Search

OBJECTIVE: To conduct a comprehensive assessment of the case-mix of patients admitted to tuberculosis hospitals and the reasons for their admission in four Russian regions: Ivanovo, Orel, Samara and Vladimir. We also sought to quantify the extent to which efficiency could be improved by reducing hospitalization rates and re-profiling hospital beds available in the tuberculosis-control system. METHODS: We used a standard questionnaire to determine how beds were being used and who was using the beds in tuberculosis facilities in four Russian regions. Data were collected to determine how 4306 tuberculosis beds were utilized as well as on the socioeconomic and demographic indicators, clinical parameters and reasons for hospitalization for 3352 patients. FINDINGS: Of the 3352 patients surveyed about 70% were male; the average age was 40; and rates of unemployment, disability and alcohol misuse were high. About one-third of beds were occupied by smear-positive or culture-positive tuberculosis patients; 20% were occupied by tuberculosis patients who were smear-negative and/or culture-negative; 20% were occupied by patients who no longer had tuberculosis; and 20% were unoccupied. If clinical and public health admission criteria were applied then < 50% of admissions would be justified and < 50% of the current number of beds would be required. Up to 85% of admissions and beds were deemed to be necessary when social problems and poor access to outpatient care were considered along with clinical and public health admission criteria. CONCLUSION: Much of the Russian Federation's large tuberculosis hospital infrastructure is unnecessary when clinical and public health criteria are used, but the large hospital infrastructure within the tuberculosis-control system has an important social support function. Improving the efficiency of the system will require the reform of health-system norms and regulations as they relate to resource allocation and clinical care and implementation of lower-cost approaches to case management for patients with social problems. Additionally, closer attention will need to be paid to the management of staff numbers in the tuberculosis system.

Objective To facilitate mental health reform in one Russian oblast (region) using systematic approaches to policy design and implementation. Methods The authors undertook a three-year action-research programme across three pilot sites, comprising a multifaceted set of interventions combining situation appraisal to inform planning, sustained policy dialogue at federal and regional levels to catalyse change, introduction of multidisciplinary and intersectoral-working at all levels, skills-based training for professionals, and support for nongovernmental organizations (NGOs) to develop new care models. Findings Training programmes developed in this process have been adopted into routine curricula with measurable changes in staff skills. Approaches to care improved through multidisciplinary and multisectoral service delivery, with an increase in NGO activities, user involvement in care planning and delivery in all pilot sites. Hospital admissions at start and end of the study fell in two pilot sites, while the rate of readmissions in all three pilot sites by 2006 was below that for the region as a whole. Lessons learned have informed the development of regional and federal mental health policies. Conclusion A multifaceted and comprehensive programme can be effective in overcoming organizational barriers to the introduction of evidence-based multisectoral interventions in one Russian region. This can help facilitate significant and sustainable changes in policy and reduce institutionalization. Resume Objectif Faciliter la reforme de la sante mentale dans une region (oblast) russe par une approche systematique de la conception et de la mise en ouvre des politiques dans ce domaine. Methodes Les auteurs ont entrepris un programme de recherche pragmatique sur trois ans, couvrant trois sites pilotes et comprenant une serie d&apos;interventions selon plusieurs axes : evaluation de la situation pour fournir une base a la planification, maintien d&apos;un dialogue politique aux niveaux federal et regional pour catalyser le changement, introduction d&apos;une collaboration multidisciplinaire et intersectorielle a tous les niveaux, organisation de formations pour ameliorer les competences des professionnels et aide aux organisations non gouvernementales (ONG) dans la mise au point de nouveaux modeles de soins. Resultats Les programmes de formation developpes dans le cadre de ce processus ont ete integres aux programmes de formation classiques, avec comme consequence une amelioration mesurable des competences du personnel. Les demarches therapeutiques se sont aussi ameliorees a travers la delivrance de services multidisciplinaires et multisectoriels, le developpement des activites des ONG et l&apos;implication plus poussee des usagers dans la planification et la delivrance des soins dans tous les sites pilotes. Entre le debut et la fin de l&apos;etude, le nombre des hospitalisations a chute dans deux des sites pilotes et dans les trois, le taux de readmission a atteint en 2006 un niveau plus faible que dans l&apos;ensemble de la region. Les enseignements tires de ce programme ont servi de base a l&apos;elaboration de politiques de sante mentale aux niveau regional et federal. Conclusion Il est possible, dans une region russe, de venir a bout des obstacles organisationnels a l&apos;introduction d&apos;interventions multisectorielles developpees a partir d&apos;elements factuels par un programme complet et pluridimensionnel. Un tel programme pourrait aussi faciliter des changements notables et durables de politique et reduire la bureaucratie. Une traduction en francais de ce resume figure a la fin de l&apos;article. Resumen Objetivo Facilitar la reforma de la atencion de salud mental en un oblast (region) de Rusia utilizando metodos sistematicos para formular y aplicar las politicas. Metodos Los autores emprendieron en tres sitios piloto un programa de accion-investigacion de tres anos que abarcaba un conjunto multifacetico de intervenciones como la evaluacion de la situacion para fundamentar la planificacion, un dialogo de politica sostenido a nivel federal y regional para catalizar los cambios, la accion multidisciplinaria e intersectorial a todos los niveles, medidas de formacion practica para los profesionales y el apoyo a organizaciones no gubernamentales (ONG) para desarrollar nuevos modelos de asistencia. Resultados Los programas de capacitacion desarrollados a lo largo este proceso han sido incorporados en los programas de estudios habituales, con cambios cuantificables en las aptitudes del personal. La asistencia mejoro gracias a la prestacion de servicios multidisciplinarios y multisectoriales, con un aumento de las actividades de ONG y la participacion de los usuarios en la planificacion y prestacion de la asistencia en todos los sitios piloto. Los ingresos hospitalarios, determinados al comienzo y al final del estudio, disminuyeron en dos sitios piloto, mientras que la tasa de reingresos en los tres sitios piloto en 2006 fue inferior a la del conjunto de la region. Las ensenanzas extraidas han fundamentado el desarrollo de las politicas de salud mental regionales y federales. Conclusion Un programa multifacetico e integral puede ayudar a superar eficazmente las barreras organizacionales a la aplicacion de intervenciones multisectoriales basadas en la evidencia en una region de Rusia, y ello puede facilitar la introduccion de cambios considerables y sostenibles en las politicas y reducir los internamientos. Al final del articulo se facilita una traduccion al espanol. [TEXT NOT REPRODUCIBLE IN ASCII.], Introduction Mental illness is a major global health burden (1) with substantial societal and economic consequences. (2) In developed countries, around 66% of people with mental disorders do not receive [...]

Long-established Medico-Social Expert Commissions (MSECs) play a pivotal role in the Russian mental health system. They act as gatekeepers to pensions, rehabilitation, and employment services. This column describes their role in encouraging or impeding the social inclusion of people with mental illness, drawing on findings of a three-year project in Sverdlovsk Oblast. In Russia the emphasis remains on medical aspects of treatment, without adequate consideration of social and occupational rehabilitation. Links with local employment services are weak. To promote social inclusion, steps must be taken to encourage and facilitate cooperation and collaboration between the MSECs, employment services, and medical services. [ABSTRACT FROM AUTHOR]