MEMORANDUM. Measures for the rehabilitation of the mental health care system in Romania

Subject: Measures for the rehabilitation of the mental health care system in Romania

The Government of Romania is concerned about the problems in the field of the psychiatric medical assistance and the protection of the persons suffering from mental disorders.
The measures to improve the medical assistance of the persons suffering from mental disorders and intellectual deficiencies are set as an priority objective within the framework of the reform of the Romanian sanitary system. The psychiatric medical assistance system does not have at the moment the alternative structures existing in certain western countries (community mental health centers, protected houses, daily stationers). For this reason, it is necessary to adopt a medium and short-term reform program, to achieve a compromise between the existing health care system and the shaped one. The Ministry of Health established a working group with the task to set the practical, specified methods, in order to take over from a system to another, depending of the existing material, financial and human resources.

I. General characteristics

In Romania there are 36 psychiatric hospitals with a total number of 11.301 beds. In addition to these hospitals of profile, there are 75 psychiatric departments from the general or regional hospitals, with a number of 5.330 beds. (Annex no. 1).
Under the authority of the Ministry of Health function 6 hospitals of psychiatry and for security measures were there are also hospitalized the patients placed under the incidence of art. 105 and 114 from the Criminal Code, on the bases of definitive sentence of criminal court. (Annex no. 2). The mandatory medical hospitalization is made in accordance with the provisions of the Law no. 487/2002 regarding mental health and the protection of persons with mental disorders. Now, in the 6 hospitals of psychiatry and for security measures with a capacity of 2.427 beds, there are hospitalized 2.237 patients, from which 807 patients are under the incidence of art. 114 from the Criminal Code. Besides the psychiatric departments there are also departments for treating toxic-addicted persons (detoxification cure and post-cure), departments for the patients addicted to drugs and alcohol and also for medical-social and social cases. The long-term hospitalization of these patients determines, in some hospitals (Sapoca - Buzau), the phenomenon of overpopulation, with a harmful effect on hospitalization conditions. (Poiana Mare - Dolj).
The patients come in majority from the districts of residence and in the 6 hospitals of psychiatry and for security measures, the hospitalization is made in accordance with the allegiance of the districts to the Courts of Appeal.
The majority of the hospitals of psychiatry from Romania function in old buildings, which were not build with a medical destination, and which were subsequently adapted for the insurance of the functional circuits for a hospital. (Annex no. 3). Some of the buildings with an advanced level of degradation were partially or totally rehabilitated, the condition of hospitalization being improved. A relative good situation exists in psychiatric hospitals Sapoca - Buzau and Jebel - Timis. (Annex no. 4).
Even if the alimentary blocks correspond to the hygienic-sanitary norms, the sanitation and heating installation are old, deteriorated and the reparations were partial.
The maintenance of these patients goes to the use of financial resources for health carrying and not for improvement of the quality of medical act and also the health carrying personnel is insufficient and without a specific preparation for the psychiatric medical assistance.
The alimentation is generally appropriate but there are differences between hospitals, that are the result of their own ability to manage themselves (Psychiatric Hospital Sapoca - Buzau, Psychiatric Hospital Socola -Iasi, which have also an annex administration).
The specific medical treatment for these diseases is prescribed at the hospitalization, revised according to the evolution of the disease and is paid from the funds of the social health insurance.
The sources of finance come from the agreements concluded between the hospitals and the regional houses of health insurance, as well from the programs of the Ministry of Health and of the National House of Health Insurance. (Annex no.5)
Between 15-31 March 2004, an Inter-ministry Commission, formed by the representatives of the Ministry of Health, the Ministry of Justice and the General Prosecutor's Office, accomplished a control in the 6 hospitals of psihiatry and security measures ( Stei Hospital -Bihor , Jebel Hospital-Timis, Poiana Mare Hospital-Dolj, Zam Hospital-Hunedoara, Sapoca Hospital-Buzau, Padureni Grajduri Hospital-Iasi).
The conclusions of the commission has been communicated to the decisional factors, for an immediate solving of the problems with which the units are confronted with (example: Poiana Mare Hospital - Dolj). The Commission considered that the special legal provisions, as well the provisions of the European Committee for Torture Prevention, are respected.
The death causes came from chronicle affections, not from the inadequate living condition.
In the verified hospitals, there is an occupational and ergo-therapy base, as an alternative to the medicinal therapy . Through the subprogram 2.5 "Prophylaxy in the Psychiatric and Psychosocial Pathology", the Ministry of Health has allocated in 2004 ,the amount of 16 billion lei for this purpose. Also, in this subprogram, the National House of Health Insurance has allocated the amount of 100 billion for the treatment of schizophrenics and depressions.

II. Legislative Framework

The legislation in the psychiatry medical assistance domain is represented by:
- Law no.487/2002 regarding the Mental Health and the Protections of the Persons with psychical disorders;
- Government Ordinance no. 150/2002 regarding the organisation and function of the social health insurance system;
- Government Decision no.743/2003 regarding the organisation and function of the Ministry of Health, with all amendments and completition;
- Government Decision no.1485/2003 for the approval of the Frame Contract regarding the conditions for the granting of the medical assistance, in the social health insurance system;
- Common Order of the Minister of Health and the President of the National House of Health Insurance no.1220/890/2003 for the approval of the Methodological Norms necessary to put into practice the Frame Contract regarding the granting of the medical assistance, in the social health insurance system;
- Law no. 519/2002 for the approval of the Emergency Government Ordinance no. 102/1999 regarding the special protection and the employment of the handicapped persons;
- Council of Ministers Decision no.1210/1970 regarding the ergotherapy activities carried out by the sanitary units;
- Law no. 143/2000 regarding the struggle against the illicit consumption and trading of the narcotics substance;
- Law no.73/1969 and the Instructions no.103/1970 regarding the circuit of the narcotic substances and products.
- The Criminal Code, article no.105, 114 and also the articles of Criminal Proceedings Code regarding the compulsory hospitalisation and medical treatment .

III. Emergency measures regarding the rehabilitation of the psychical medical assistance, in Romania.

A. In order to improve the medical assistance in Romania, the Ministry of Health has accomplished between may - december 2004, the following emergency measures:
a) modifications of the legislative framework, such as:
- the emitting an Emergency Government Ordinance for amending and changing the law no. 487/2002 ,especially article 63 regarding the mental health and the protections of the persons with mental diseases, for the elaboration of the methodological norms necessary in order to put into practice the provisions of the laws;
- the modification of the National Authority of the Handicapped Persons' Disposal no. 1649/2002 regarding the allowance of the persons with a psychology handicap into the psychiatry rehabilitation centres;
- the establishment of an Inter-ministry Commission for Mental Health, absolutely necessary for the mutual co-operation, which must include representatives of the Ministry of Health, the Ministry of Justice, the Ministry of Administration and Internal Affairs, the Ministry of Labour, Social Solidarity and Family, the Ministry of Education and Research and the National House of Health Insurance;
The Legislative Framework will be changed in a deadline of three months.
b) measures of rehabilitation of the infrastructure of the six hospitals of psychiatry and security measures:
- Stei Hospital - Bihor- for the arrangement of some accommodations rooms, through the central pavilion's extension and rehabilitation-12 billions lei; - Jebel Psychiatry Hospital -Timis - for the rehabilitation of five pavilions from those twenty available -10 billion lei;
- Sapoca Hospital - Buzau - for the construction of a new pavilion, with sixty beds for the patients which are framed in accordance with article 114, Criminal Code -10 billion lei;
- Padureni Hospital - Grajduri City-Iasi - for the physical rehabilitation of three pavilions - 8 billion lei;
- Poiana Mare Hospital - Dolj - for the physical rehabilitation of two pavilions - 4.5 billion lei (the amount has been approved by Government Decision);
- in the Municipal Hospital Lugoj - Timis will be arranged a section for children with various diseases, who are under the incidence of the article105 of the Criminal Code.
In order to accomplish these workings of investments and reparation, it is necessary to supplement the budget of the Ministry of Health with the sum of 40 billion lei.
c) the improvement of the living conditions and of the specific therapy:
- the qualitative and quantitative improvement of the alimentation of the ill persons, through the growth of the daily allocation for hospitalization from 53.000 lei to 70.000 lei (the modification of the Government Decision and the insurance of the necessary funds from the budget of the social health insurance);
- the growth of the funds allocated for the subprogram 2.5 "The profilaxy in the psychiatric and psychosocial pathology" for the insurance of a specific therapy, as well as for the development of the alternative therapies, especially of the ergotherapy, methods that can improve the state of health and the rehabilitation of the interned patients;
- the modification of the provisions of the Government Decision no.1485/2003 for the approval of the Frame Contract, regarding the discount of the medical services delivered in the psychiatric institutions. Deadline: September 2004.

d) the training of the medico-sanitary and auxiliary personnel and its financial motivation:
- the Ministry of Health will draw up a program of continuous perfecting of the medico-sanitary personnel, especially of the medium personnel and of the healthcare personnel in specific activities for the psychiatric medical assistance;
- it will be taken into consideration the raise of the number of specialist physicians in a form of professional attestation for the position;
- there will be organized perfecting courses for the family physicians in the area of mental health and social insertion;
- the Ministry of Health will elaborate a new order regarding the norm of personnel from the psychiatric institutions, including the modification and payment of the emergency lines, in order to ensure the emergency assistance in these units;
- in order to motivate the personnel that works in psychiatric medical assistance, The Ministry of Health will create the legal frame for granting benefits between 50 and 100%, corresponding to the risks and specific danger conditions.
Deadline: October 2004.

e) The individual evaluation of the residents from the psychiatric institutions, from the medical, social and juridical point of view:
- because in the hospitals of psychiatry and measures of high security, apart of the patients with mental disorders (who are or are not under the incidence of article114 from the Criminal Code), are also interned patients with other diseases and social problems, the commissions of the Ministry of Health (University Center Craiova - responsible prof.dr.Dragos Marinescu for verifying the Hospital of Psychiatry Poiana Mare; University Center Iasi - responsible prof.dr.Petru Boisteanu for the Hospital of Psychiatry Padureni Grajduri and for the Hospital of Psychiatry Sapoca; University Center Oradea - responsible prof.dr. Gavril Cornutiu for the Hospital from Stei; University Center Timisoara - responsible prof.dr. Pompilia Dehelean for the Hospital from Jebel; the Clinic of Psychiatry Sibiu - responsible prof.dr.Gheorghe Talau for the Hospital of Psychiatry and Measures of High Security from Zam - Hunedoara), will evaluate all the interned patients, as follows:
 in the period may - June 2004 will be evaluates all the patients interned in the hospitals of psychiatry and measures of high security; under the authority of the Ministry of Health will remain only 4 out of the 6 hospitals that will ensure the assistance for the patients who are under the incidence of article 114 of the Criminal Code;
 in the period July - October 2004 will be evaluated the patients interned from the other 28 hospitals of psychiatry and from the sections of specialty from the regional hospitals.
The hospitals in which the social and medico-social cases are predominant, will be transformed in medico-social centers with a psychiatric profile, and will be placed under the administration of the local authorities.
B. For the period 2005 - 2007, will be taken measures in order to diminish the morbidity caused by the psychiatric diseases and the improvement of the parameters of mental health at the level of the entire population. The Ministry of Health intends to deliver accessible, qualitative and based upon the existing needs services of mental health, in an environment as little restrictive as possible, as well as programs of promotion, prevention and education in the domain of mental health:
a) in relation with the strategic objectives it is necessary to restructure the healthcare system from the domain of mental health, which will realize a primary, secondary and tertiary profilaxy;
b) the development of the ambulatory psychiatric assistance (centers of mental health, laboratories of mental health, specialty cabinets) at the level of each county, as well as the creation of a mobile team from the centers of intervention in crisis in order to solve the psychiatric emergencies;
c) the development and improvement of the medico-social units for the patients with psychical diseases, through the implication of the local authorities, who will sustain materially the function of these centers, as well as of the directions of public health, which will ensure the specialty medical assistance;
d) the staidly, progressive development of the structure of healthcare with a communitary character, appropriate for the needs and local resources and which will correspond to the requests of continuity in granting the mental health cares;
e) the elaboration of an action plan that will implement the policy of mental health and to improve the quality of the institutionalized persons with psychical problems (medium term measures); f) the launching of the action plan within an international meeting set to take place in Bucharest.

IV. International cooperation

The Center for Mental Health (The TREPTE Center), set in Bucharest within the Clinical Psychiatry Hospital "Prof. Dr. Alexandru Obregia", was established in the World Bank Project for the Reform of the Romanian Sanitary System, financed trough the RO-4569 loan; the project's purpose is to ensure the continuity of the care for the ambulatory discharged patients and their social reintegration. The World Bank could consider extending the experience of this center to other university centers (Iasi, Cluj, Timisoara) eligible.
At present there is in work the implementation of a community center within the Psychiatry Hospital "Dr. Constantin Gorgos", Bucharest, financed with 80,000 Euro through the Stability Pact and World Health Organization. This center will open in September 2004 as a model for establishing county community centers.
The Ministry of Health will support the psychiatry hospitals across the country to initiate infrastructure rehabilitation programs through the World Bank Program and the European Bank for Investment.
There will be proposed to focus on the psychiatric services improvement within the project of rehabilitation of mother and child care, to be financed through a USD 120 million loan from the World Bank.
Within the PHARE project for non-transmissible diseases and mental health, the Ministry of Health set as a priority the implementation of a information network as a basis for Unique National Registry of the Psychiatric Patients.
At present there is the possibility for the Ministry of Health to obtain an approximately 250,000 Euro financing from the European Union, through the PHARE Program (the letter addressed by the chief of the Delegation of the European Union in Bucharest, Mr. Jonathan Scheele to the Minister of Health, dr. Ovidiu Brinzan. It is possible to establish a community mental health center and to elaborate an action plan to follow the implementation of the mental health policy within this financing.