated network of inpatient
facilities and critical lack of community care facilities in both countries. Even though Slovak Republic adopted national programme at the
governmental level, it still struggles with its implementation. The ongoing reform attempt in the Czech Republic may bring some change,
thanks to a new approach towards strategic governance of the mental health care system and the mechanism of layering that the promoters
of the reform use.
KEYWORDS: Mental health care, health policy, healthcare reforms, Czech Republic, Slovak Republic
RECEIVED 15 January 2015; ACCEPTED 17 June 2016.
INTRODUCTION
The system of mental health care in the Czech Republic (CR) has not seen any fundamental systematic change since the 1990s. The
field faces the consequences of a continuing lack of financial resources (Ministry of Health 2013, Dlouhý 2014). The CR has no
national policy of mental health care approved by the Government. The lack of political interest together with insufficient funding
result in poor availability of basic psychiatric care, outdated network of inpatient facilities and a critical lack of community care
facilities (Ministry of Health 2013).
In addition, the current rules for healthcare expenses reimbursement from the public health insurance motivates outpatient
psychiatrists to see a high number of patients without taking the time to provide a proper therapy. The current system stimulates
quantity at the expense of quality (Raboch & Wenigová 2012).
While there has been a steep rise in the number of psychiatric patients in outpatient care, the number of outpatient psychiatrists
rises very slowly (IHIS 2013). A vast majority of psychiatric patients are treated only with psychopharmacotherapy, which does not
correspond with the bio-psycho-social approach of today’s psychiatry (Raboch & Wenigová 2012). The main sore point of the whole
system lies in the absence of functional relations between outpatient and inpatient facilities, insufficient collaboration with general
practitioners (GPs) and clinical psychologists (Ministry of Health 2013).
The Ministry of Health is currently working on plans for implementation of the new Psychiatric Care Reform Strategy which
addresses the above mentioned problems. The implementation of the reform depends on various factors, both within and outside
the field of psychiatry. In this respect, the CR could learn from the experience of other countries. We decided to compare the
development of mental health care policies in the CR and Slovak Republic (SR), as both countries have very similar healthcare
systems, which provides for easier transfer of policies (Marmor et al. 2005).
Our article aims to describe the key events in the development of mental health care policies and explain the main reasons for
stagnation or incremental changes to the institutional setting in the field of mental health care in both countries.
1
Dobiášová Karolína, Tušková Eva, Hanušová Pavla, Angelovská Olga: Institute of Sociological Studies, Faculty of Social Sciences, Charles University, Prague, Czech Republic.
Email: karolina.dobiasova@fsv.cuni.cz
2
Ježková Monika: Faculty of Economics and Administration, Masaryk University, Brno, Czech Republic.
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METHODOLOGY
The analysis itself uses a comparative method and builds on the examination of crucial political events. It was preceded by an extensive
desk research, scrutinising documents and other available data in order to identify the relevant areas of mental health care in the CR
and SR. The desk research focused on expert reports in the field (such as Mental Health Care Reform in the Czech and Slovak Republics,
1989 to the Present from 2008, edited by Scheffler and Potůček), formal and informal documents, relevant legal standards, strategies,
policies and programmes (e.g. the Czech National Psychiatric Programme or the Slovak National Programme on Mental Health) and
other available documents. Statistical data were obtained mainly from the Institute of Health Information and Statistics of the CR,
the Public Health Authority of the Slovak Republic, and international comparisons are based on the World Health Organisation’s
(WHO’) Mental Health Atlas (WHO 2005, 2011).
The CR and SR shared their history until 1992, but afterwards, they took different approaches towards the reforms in the area of
mental health care. Therefore, we used the method of agreement (Karlas 2008) in our comparison. The selection of two entities and
the comparison of a high number of instances allows us to see the problems in more detail and avoid excessive generalisation (Mills et
al. 2006, Clasen 1999). The comparison looks at the period from 1989 to the present. We intended not only to describe the situation
but also to explain the key events in the development of mental health care policies. That is why we chose the method of event analysis
– so that instead of focusing on one selected event, we could methodically investigate all events within the relevant area and period of
time (Purkrábek 1994). The method allowed us to observe all changes (or attempts at changes) made to the institutional setting, as
well as the interaction between individual stakeholders in the area of mental health care in the CR and SR since 1989.
THEORETICAL FRAMEWORK
Our analysis of the development of mental health care policies in the CR and SR is provided within the framework of historical
institutionalism (HI). We rely on this explanatory framework because the institutional setting of the area has been very stable for
more than 25 years, despite all the changing internal and external conditions (Oliver & Mossialos 2005, Kümpers et al. 2006). This
corresponds to the ‘path dependency’ theory which shows how previous political decisions limit the options for later ones because it
is difficult to change political tendencies that became a part of the institutional structure and discourse. Although HI admits that the
political process is occasionally disturbed by ‘critical junctures’ that make decision makers choose a particular institutional setting,
after the choice is made, the selected alternative will limit future institutional changes because it is easier to follow the set direction
than change it radically (Pierson 2000).
HI is one of the three streams of the so-called new institutionalism. It allows for the influence of time and history on the
development of the political processes and decisions (Hay & Wincott 1998, Immergut 1998). In the context of HI, an institution
means either a formal organisation or any informal rules or procedures that shape the structure of human actions (Steinmo & Thelen
1992). HI presumes that on one hand, institutions can substantially influence the creation and implementation of political strategies,
while on the other hand, institutions themselves are products (either intentional or accidental) of the strategies created within the
political struggle (Steinmo & Thelen 1992, Hay & Wincott 1998).
HI theorists explain the incremental changes in policies (that means, formal institutions) using five fundamental causal
mechanisms: displacement, layering, drift, conversion and exhaustion. Displacement is a process in which the dominant institution
is gradually replaced with a new alternative institution. The new institution consequently generates a discord within the institutional
framework that opens the way for incongruent actions and gradual development of a new institutional logic. The new institution may
come from suppressed historical alternatives or may coexist along the dominant institution or may be promoted by some external
powerful actor. Layering is a process that adds a new, potentially transformative element in the old structure. It’s a gradual process,
usually the emergence of a new element does not provoke countermobilisation of defenders of the status quo. This may occur so that
the new institution is growing faster and takes resources the old institution. The new arrangement can also destabilise an existing
institution, and compromise between the old and the new institutions can gradually change in the defeat of the old one. Drift denotes
the consequence of deliberate negligence – an institution that is required to adapt to new conditions (e.g. new demographic trends)
deliberately chooses not to, and as a result, the institutional structure becomes outdated and it loses its meaning or functionality.
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Conversion occurs when old institutions are required to take up new functions or roles, when the reinterpretation of old rules serves
to fulfil new goals. Finally, exhaustion denotes a gradual collapse of an institution that undermines itself (Streeck & Thelen 2005).
These five mechanisms show that institutions can be gradually transformed even when we can see only incremental, if any,
changes. In their elaboration of this theory, Mahoney and Thelen considered the general prerequisites that increase the probability of
success for particular kinds of strategies or changes. By doing this, they specified the analytical framework combining the characteristics
of political context with the characteristics of the targeted institution. They assessed to what extent the political context allows the
supporters of status quo to veto decisions and how much space for implementation of the changes is granted by the examined
institutions (Mahoney & Thelen 2010).
KEY INDICATORS OF MENTAL HEALTH CARE IN THE CZECH REPUBLIC AND SLOVAK
REPUBLIC
Within the European region, WHO estimates the mean share of mental health care expenses at 6% of the overall healthcare expenses
(Jacob 2007 quoted by Dlouhý 2014). In this respect, both the CR with estimated 3% and SR estimated 5% rank among countries
with considerably underfunded mental health care (Dlouhý 2014).1
In terms of the network of psychiatric facilities, SR started to develop community mental health centres in 2002 within the
pilot project “Transformation and integration of mental health care system“ (Potůček & Scheffler 2008), but since then, only a few
other pilot centres emerged. CR has been unable to anchor community mental health centres firmly in its mental health care system
(Raboch & Wenigová 2012). The CR has a higher number of day-care centres for people with mental illness and more outpatient
psychiatric facilities per 100,000 inhabitants (Table 1). There is a critical shortage of day-care centres in the SR. According to experts
from practice, crisis day-care centres with mobile teams, rehabilitation facilities and psychiatric home care are insufficiently available
or unavailable in some regions (Bražinová et al. 2011). In terms of inpatient care, most psychiatric beds in the CR are in psychiatric
hospitals, although the number has slightly decreased between 2005 and 2011 (Table 2). SR has seen a substantial drop in the number
of beds in psychiatric hospitals, balanced with a growing number of beds in psychiatric departments of general hospitals (Table 2).
Both countries differ significantly in terms of the average number of beds per institution. While the CR with its 502 beds places
the highest of all EU countries (Winkler et al. 2013), SR’s 182 beds per institution correspond to the EU average (193 beds per
institution in EU 15 and 218 in EU 27) (WHO 2011 quoted by Winkler et al. 2013). In terms of human resources in mental health
care, the CR has more psychiatrists, but both countries are below the average of the EU 15. Compared with the EU 15 and EU 27
average, both countries have significantly lower number of psychiatric nurses (Table 3).
TRANSFORMATION IN THE CZECH REPUBLIC AND SLOVAK REPUBLIC
In the period before the Velvet Revolution of 1989, the psychiatric care in former Czechoslovakia gradually moved from long-term
care to the more efficient acute care. This was facilitated by the development in psychopharmacology and the growing number of
physicians specialising in the area of mental health care. Between the years 1960 and 1989, the number of physicians in psychiatric
hospitals increased by 60%, in psychiatric departments of general hospitals by 319% and in outpatient services by 479%. This might
look like a favourable development in psychiatric care, but it can also be interpreted as a result of serious neglect of the psycho-social
aspects of mental disorders and narrow focus on their medical aspects in that period. The upward trend in the number of psychiatrists
corresponds to the increasing number of contacts with outpatient facilities (Potůček & Scheffler 2008: 33)
1
Regarding the WHO data, used in this article, they should be interpreted with caution. WHO statistics do not show a significant difference in the quality of psychiatric beds in
the monitored countries (Winkler et al. 2013). It is also necessary to take into account the varying reliability of the information that the states provide (Muijen 2008 quoted by
Winkler et al. 2013).
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As oft
January 1993, Czechoslovakia split into two independent states. The new countries adopted the basic international human
rights documents in 1992. The CR endorsed the Charter of Fundamental Rights and Basic Freedoms – in terms of mental health
care, the most relevant articles are those about freedom and equality, dignity, rights, and protection of health for everyone, as well
as protection against torture and inhumane or humiliating treatment. The SR incorporated stipulations on fundamental rights and
freedoms into the new Constitution which says that nobody is to be tortured or subject to any similar cruel, inhumane or humiliating
treatment or punishment, and everybody has the right to dignity, personal honour, good reputation and respect. In the early 1990s,
both countries switched from the Semashko model of health care delivery (centralised and fully funded by the state) to the health
insurance system (with the compulsory health insurance and partial liberalisation of the ownership of health care facilities). In the
following years, the CR focused on the economic and political transformation and neglected most other areas, including mental
health care; while SR made the first steps of mental health care reform already in 1991 (see below).
Tab. 2: Number of psychiatric beds per 100,000 inhabitants in 2005 and 2011
Year Czech Republic Slovak Republic EU 27 EU 15
Beds in psychiatric hospitals
2005 98 60 68* 57*
2011 92 31 62** 53***
Beds in psychiatric departments of
general hospitals
2005 15 30 23**** 26****
2011 13 38 24***** 24****
Source:WHO (2005, 2011), quoted byWinkler et al. 2013
* Except for Denmark, theUnited Kingdom andSweden. ** Except for Denmark, theUnited Kingdom,Sweden, Italy, Estonia and Hungary. ***
Except for Denmark, the United Kingdom, Sweden and Italy. **** Except for Denmark and United Kingdom. ***** Except for Denmark, the
United Kingdom, Estonia and Lithuania.
Tab. 3: Number of psychiatrists and psychiatric nurses per 100,000 inhabitants
Year Czech Republic Slovak Republic EU 27 EU 15
Psychiatrists
2005 12 10 11* 13*
2011 12 11 12** 14**
Psychiatric nurses
2005 33 32 47*** 60**
2011 28 19 42**** 57*****
Source:WHO (2005, 2011), quoted byWinkler et al. 2013
* Except for United Kingdom. ** Except for Belgium and the United Kingdom. *** Except for Belgium, the United Kingdom and Estonia. ****
Except for the United Kingdom, Belgium, Luxembourg, Denmark, Greece, Finland, Austria, Estonia, Lithuania and Bulgaria. ***** Except for
the United Kingdom, Belgium, Luxembourg, Denmark, Greece, Finland and Austria.
Tab.1: The number of psychiatric facilities per 100,000 inhabitants in 2011
Outpatient care Day-care centres
Community residential
facilities
Psychiatric
hospitals
Czech Republic 7.92 0.74 Unavailable data 0.18
Slovak Republic 6.39 0.33 4.93 0.17
Source:WHO 2011
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THE DEVELOPMENT OF MENTAL HEALTH CARE IN THE CZECH REPUBLIC
The new Framework of Psychiatry
An informal work group was appointed in 1992 to create the Framework of Psychiatry. In 1995, the group was officially confirmed by
the Committee of the Psychiatric Association as the Commission for the Creation of a Draft Framework of Psychiatry. The Psychiatric
Association endorsed the Framework proposed by the Commission in 2000, and in 2002, the new Framework of Psychiatry was
acknowledged by the Scientific Council of the Czech Ministry of Health. The Framework proposed to shift the acute psychiatric care
from mental hospitals to psychiatric departments of general hospitals. Consequently, the number of beds in both types of facilities
was to be reduced, and patients were to be preferably placed in home care or community mental health centres. The number of beds
gradually decreased, but there was no transfer of the acute care to psychiatric departments and the community services where not
developed (Raboch & Wenigová 2012). The Framework also tackled the problems of several vulnerable groups (the elderly, children
and youth, persons with addiction, people with chronic diseases, people with eating disorders, and criminals with mental illness).
The Framework identified the essential problems and included a list of goals, but failed to specify methods of implementation and
distribute responsibilities (Framework of Psychiatry 2000). Two years later (responding to a constant pressure from the Centre for
Mental Health Care Development (CMHCD)), the Ministry of Health decided to support the implementation of the Framework by
appointing the Implementation Committee which included representatives of all the segments of mental health care, the Psychiatric
Association, CMHD and, representatives of psychiatric patients and their families. The Implementation Committee was authorised
to propose specific methods and processes of implementation. Within the workshop called Does our Level of Mental Health Care
Match the EU? held in the Chamber of Deputies of the Czech Parliament in 2004, the Framework was discussed by numerous
specialists and politicians, both local and international. In 2005, several members of the Implementation Committee published a
document titled Mental Health Care Policy – Roads to Implementation (Centre for Mental Health Care Develpment… 2005). The
document offered three alternatives of the reform: (1) diversification of services provided in psychiatric hospitals (in order to maintain
the capacity and staff of the hospitals while lowering the number of hospitalised patients, (2) closing of selected departments in
psychiatric hospital, (3) closing of selected psychiatric hospitals. The authors of the document clearly stated that any changes in the
field of mental health care depend on multilevel coordination of policies and the existence of ‘“political will’” supported by a clear
vision. Authors believed that the reform should be supported by active lobbying (especially by experts in psychiatry) both at the
regional and national levels. The implementation was to draw from intense negotiations with other stakeholders (e.g. health insurers,
care providers), extensive public discussion which could effectuate a change in the general attitude towards psychiatry and people with
mental illness, and a shift of responsibilities from the Implementation Committee to the national government (Centre for Mental
Health Care Develpment… 2005). These goals, however, remained unfulfilled, and the Implementation Committee was dissolved by
the Minister of Health Tomáš Julínek (2006–2009).
Implementation of the Health 21 strategy in the field of mental health
WHO’s Health 21 strategy tackles a wide scale of health aspects. One of its goals concerns a complete transformation of the mental
health care system, including the transfer of a large part of psychiatric care from psychiatric hospitals to psychiatric departments
in general hospitals, home care and field mental health centres. The goal was acknowledged by the government of Vladimír Špidla
which set the ‘“Health 21’” Committee within the Czech Government’s Health and Environment Committee. This tool, however,
proved entirely inefficient, and the Committee carried out only a formal evaluation of the programme. The programme was not
legally binding and no funds were allocated to its implementation (Kříž 2013).
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The National Psychiatric Programme of 2007
In reaction to the negligible effect of all the actions taken since 2000, the Committee of the Psychiatric Association decided to publish
a new strategic document in 2007. The National Psychiatric Programme was created in collaboration with the regional WHO office
and it responded to two important WHO and EU documents of 2005 – WHO’s Mental Health Action Plan for Europe and the
EU Commission’s Green Paper. The publication of the National Psychiatric Programme of 2007 was supported by a workshop held
in the Senate of the Czech parliament under the patronage of its chairman. The document focused on the support of the primary
psychiatric care, development of community care, innovation of inpatient facilities, and encouragement of the bio-psycho-social
model combining pharmacotherapy, psychotherapy and social intervention. The programme listed general goals and tasks, but failed
to tackle the question of implementation and responsibilities (National Psychiatric Programme 2007).
The Revised Framework of Psychiatry of 2008
The work on the review of the Framework of Psychiatry began in 2006, partly in response to the dissolution of the Implementation
Committee by the Minister of Health Tomáš Julínek. The Congress of the Psychiatric Association appointed the Commission for
the Revision of the Framework of Psychiatry. Before it started to work on the review, the Commission asked all mental health care
providers to submit their own proposals for changes. In 2008, the Congress of the Psychiatric Association endorsed the Revised
Framework of Psychiatry. The Revised Framework describes all the segments of mental health care and assesses their needs. It advocates
the model of balanced care (in Czech environment, this refers mainly to the strengthening of community care). The Psychiatric
Association published the document on its website and allowed an online discussion. Unfortunately, the Revised Framework does not
specify intended methods and timeline of implementation (Revised Framework of Psychiatry 2008).
The current strategy for the reform of mental health care in the Czech Republic
The creation of the current reform strategy began in late 2012 by the decision of the Czech Minister of Health. The Psychiatric Care
Reform Strategy (PCRS) (Ministry of Health 2013) addresses the problems identified in the Revised Framework of Psychiatry of 2008
and responds to earlier strategic documents, as well as many international documents, primarily the UN Convention on the Rights of
Persons with Disabilities of 2008, which was ratified by the Czech Parliament and the President of the Czech Republic, incorporated
in the Czech legal system, and the European Mental Health Action Plan (2013), a guideline for the creation of national mental health
policies, endorsed and ratified by WHO (Hollý 2014).
Adopted as part of the National Reform Programme in March 2013 (Ministry of Health 2013), PCRS specifies the basic assumptions
and lists the consensual proposals for changes in the psychiatric care system for the next decade (Hollý 2014). Unlike earlier documents,
PCRS was co-authored by a vast majority of key stakeholders: the Ministry of Health, the Ministry of Social Affairs, health insurers,
professional associations, representatives of healthcare facilities, the Association of Regions in the Czech Republic, patients and nongovernmental
organisations (NGOs) (Duškov 2013, Ministry of Health 2013). The implementation plan of PCRS assumes a close
collaboration between various stakeholders, especially the Ministry of Health and the Ministry of Social Affairs. Since the funding of
social services will be governed by regional authorities as of 2015, the implementation also includes cooperation with the Association of
Regions in the Czech Republic (Ministry of Health 2013). Because various aspects of mental health care relate to the responsibilities of
other authorities, such as the Ministry of Regional Development (sheltered and supported housing), the Ministry of Justice (detention),
the Ministry of the Interior (education of the police, involuntary treatment assistance), the Ministry of Culture (the Council for Radio
and Television Broadcasting, control of mental illness connotations in public media, education), the Ministry of Finance (incentives
for employers of people with mental illness) etc., the later stages of PCRS implementation is expected to be managed on the level of
the Government, with the Ministry of Health coordinating the individual processes (Duškov 2013).
The transitory costs (i.e. the costs of the modifications to the structure of the system) are planned to be partly covered from the
European Structural and Investment Fund (Duškov 2013). The costs of other individual steps in the process will be determined based
on the economic analyses (Ministry of Health 2013). The funding will require an agreement with public health insurers (Hollý 2014).
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The central objective of the Psychiatric Care Reform Strategy is to improve the quality of life for people with mental illness. To do
this, it will be necessary to:
•	 improve the quality of psychiatric care through a methodical change of the mental health care system;
•	 moderate the stigmatization of psychiatric patients and the field of psychiatry in general;
•	 improve the satisfaction of patients with the provided psychiatric care;
•	 increase the efficiency of psychiatric care via early diagnosis and pro-active identification of hidden cases of mental disorders;
•	 support the integration of people with mental illness in the society (especially through better employment conditions, education,
housing, etc.);
•	 improve the communication between healthcare and social services and other related services;
•	 make the psychiatric care in the CR more humane. (Ministry of Health 2013)
Finally, the fulfilment of the aforesaid goals should result in a complex change to the Czech system and shift the general character of
the system from the current institutional model towards an arrangement that balances community and hospital care (Hollý 2014).
The most dramatic change to the current system concerns the establishment of complete new institutions – Mental Health Centres
(MHC), facilities located in ordinary residential areas that provide complex healthcare and social services to clients with a serious
mental illness (SMI). MHCs are intended to help people with mental illness to live in their homes and community. MHCs should
employ interdisciplinary teams that are able to respond to the complex needs of their clients and procure-related services within the
region. These facilities should also collaborate with other providers of healthcare and social care services (Hollý 2014).
Unlike earlier attempts, the authors of the PCRS aspire to systematically create a comprehensive implementation plan and detailing
individual steps in each area of the reform. At present, several work groups are discussing various aspects of the document’s
implementation (Ministry of Health 2013).
There are still several questions that need to be solved in relation to the new institutions: Who will run MHCs? Big hospitals,
experienced NGOs or newly established institutions? The new system needs to secure stable financial resources because the funding
from ESIF only concerns the reform itself, and after the reform has been finished, the newly created system should fully depend on
national resources (Třešňák 2014). Furthermore, up to now, deinstitutionalisation and reduction of the number of beds in mental
hospitals is not specified. PCRS plans to carry out economic analyses in order to assess the future costs of the new system which will
be the basis for the creation of a new model of psychiatric care funding (Ministry of Health 2013).
Unlike the international academic and political discourse (WHO, EU), the field of mental health promotion and protection as
specified in the National Strategy for Health Protection, Health Promotion and Disease Prevention –- Health 2020 is rather marginalised
in the before mentioned reform attempts of mental health care.
THE DEVELOPMENT OF MENTAL HEALTH CARE IN THE SLOVAK REPUBLIC
Reform of Psychiatric Care
In 1990, a group of experts from the fields of psychiatry and psychology prepared a document titled Reform of Psychiatric Care, which
was endorsed by the Slovak Ministry of Health in 1991. The suggestions conveyed in the document were later used in the creation
of the Framework of Psychiatry, published in 1997. Unfortunately, the Ministry never gave the Framework an official status and the
document served merely as a source of inspiration, especially with respect to the need for greater role of the community care within
the system. Although there was some increase in the overall number of outpatient psychiatrists and the accessibility of outpatient
psychiatric services in some critical regions improved in the years following the publication of the Framework, it could not match the
steep rise in the number of psychiatric patients (Breier 2005, Framework of Psychiatry 1997).
Neither the Framework of Psychiatry nor the Reform of Psychiatric Care specified the timeline of implementation, the distribution
of responsibilities or any proposal for funding, which led to the failure of their implementation and the continuing absence of a
national mental health care policy (National Programme on Mental Health 2004).
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2004 – National Programme on Mental Health
At the time of SR’s entry into the EU, the country went through extensive reforms of the healthcare2 and social systems, creating
completely new socio-economic conditions. At the same time, the country experienced a steep rise in the rate of certain somatic
conditions and there was an urgent need for the prevention of mental disorders. All this led to the creation of the Slovak National
Programme on Mental Health which reflected the economic and social situation of the country, its cultural heritage, demographic
specificities and the desired development of the society.
The Slovak Government approved the National Programme on Mental Health in 2004, with the following goals for the period
2005–2015: to reduce the stigma associated with mental illness; to establish homecare agencies; to set up intervention services and
mental health programmes; to improve the general availability of prevention (primary, secondary and tertiary); promotion of mental
health; active participation of people with mental illness and their families in the planning; to implement execution and evaluation
of mental health care processes; adequate funding and authorisation of mental health care providers. The goals of the programme
respond to the dialogue between EU Member States and the EC (Green Paper on Mental Health) and their further development is
discussed in several EU documents. The Slovak Ministry of Health adopted several strategic documents concerning mental health
care and drug addiction treatment in 2006 (European Observatory on Health System and Policies … 2011).
Unlike the Framework of Psychiatry and the Reform of Psychiatric Care, the National Programme on Mental Health was accompanied
with a comprehensive implementation plan, including a detailed timeline, distribution of responsibilities and proposal of methods
of funding. The plan was prepared in collaboration with various stakeholders. The key principles include decentralisation, demandoriented
management and patient-oriented design of services (National Programme on Mental Health 2004). The general plan
for the decade 2005–-2015 is supplemented with plans for shorter periods of two or three years which allows to more detailed
specification of individual tasks for each year (Ministry of Health 2015).
Implementation plans of the National Programme on Mental Health for the period 2006–2007
The implementation plan for the period 2006–2007 included a number of particular tasks, e.g. to define the optimum and minimum
network of mental health care facilities in the regions, to establish health-social departments in the psychiatric inpatient facilities, to
develop the concept of the establishment of psychiatric home care and, to create the regional plans of mental health care in selected
regions. Majority of the 54 tasks were fulfilled. (Ministry of Health 2015)
Implementation plans of the National Programme on Mental Health for the period 2008–2010
The main priority of the plan for the period 2008–2010 was to improve the mental health of the general population, reduce the
incidence of mental disorders, and cut the mortality rates related to mental disorders. The proposed tasks included activities in various
areas of psychological intervention in all age groups and related to the prevention of mental disorders and elimination of their most
frequent causes; improvement of the conditions for psychosocial well-being; and improvement of people’s ability to manage stressful
situations that might lead to mental disorders. Their implementation involved complex solutions requiring the contribution and
participation of various ministries, NGOs, regional authorities and associations (Meeting of the Slovak Government 2008). The
institutional framework was selected carefully to maintain the stability and development of mental health policies. The individual
steps of the implementation of the National Programme on Mental Health were approved by government decrees (ibid 2008).
2
The reform of the Slovak healthcare system in the period 2002–2006, launched by the government of Mikulas Dzurinda, is generally considered the most radical market-driven
reform that was ever seen in Europe. The concept of the reform is regarded as globally unique. The healthcare reform was a part of a larger reform plan labelled ‘Slovak Republic’s
neoliberal turn’ (European Observatory on Health Systems and Policies 2011).
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Cent. Eur. J. Public Policy 2016; 10(1): 35–46
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Implementation plans of the National Programme on Mental Health for the periods
2011–2013 and 2014–2015
The plan for the period 2011–2013 focused on youths’ mental health education, prevention of depressions and suicides, protection of
mental health at work and within the society, but it also addressed the questions of mental health amongst older adults and proposed
actions against stigmatisation and social exclusion. These tasks responded to the EU Council’s Conclusions on the European Pact for
Mental Health and Well-being (2011/C202/01), published in the Official Journal of the European Union on 8 July 2011 (Meeting of
the Slovak Government 2012a, Meeting of the Slovak Government 2012b).
The implementation of the National Programme on Mental Health in the period 2014–2015 focused on various projects of mental
health support, prevention of risk behaviour, encouragement of social integration of people with serious physical or mental health
illness or behavioural disorders and creating conditions for better accessibility of high-quality social services for people with mental
illness. The objective is to provide services that respect the individual needs of the clients and minimise the need for institutional care
(Ministry of Justice 2013).
In the period 2011–2013, the implementation of the National Programme on Mental Health was hindered by insufficient
funding. The allocated funds could not cover the planned activities (Ministry of Justice 2013). Activities planned for the period
2014–2015 have already had financial support (Ministry of Health 2015).
2007 –The establishment of the Council for Mental Health
The Council for Mental Health was established in 2007 as an advisory body to the Slovak Ministry of Health. Its tasks are related to the
creation and implementation of the National Programme on Mental Health. The Council is an interdisciplinary body – the individual
members are appointed by ministries and other governmental institutions, NGOs and regional authorities and associations, and their
appointment is confirmed by the Ministry of Health. The Council monitors, coordinates and evaluates the fulfilment of individual
tasks and analyses the overall success of the National Programme on Mental Health. Beside this governmental body, there are numerous
NGOs that influence the creation of the mental health policy, especially by raising the general awareness of various aspects of mental
health. These organisations, however, are less likely to influence the allocation of resources (Dlouhý 2010).
DISCUSSION AND CONCLUSIONS
The CR and SR still struggle with the burden of the totalitarian regime. Even 25 years after the Velvet Revolution, there are serious
deficiencies in the social and economic area, including health care in general and mental health care in particular. After 1990, both
countries started to develop new mental health policies (Table 4), but because of a long tradition of care concentrated into large
psychiatric hospitals (i.e. the influence of the path dependency) neither has managed a thorough reform of the mental health care
system. The crucial event for both countries was their joining of the EU in 2004 and the subsequent adoption of WHO and EU
documents of 2005 – WHO’s Mental Health Action Plan for Europe and the EU Commission’s Green Paper on Promoting the Mental
Health of the Population – which propose to shift national policies towards deinstitutionalisation of mental health care, and their
incorporation into the national policy frameworks.
SR was the first to adopt changes to the mental health care institutional framework. In terms of the theoretical concept of HI,
it was an attempt to change the mental health care policy by incorporation of new elements into the existing system (layering).
The mental health care policy in SR was most notably influenced by the National Programme on Mental Health adopted by the
Slovak Government in 2004. The programme includes a comprehensive plan of implementation, detailed timeline, distribution of
responsibilities between individual stakeholders and proposals for a funding framework. The development in SR was considerably
furthered by the Council for Mental Health of the Slovak Ministry of Health established in 2007. The Council monitors, coordinates
and evaluates the fulfilment of individual tasks within the National Programme on Mental Health and analyses its overall success. The
plans for the implementation of the National Programme and the assessment of its fulfilment are overseen by the Slovak Government.
The central problem of the implementation lies in insufficient funding.
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Professional associations together with providers and users of mental health care in the CR have created numerous strategic documents
that described the current state, identified the key problems and defined the essential goals but failed to address the question of
implementation. The documents were intended to serve as an expert background for political decisions but were largely neglected by
politicians. In 2013, the Czech Ministry of Health created the Psychiatric Care Reform Strategy, including a plan of implementation,
outline of the individual steps, and proposals for a funding framework. The key aim of the reform is to incorporate a new model of
care – the aforementioned mental health centres – into the existing system. It is assumed that these centres will gradually become a
key element of the mental health care system and contribute to its transformation from current model based on inpatient care towards
the balanced care model (an arrangement that balances community and inpatient care). Similarly to the SR, the Czech policy makers
are also trying to change the existing system through the mechanism of layering. The theory presupposes that a careful incorporation
of a new institutional element into an existing system might successfully change the old institutional structure under the proviso
that the new element does not threaten the existing institutional regime (and, hence, does not provoke counteraction of defenders
of the status quo). It is probably the case of the Czech approach towards the reform, because the exact form of deinstitutionalisation
(i.e. a reduction of beds in inpatient facilities) is still not properly scheduled. Although the current reform document was created in
close cooperation with all relevant stakeholders, the interdisciplinary character of the proposed reform will make it necessary to have
the reform managed on the level of the Government. In order to secure the funding of the new institutional framework, it will be
vital to create new mechanisms of sustainable funding. As the document concentrates on the reform of the system of psychiatric care
Tab. 4: Key events in the development of mental health policies in the CR and SR
Czech Republic Slovak Republic
1992–
2000
Informal work group was appointed in 1992 to
create the Framework of Psychiatry.The Framework
of Psychiatry was published by the Psychiatric
Association in 2000
1991
A document titled Reform of Psychiatric Care was
endorsed by the Slovak Ministry of Health
2002
The national strategy Health 21 was
acknowledged by the Czech Government; the
Framework of Psychiatry was acknowledged by the
Scientific Council of the Czech Ministry of Health
1997 The Framework of Psychiatry was published
2004
The Ministry of Health appointed the Framework of
Psychiatry Implementation Committee
2004
The Slovak Government approved the National
Programme on Mental Health.
2005
Several members of the Implementation Committee
published a document titled Mental Health Care Policy
– Roads to Implementation
2005
The Slovak Government adopted the National
Programme on Mental Health implementation plans
for 2005–2015.The general plan was divided into
shorter periods of two or three years
The National Programme on Mental Health for the
period 2006–2007
2007
The National Psychiatric Programme was created
by the Committee of the Psychiatric Association in
collaboration with the regionalWHO office
2007
The Council for Mental Health was established as an
advisory body to the Slovak Ministry of Health
2008
The Congress of the Psychiatric Association endorsed
the Revised Framework of Psychiatry
2007
The National Programme on Mental Health for the
period 2008–2010
2012
The Czech Minister of Health established a team to
produce a new Psychiatric Care Reform Strategy
2010
The National Programme on Mental Health for the
period 2011–2013
2013
The Psychiatric Care Reform Strategy
was adopted as a part of the National Reform
Programme
2013 The National Programme on Mental Health for the
period 2014–2015
Source: Authors
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institutions and pays little attention to the need for prevention and mental health promotion, the Czech Government will need to
follow the example of the Slovak Government and adopt a complex national programme on mental health.
ACKNOWLEDGEMENTS
Work of Karolína Dobiášová has been supported by Czech Science Foundation grant Nr. 16-14292S, Does policy design matter?
A comparative study of target populations in the Czech Republic. Work of Eva Tušková has been supported by specific Charles
University research project no. 260339. Work of Olga Angelovská has been supported by the Charles University Grant Agency as part
of project no. 1122214, Changes in the roles of the state and market in the Czech healthcare system.
REFERENCES
Bražinová, A. et al. (2011). Sociálna rehabilitácie pre osoby s duševnými
poruchami [Social rehabilitation for persons with mental disorders].
Národná rada občanov so zdravotným postihnutím. available atWWW:
http://www.nrozp.sk/index.php/soc-rehabilitacia/psychicke-
postihnutie/98-socialna-rehabilitacia-ludi-s-dusevnymi-poruchami.
Breier, P. (2005). Súčasný stav psychiatrickej starostlivosti na Slovensku
[The current state of psychiatric care in Slovak Republic]. Available at
WWW: http://www.politikon.cz/index.php/publicistika/6/2231-suasny-
stav-psychiatrickej-starostlivosti-na-slovensku.
Centre for Mental Health Care Development. 2005. Politika péče o
duševní zdraví – cesty k její realizaci [Mental Health Care Policy - Roads to
Implementation].
Clasen, J. (1999). Comparative Social Policy: Concepts, Theories and
Methods. Oxford: Blackwell Publishers.
Dlouhý, M., Cosoveanu, G., Čižmárik, P., & Hinkov, H. (2010). Mental
Health Policies in Four Eastern European Countries. Central European
Journal of Public Policy.Vol.4, No 2.
Dlouhý, M. (2014). Mental health policy in Eastern Europe: a
comparative analysis of seven mental health systems. BMC health
services research,14(1), 42.
Duškov, I. (2013). Vydání 1. verze strategického dokumentu - Strategie
reformy psychiatrické péče [Release of the first version of the strategic
document - Psychiatric care reform strategy]. Presentation on 8.10. 2013.
EuropeanCommission. (2005). Green Paper: Improving the mental health
of the population: Towards a stratégy on mental health for the European
Union. European Communities.
European Observatory on Health Systems and Policies. (2011). HIT Health
in Transition: Slovak Republic. Vol. 13 No 2. Available at WWW:
http://www.euro.who.int/__data/assets/pdf_file/0004/140593/e94972.
pdf
Framework of Psychiatry. [Koncepcia psychiatrie]. 1997. Available at
WWW: http://www.psychiatry.sk/sps-sls-o-nas/koncepcia-psychiatrie.
Framework of Psychiatry. [Koncepce oboru psychiatrie]. 2000.
Psychiatrická společnost České lékařské společnosti Jana Evangelisty
Purkyně.
Meeting of the Slovak Government. (2008). Predkladacia sprava k Plánu
realizácie úloh Národného programu duševného zdravia na obdobie
rokov 2008 – 2010. [Explanatory memorandum to the implementation
plan tasks of the National Programme on Mental Health for the period
2008 – 2010]. Available at WWW: http://www.rokovania.sk/File.aspx/
ViewDocumentHtml/Mater-Dokum-37239?prefixFile=m.
Meeting of the Slovak Government. (2012a). Uznesenia vlády Slovenskej
republiky k plánu realizácie úloh Národného programu duševného zdravia
na obdobie rokov 2012 – 2013. [Resolution of theGovernment of theSlovak
Republic to the implementation plan tasks of the National Programme on
Mental Health for the period 2008 – 2010]. Available at WWW: http://
www.rokovania.sk/Rokovanie.aspx/BodRokovaniaDetail?idMateri
al=21361.
Meeting of the Slovak Government. (2012b). Predkladacia sprava
k plánu realizácie úloh Národného programu duševného zdravia na
roky 2012 – 2013. [Explanatory memorandum to the implementation
plan tasks of the National Programme on Mental Health for the period
2012 – 2013]. Available at WWW: http://www.rokovania.sk/File.aspx/
ViewDocumentHtml/Mater-Dokum-146661?prefixFile=m.
Hay, C., & Wincott, D. (1998). Structure, Agency and Historical
Institutionalism. Political Studies, XLVI, 951-957.
Hollý, M. (2014). Reforma psychiatrické péče [Reform of the Psychiatric
Care]. Postgraduální Medicína, 06/2014.
IHIS. (2013). Psychiatrická péče 2012 [Psychiatric care 2012]. Praha: ÚZIS.
Immergut, E.M. (1998).The theoretical core of the new institutionalism.
Polit Soc. 26:5–34.
Jacob KS, Sharan P, Mirza I, Garrido-Cumbrera M, Seedat S, SreenivasV,
Saxena S. (2007).
Mental health system in countries: where are we now? Lancet, 370:1061–
1077.
Karlas, J. (2008). Komparativní případová studie. [Comparative case
study] In: Drulák, P. et al. Jak zkoumat politiku: kvalitativní metodologie v
politologii a v mezinárodních vztazích. Praha: Portál, s. 62-91.
Kříž, J. (2013). Hodnocení programu Zdraví 21. [Evaluation of
implementation of National Health 21 Programme]. Presentation at the
45Brought to you by | Masarykova Univerzita v Brne
Authenticated
Download Date | 3/30/17 11:00 AM
Cent. Eur. J. Public Policy 2016; 10(1): 35–46
DOI: 10.1515/cejpp-2016-0022
2015 licensee De Gruyter Open. This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 License.
seminar of the Society for Public Health and the Society of Hygiene and
Community Medicine of the Czech Medical Association. 6.2. 2013.
Kümpers, S., Mur-Veeman, I., Hardy, B., van Raak, A., & Maarse, H.
(2006). Integrating dementia care in England and the Netherlands: Four
comparative local case studies. Health & Place, 12(4), 404–420.
Mahoney, J., & Thelen, K. A. (2010). Theory of Gradual Institutional
Change In Mahoney, J., & Thelen, K. (Eds.) Explaining Institutional
Change: Ambiguity, Agency, and Power. NewYork: Cambridge University
Press.
Marmor, T., Freeman, R., & Okma, K. (2005). Comparative perspectives
and policy learning in the world of health care. Journal of Comparative
Policy Analysis, 7(4), 331–348.
Mills, M., van de Bunt, G., & de Bruijn, J. (2006). Comparative research:
Persistent problems and promising solutions. International Sociology, 21
(5): 619–31.
Ministry of Health of the Slovak Republic. (2015). Plán realizácie
úloh Národného programu duševného zdravia na roky 2014-2015
[Implementation plan tasks of the National Programme on Mental
Health for 2014-2015]. Available at WWW: http://www.health.gov.sk/
Clanok?rada-dusevneho-zdravia.
Ministry of Justice of the Slovak Republic. (2013). Plán realizácie
úloh Národného programu duševného zdravia na roky 2014-2015
[Implementation plan tasks of the National Programme on Mental
Health for 2014-2015]. Available at WWW: https://lt.justice.gov.sk/
Attachment/02_vlastny_mat_NPDZ_2014_2015_doc.pdf?instEID=-
1&attEID=61261&docEID=342282&matEID=6871&langEID=1&tSta
mp=20131203123653997.
National strategy for health protection, health promotion and disease
prevention Health 2020 [Národní strategie ochrany a podpory zdraví
a prevence nemocí Zdraví 2020]. 2014. Ministry of Health of the Czech
Republic .Available at WWW: http://www.mzcr.cz/dokumenty/zdravi-
2020-narodni-strategie-ochrany-a-podpory-zdravi-a-prevence-
nemoci_8690_5.html
Ministry of Health of the Czech Republic. (2013). Strategie reformy
psychiatrické péče. [Psychiatric Care Reform Strategy].
Muijen, M. (2008). Mental Health Services in Europe: An Overview.
Psychiatric Services, 59: 479–482.
National Programme on Mental Health [Národný program duševného
zdravia]. (2004). Úrad veřejného zdravotnictva. Available at WWW:
http://www.uvzsr.sk/docs/info/podpora/NPDZ.pdf.
National Psychiatric Programme [Národní psychiatrický program].
(2007). Praha: Psychiatrická společnost České lékařské společnosti
Jana Evangelisty Purkyně. Available at WWW: http://www.psychiatrie.
cz/index.php/deni-reforma-psychiatrie/deni-narodni-psychiatricky-
program.
Oliver, A., & Mossialos, E. (2005). European health systems reforms:
Looking backward to see forward? Journal of Health Politics, Policy and
Law, 30(1–2), 7–28.
Pierson, P. (2000). Increasing returns, path dependence, and the study of
politics. American political science review, 251-267.
Potůček, M., & Scheffler, R. (Eds.). (2008). Mental Health Care Reform in
the Czech and Slovak Republics 1989 to the present. Prague: Karolinum.
Purkrábek, M. (1994). K metodologii výzkumu formování a realizace
veřejné politiky [The research methodology of formation and
implementation of public policies] In: Potůček, M., Purkrábek, M., &
Vavroušek, J. Zrod teorie veřejné politiky vČeské republice.Úvodní studie k
analýze formování a realizace veřejné politiky v České republice po r. 1989.
Praha: FSV UK. Sborník řadyVeřejná a sociální politika 1/1994.
Raboch, J. & Wenigová, B. (2012). Mapování stavu psychiatrické péče a
jejího směřování v souladu se strategickými dokumenty České republiky
(a zahraničí). [Mapping the state of psychiatric care and its direction in
accordance with the strategic documents of the Czech Republic (and other
countries)]. Praha: Česká psychiatrická společnost.
Revised Framework of Psychiatry. [Revidovaná koncepce psychiatrie].
2008.
Steinmo, S. & Thelen, K. A. (1992). Historical Institutionalism in
Comparative Politics In:Steinmo,S.,Thelen, K.A, & Longstreth, F. (eds.).
Structuring Politics: Historical Institutionalism inComparativeAnalysis (pp
1-32). Cambridge, UK: Cambridge University Press.
Streeck,W., &Thelen K.A. (eds.). (2005). BeyondContinuity,Oxford, UK:
Oxford University Press.
Třešňák, P. (2014). Taking mental health into the community. Bulletin of
theWorld Health Organization; 92, 702-703.
United Nations. (2008). Convention on the Rights of Persons with
Disabilities.
WHO. (2013). The European mental health action plan. Proceedings of
the Regional Committee for Europe, Sixty-Third Session, Cesme Izmir,
Turkey, 16-19.
WHO. (2005). Mental health action plan for Europe: facing the challenges,
building solutions. FirstWHO European MinisterialConference on Mental
Health, Helsinki, Finland 12-15 January 2005.
WHO. (2005). Mental Health Atlas 2005.
WHO. (2011). Mental Health Atlas 2011.
Winkler P., Španiel F., Csémy L., Janoušková M., Krejníková L. (2013).
Reforma systému psychiatrické péče: mezinárodní politika, zkušenost
a doporučení [Mental health care system reform: international policies,
experience and recommendations] Praha: Psychiatrické centrum Praha.
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