Introduction by the editor: In this issue of Psychiatric Services, we are pleased to launch a new column, Mental Health Care Reforms in Asia, which joins columns on mental health reforms in Europe and in Latin America. Reforms are emerging in Asia as well, and the journal plans to stay abreast of developments and report them to our readers. This column by Samson Tse and his colleagues reports on recent mental health reforms in China. This highly populous country, with a growing economy and an interest in health and health care, passed a new mental health law on May 1, 2013. As the column explains, China is poised to make dramatic new reforms in its mental health system.
China has a population of 1.3 billion, approximately one-fifth of the world’s population. A recent study estimated that 173 million Chinese citizens suffer from diagnosable mental disorders, of whom 158 million have never received any treatment (1). Furthermore, approximately 16 million Chinese citizens are affected by severe mental illness (1). Inpatient treatment is neither affordable nor desirable for such a large number of people, yet resources are lacking in the community to treat, support, and care for people with mental illness.
The development of a community mental health service (CMHS) in China is now at a crossroads, marked in late 2012 by two signposts. First, in his inaugural speech as the new General Secretary of the Communist Party of China at the Great Hall of the People in Beijing on November 15, 2012, Xi Jinping mentioned the Chinese people (人民, rénmín) 19 times. In particular, he said, “Our people love life and expect better education, more stable jobs, better income, more reliable social security, [and] medical care of a higher standard. . . . The people’s yearning for a good and beautiful life is the goal we must strive for.” In March 2013, Mr. Xi was elected President of the People’s Republic of China by the National People’s Congress. While his words are aspirational, it will take more than noble sentiments to create a program of sustained action to benefit people affected by mental illness and their families. The other signpost, and a more concrete one, was the approval of the National Mental Health Law by the Standing Committee of the 11th National People’s Congress on October 26, 2012, a full 27 years after it was first proposed. The implementation of the new law has required careful planning and monitoring (2), and it has highlighted the urgent need to properly develop the CMHS.
China’s overall improvement in standard of living means that Chinese citizens now have higher expectations for the care of their loved ones. Reliance on hospital services as the solution to severe mental illness has never been viable in the China because of the cost. In contrast, community care offers a more affordable option. The concept of community care can be traced back to 1958, when the first national meeting on the prevention of psychiatric illness took place. Almost five decades later, the National Mental Health Project of China 2002–2010 stated that “Community care will take over . . . from traditional hospital care in the 21st century” (3). Currently 16 million Chinese citizens have severe mental illness, and that figure is expected to grow; most people with severe mental illness in China go without any treatment at all (4,5).
Before China’s economic reform in 1979, Chinese citizens were covered by the Cooperative Medical System (CMS) in rural areas and the Government Insurance Scheme and Labor Insurance Scheme in urban areas. After the reform, the funding base of the nation’s near-universal coverage schemes was no longer available; it was replaced by a city-based social health insurance scheme. The collapse of the CMS left up to 90% of rural Chinese uninsured (6). The collapse is also part of the reason why at least a quarter of the Chinese general population with moderate and severe mental disorders have never received treatment (1). Apart from the problems with the wider insurance system, mental health services also face their own challenges, such as implementation of the newly adopted mental health legislation, the huge resource disparity between provinces and cities, and lack of community treatment approaches uniquely suited to the Chinese population (7–9). Presently, China has only 4,000 fully qualified, licensed psychiatrists (8). The discussion must begin now. For a review of the current state of mental health services in China, and the challenges they face, see the commentary by Xiang and colleagues (8), as well as earlier work by Pearson and Phillips (10).
It is clear that the CMHS in China is still in the early stages of development for reasons of history and resources, as in many low- and middle-income countries (7). We conducted a SWOT analysis—for strengths, weaknesses, opportunities, and threats—to review the general development of the CMHS system in China so far and the scale of the work that remains to be done. We summarize our findings in this column. [Details of the SWOT analysis are available online as a data supplement to this column.]
China’s current delivery of general health services relies heavily on primary health care, attached to local community health centers in cities and township health centers in rural areas. Providers of primary health care monitor and manage referrals to specialist care and hospitals. In contrast, the delivery model of mental health care focuses on hospital-based or institution-based services provided by three major ministries—the Ministry of Health, Ministry of Civil Affairs, and Ministry of Public Security—which operate the 25 Ankang hospitals (ankang means “peace and health”) for individuals with mental illness. Some institutions are run as prison hospitals under the local Public Security Bureau.
Mental health has been recognized as a significant public health issue in China since 2004 (7). The CMHS has been found to be effective in supporting individuals and their families in recovery from mental illness and to support a broad population of diverse cultural and linguistic backgrounds (11). A systematic review has concluded that CMHS methods (such as intensive case management) are more effective than standard care (such as hospital-based outpatient services) in terms of acceptance of treatment and reduction of hospital admissions, treatment dropout, deaths by suicide, and health care costs (12). Since the 1960s, different CMHS models have been implemented in China, depending on population density, with three-tier primary prevention and treatment networks and guardianship networks in urban areas and psychiatric rehabilitation villages in rural areas (13). Broadly speaking, the most popular model in China is the prevention and treatment network involving integrated services across the three tiers of city, neighborhood, and street (14).
We base the following suggestions for CMHS development through the next century on two very hopeful assumptions. First, considerably more resources will become available, with better funding for services and a reduction in the resource gap between cities and rural areas. Second, the central government will take a strong leadership role in steering the development of the CMHS across the country.
Building on strengths of the 686 Project
Professional skills of the mental health workforce in China must be significantly improved. We can learn a great deal here from the 686 Project, China’s 2004 mental health reform initiative. First, it was modeled on the World Health Organization’s recommended framework for integrating hospital-based services with a CMHS system (7,15). Indeed, the CMHS has to be effectively integrated with hospital-based services, and mental health services have to be an integral part of general health systems. People with mental illness and their families are often frustrated at being offered treatment by different providers that do not communicate with each other and then having to negotiate the many gaps by themselves. Second, it offers a sound train-the-trainers infrastructure (382,000 individuals were trained by the end of 2011) readily transferable to other locations, and its delivery has demonstrated characteristics that seem to suit the ideology and belief systems of Chinese culture. Third, the 686 Project has secured government investment. The central government has invested an additional RMB 220 million (US$32.2 million) since its inception in December 2004 with a seed grant of RMB 6.86 million. By November 2011, 1.83 million citizens with severe mental illness were treated through the project, which covered 766 sites in 170 cities with a total catchment population of 43 million (8,15).
Moving toward a recovery approach
We also propose training for CMHS staff (including physicians specializing in mental health, social workers, nurses, and occupational therapists) in the recovery approach. We suggest that the recovery approach resonates strongly with traditional Chinese culture and is highly consistent with the values embedded within the 686 Project, such as paying more attention to the person’s level of functioning and strengths, rather than disabilities and psychopathology (15). The recovery approach emphasizes self-confidence (自信), self-help (自助), and self-sufficiency (自給自足). It is not a model of service delivery as such, but an encompassing ethos or approach that can be applied to any model (including any indigenous health initiatives) that focuses on the strengths and resources of service users and their communities, as well as mental health services (16) (online data supplement, Opportunities column).
The recovery approach draws on a series of principles and theories (such as partnership, capacity building of local service providers, and strategies to instill hope) based on three decades’ worth of studies and clinical evidence, most of which has been collected in the United States, United Kingdom, Australia, New Zealand, and, more recently, Hong Kong (17,18). From this empirical base, various international practice guidelines for supporting recovery have been developed, primarily in community settings (19). Examples of specific recovery practices are peer support services, strengths-based case management, and the Wellness Recovery Action Plan (illness self-management).
Nevertheless, it is important to investigate how recovery is redefined by individuals with personal experience of mental illness—and negotiated within—a Chinese cultural and practice context and how acceptable it is for more traditionally trained medical staff. What are the factors that facilitate or hinder recovery for individuals at different stages of their journey in the modern cultural landscape of China, where mental illness remains taboo and only limited resources are allocated to the CMHS? By gaining further insight and knowledge about the meaning of recovery for Chinese service users and how these are similar to or different from ideas of recovery espoused by mental health staff (20), a more culturally applicable CMHS can be developed, which will better address service users’ needs.
Empowering families to continue support
As well as building staff skills, we must also empower families and caregivers to support individuals with severe mental illness, especially in rural areas. Caregiving is absolutely central to who we are as human beings. For a number of reasons, supporting family-based caregiving is also a strategic intervention. First, up to 80% of individuals with mental illness in China (especially in rural areas) are looked after by family members at home, by choice or otherwise (13). This figure will increase as the National Mental Health Law is implemented. Second, the burden of caregiving in the Chinese context and the related feelings of strain (caused by factors such as the significant cost), coupled with family dysfunction (for example, high levels of expressed emotion and negative affective style), often have a combined negative effect on outcomes, although the mechanism of influence remains unclear. Third, there is increasing evidence of the effectiveness of family-based interventions embedded within the CMHS, in terms of relapse prevention and improved clinical outcomes (21). In such interventions, family members are supported through home visits where service users’ well-being and adherence to interventions are reinforced and their ongoing supply of medication ensured.
Using technology to promote self-help and reduce stigma
The number of Internet users in China has risen to 538 million, and the number of mobile Internet users has grown rapidly to 388 million (22). We must make better use of information and communications technology (ICT) to promote self-help and reduce the stigma associated with severe mental illness. China has a vast population of diverse cultures and dialects spread over a wide geographical area. The potential to use ICT in mental health interventions in the Web 2.0 era should not be underestimated. ICT applications (such as those available on 3G network phones) and Chinese social networking sites (such as Tencent QQ, Renren, and Weibo) can help fight the stigma of mental illness, combat discrimination, and create new platforms for computer-literate people, particularly those in the younger generation (23) who are affected by mild or subclinical mental health problems.
Using social networking to find out how someone with personal experience of mental illness has learned to function again and find a new role in life may inspire others and help combat stigma. Computer-automated, mobile applications–based assessments and behavioral change interventions are also being implemented around the world, and guidelines for developing computer-based adjunct psychotherapy are being established (24). Preliminary results from the Organization for Economic Cooperation and Development countries indicate that ICT improves service quality, with little corresponding increase in cost or clinicians’ time; however, limited evidence has been gathered so far in developing countries, including China. Furthermore, despite their good intentions, both clinicians and computer programmers often neglect the subtly different needs of individuals from non-European cultural backgrounds when designing high-powered, technology-based programs for use in the developing world.
Of course, the critical question is how all these proposed changes will be financed. To complicate the matter further, presently less than 4% of the total health budget was spent on mental health care, most of which went to hospital-based services, not community-based services (“Weaknesses” column in online data supplement). In contrast, mental health costs accounted for approximately 20% of total health expenses (25). On the other hand, the promising sign is that the government is planning to increase the mental health budget from 3%−4% of the total national health budget in 2010 to 7%−8% by 2015 and is planning to ensure that up to 55% of health dollars will be spent on public and rural health in particular (26). Perhaps this unprecedented challenge in human history is not only to fund huge and complex health care reforms for the 1.3 billion people in China but to find the paths to achieving its stated goals (6). These are the questions or challenges for which we do not necessarily have the answer, but they speak to the urgent need for clinicians, policy planners, researchers, service users, and caregivers alike to begin a dialogue and work together at this seminal moment for the development of community-based mental health care in China. We must open the forum now for further discussion.
This column has outlined China’s accomplishments thus far in improving its mental health services. In conclusion, raising the skill standards of the Chinese mental health workforce (especially in the use of a recovery approach), improving resources for families, and making effective use of ICT are all essential components for developing the CMHS system. Finally, collaborating with local champions to train local health workers can provide the critical infrastructure that will enable new CMHS initiatives to be sustained beyond small pilot studies and limited grants.