Balancing Community and Hospital Care: A Case Study of Reforming Mental Health Services in Georgia

Psychiatric services in the former Soviet Union were characterized by high rates of institutionalization and a strong focus on biological treatment. In the post-Soviet states, these features remain—there is strong resistance to the introduction of modern, community-based, and user-oriented services [1]. In many cases, psychiatric reform programs have come to a halt or even been reversed [2]. It is against this backdrop that Georgia began a critical phase of its mental health reform program almost two years ago. Georgia, which has a population of 4.4 million and ranks 75th on the United Nations Development Programme’s Human Development Index, is one of the three Caucasian countries that regained independence in 1991. Its recent history has been turbulent. The country was ravaged by a bitter civil war from 1991 to 1993, the economy almost came to a standstill, and the health care system collapsed. It took until the end of the 1990s for basic health care services to be reestablished. Progress continued during the first years of this century, with health systems reforms that included moving away from the ‘‘Semashko system’’ (a Soviet system of state-owned health facilities and state-funded health professionals [3]), changes in health care financing and provision, development of private health care insurance, and the privatization of health care providers. The recent National Health Care Strategy 2011–2015 [4] developed by the Ministry of Labour, Health and Social Affairs (MoLHSA) stresses the importance of mental health care and of ensuring a balance between providing communitybased and hospital-based mental health services. In this article, we provide an overview of the mental health reform process, including its complexities and challenges. The reform process is still very much in progress, which makes it difficult to assess its impact. Nevertheless, the case of Georgia might provide insights that can help other countries that are embarking on a similar mental health reform program.