Shen Gordon C, Eaton Julian, Snowden Lonnie R
a Department of Health Policy and Management, Graduate School of Public Health and Health Policy , City University of New York , New York , NY , USA.
b Centre for Global Mental Health, London School of Hygiene and Tropical Medicine , London , UK.
Health Syst Reform. 2017 Oct 2;3(4):313-324. doi: 10.1080/23288604.2017.1356424.
Abstract-Global consensus and national policies have emphasized deinstitutionalization, or a shift in providing mental health care from institutional to community settings. Yet, psychiatric hospitals and asylums receive the majority of mental health funding in many countries, at odds with research evidence that suggests that services should be delivered in the community. Our aim is to investigate the norms, actors, and strategies that influence the uptake of deinstitutionalization internationally. Our study is informed by prior literature on management and implementation science. The success and failure of mental health care operations depend on identifying and overcoming challenges related to implementing innovations within national contexts. We surveyed 78 experts spanning 42 countries on their knowledge and experiences in expanding community-based mental health care and/or downsizing institution-based care. We also asked them about the contexts in which said methods were implemented in a country. We found that mental health care, whether it is provided in institutions or in the community, does not seem to be standardized across countries. Our analysis also showed that moving deinstitutionalization forward requires meaningful engagement of three types of actors: government officials, health care professionals, and local experts. Progress toward deinstitutionalization depends on the partnerships formed among these actors and with diverse stakeholders, which have the potential to garner resources and to scale-up pilot projects. In conclusion, different countries have adapted deinstitutionalization in ways to meet idiosyncratic situations and population needs. More attention should be given to the management and implementation strategies that are used to augment treatment and preventive services.
摘要——全球共识和国家政策都强调去机构化，即精神卫生保健的提供从机构环境向社区环境转变。然而，在许多国家，精神病医院和收容所获得了大部分精神卫生资金，这与研究证据相悖，该证据表明服务应在社区提供。我们的目的是调查影响国际上去机构化实施的规范、行为主体和策略。我们的研究参考了之前关于管理和实施科学的文献。精神卫生保健运营的成败取决于识别和克服与在国家背景下实施创新相关的挑战。我们调查了来自42个国家的78位专家，了解他们在扩大社区精神卫生保健和/或缩减机构精神卫生保健方面的知识和经验。我们还询问了他们这些方法在一个国家实施的背景情况。我们发现，无论是在机构还是在社区提供的精神卫生保健，各国之间似乎都没有标准化。我们的分析还表明，推进去机构化需要三类行为主体的积极参与：政府官员、医疗保健专业人员和当地专家。去机构化的进展取决于这些行为主体之间以及与不同利益相关者形成的伙伴关系，这些伙伴关系有可能获取资源并扩大试点项目。总之，不同国家以适应特殊情况和民众需求的方式采用了去机构化。应更多关注用于加强治疗和预防服务的管理和实施策略。
