ACCESS TO CARE IMPEDIMENTS : AFRICAN, AMERICAN AND EUROPEAN EXPERIENCES

ACCESS TO CARE IMPEDIMENTS : THE EXAMPLE OF TUNISIA

S. Douki, S. Ben Zineb, E Nacef
Hopital Razi, La Manousa, Tunisia

Up until recently, mental health was afforded low priority in Tunisia as in other developing countries faced with major health concerns such as epidemic diseases or infant mortality. Consequently, despite steady advances, psychiatric care did not share the progress of the rest of medicine and remains greatly underdeveloped. Thus, today, the access to mental health care is significantly hampered by a crucial shortage of resources (one bed/10,000) and manpower (one psychiatrist/75,000) facing a huge growing request of care. Furthermore, the expressed needs are far below the potential needs, as shown by some epidemiological data. As an example, less than 10% of patients with major depressive disorder and only 50% of individuals with schizophrenia are seeking professional help and benefit from specific treatments. In fact, many cultural constraints still stand in the way of mental health care seeking and access, such as the strong belief in a variety of supernatural causes of mental illnesses, the cultural-bound « somatoform symptomatology », and above all the stigmatisation of mental disorders and psychiatric care. Last but not least, health care is becoming increasingly expensive and low-income people cannot benefit from the new but costly therapeutic opportunities that can optimise the compliance and minimize the risk of relapse. Information and sensitisation are the best tools to enhance mental health care access in countries where psychiatric care hasn’t always been fully in harmony with the prevailing cultural norms in the community.

ACCESS TO CARE IMPEDIMENTS :

M. Kastrup
Centre of Transcultural Psychiatry, Rigshospitalet, Copenhagen, Denmark

Free and equal access to health services, including mental health irrespective of sex, race, age, ethnic group or social class, is a basic assumption of the health systems in the Scandinavian countries. An increasing number of patients entering mental health care come from other cultures and till now insufficient focus has been directed towards investigating special needs and demands of psychiatric ill immigrants. About 8-10% of patients treated in Danish psychiatric institutions have a non-Danish background with large geographical variations. No mental health policy is directed towards immigrant, and no special public services provided. In order to elucidate the particular problems related to the immigrant population, a questionnaire was sent to all Danish psychiatric institutions to assemble information about local services/projects involving immigrants. Based upon this regional focus, group interviews were carried out with the local liaison officers. The paper will concentrate on issues of concern related to : delineation of the population treated at psychiatric institutions available psychiatric services, staff competence and treatment. Recommendations for strategies to overcome care impediments and enhance the cultural competence of psychiatric staff will be outlined

MEDICAL NECESSITY : ITS USE AND MISUSE IN THE AMERICAN MANAGED CARE SYSTEM

E. Sorel
George Washington University, Washington, DC, USA

Medical necessity has become the fulcrum upon which criteria for approval or denial of health care have evolved in the context of man aged care in the United States in the last two decades. Initial lack of 1 professional societies’ involvement in defining the terms and reaching – a consensus regarding « medical necessity » combined with the misus(and abuse of the term by managed care companies contributed to significant impediments to mental health care, in general, and in-patien care, in particular. Furthermore, the virtual autonomy that physicians had, in the last century, to determine what was medically necessary has been significantly eroded. The author presents data of a United States study on medical necessity that he stimulated as chairman of the Partnership for Parity Working Group of the Washington Psychiatric Society and as a consultant to the project. The study data indicate that American health insurers increasingly reserve the contractual authority to make medical necessity decisions that depart from scientific evidence regarding what is appropriate treatment for psychiatric disorders. Common procedural problems and challenges to « medical necessity » will be presented. as well as the important role of professional organizations, advocacy and advocacy alliances networks in stemming and possibly reversing such misuses and abuses of « medical necessity ».