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71st session
Virtual session, 13–15 September 2021 2 August 2021
210732
Provisional agenda items 7 and 14 ORIGINAL: ENGLISH
Final reports on implementation of
1. The European Mental Health Action Plan (2013–2020) 2. The WHO European Declaration and Action Plan on
the Health of Children and Young People with Intellectual Disabilities and their Families (2011–2020)
These final reports provide an overview of implementation of the European Mental Health Action Plan (2013–2020), in line with the commitments made through the adoption of resolution EUR/RC63/R10 at the 63rd session of the WHO Regional Committee for Europe in 2013, and the WHO European Declaration and Action Plan on the Health of Children and Young People with Intellectual Disabilities and their Families, adopted at the 61st session of the Regional Committee in 2011 in resolution EUR/RC61/R5.
These reports are submitted for consideration by the Regional Committee at its 71st session.
Contents
Background ... 3
Final report on the European Mental Health Action Plan (2013–2020) ... 3
Promotion and protection of mental health and human rights for all (objectives 1 and 2) ... 4
Mental health service development, treatment and care (objectives 3 and 4) ... 5
Mental health services integration, intersectoral collaboration and information systems (objectives 5, 6 and 7) ... 7
Final report on the WHO European Declaration and Action Plan on the Health of Children and Young People with Intellectual Disabilities and their Families ... 8
Equal opportunities (priority action areas 4, 7, and 10) ... 9
Safety and safeguarding (priority action areas 1, 3, 6 and 7) ... 9
Community care (priority action areas 2, 3, 4 and 5) ... 10
Health and social care (priority action areas 5, 6, 8 and 9) ... 10
Conclusion and way forward ... 11
Background
1. At its 61st session in 2011, in resolution EUR/RC61/R5, the WHO Regional Committee for Europe adopted the WHO European Declaration and Action Plan on the Health of
Children and Young People with Intellectual Disabilities and their Families (2011–2020), and at the 63rd session in 2013, in resolution EUR/RC63/R10, it adopted the European Mental Health Action Plan (2013–2020). The overall goals of these action plans are to enable persons with mental health conditions and intellectual disabilities, along with their families, to realize their full potential for health, development and well-being and to reduce avoidable disease, disability and mortality.
2. Mid-term reports for these two separate action plans were prepared, submitted and considered by the Regional Committee in 2016 and 2017, respectively. This document presents final reports covering the entire period of their implementation.
Final report on the European Mental Health Action Plan (2013–2020)
3. Resolution EUR/RC63/R10, which endorsed the European Mental Health Action Plan, urges Member States:
(a) to improve the mental health and well-being of the entire population and reduce the burden of mental disorders, ensuring actions for promotion and prevention, and intervention on the determinants of mental health, combining both universal and targeted measures, with a special focus on vulnerable groups;
(b) to respect the rights of people with mental health problems, promote their social inclusion and offer equitable opportunities to attain the highest quality of life, addressing stigma, discrimination and isolation;
(c) to strengthen or establish access to and appropriate use of safe, competent, affordable, effective and community-based mental health services.
4. This report presents the progress made towards achieving the objectives of the Action Plan by Member States, in collaboration with the WHO Regional Office for Europe
(WHO/Europe) and international partners. The seven objectives are shown in Table 1.
Table 1. Objectives of the European Mental Health Action Plan (2013–2020) Objective Description
1 Everyone has an equal opportunity to realize mental well-being throughout their lifespan, particularly those who are most vulnerable or at risk
2 People with mental health problems are citizens whose human rights are fully valued, respected and promoted
3 Mental health services are accessible, competent and affordable, available in the community according to need
4 People are entitled to respectful, safe and effective treatment 5 Health systems provide good physical and mental health care for all
6 Mental health systems work in well-coordinated partnership with other sectors 7 Mental health governance and delivery are driven by good information and knowledge
5. The WHO Mental Health Atlas (2014 and 2017) has provided a primary mechanism for monitoring progress. In 2019, Monitoring mental health systems and services in the WHO European Region: Mental Health Atlas, 2017 was published by WHO/Europe to provide a snapshot of the situation in Member States across the WHO European Region with regard to a number of global mental health targets and indicators. Results from these reports are
integrated into the reporting below, which is grouped into (a) objectives 1 and 2;
(b) objectives 3 and 4; and (c) objectives 5, 6 and 7.
Promotion and protection of mental health and human rights for all (objectives 1 and 2)
6. Objectives 1 and 2 seek to improve the mental health and well-being of the population through the strengthening of health promotion and protection measures through the life course with a focus on vulnerable groups, including those living with mental health conditions or psychosocial disabilities. To achieve these objectives, there was a focus on adopting and updating policies and legislation according to ratified conventions on human rights; on mental health promotion across the life course with a focus on children and adolescents; and on suicide prevention.
7. In the area of mental health policy and legislation, many efforts were made by Member States to advance their national policies and legislation during the period of the Action Plan.
Results from the Mental Health Atlas 2017 survey indicate that two thirds of Member States from the Region had developed or updated their policies and laws for mental health in line with international and regional human rights instruments (against a global target of 80% and 50% for policies and laws, respectively). In just under half of the countries (45%), mental health
legislation is enforced by a dedicated authority or independent body, which provides regular inspections of mental health facilities and reports at least annually to stakeholders.
WHO/Europe’s mental health programme has assisted several Member States in drafting, contributing to or reviewing new mental health policies, plans and laws, including Bulgaria, Estonia, Finland, Lithuania, Malta, Montenegro, Slovenia, Turkey, Turkmenistan and Ukraine.
8. In the area of children and adolescent mental health, a specific plan or strategy was available in 60% of the European Member States as of 2017; of these, most (82%) had
developed or updated such plans in the past five years. Efforts were focused on data collection and synthesis, as well as development and promotion of evidence-based interventions in Member States. Through close collaboration with relevant programmes or departments at WHO/Europe and headquarters, WHO collaborating centres and the United Nations
Children’s Fund (UNICEF), vital improvements were made in: data availability on the mental health status of young people, notably through increased inclusion of mental well-being in the Health Behaviour in School-aged Children study and its periodic surveys across more than 40 countries in the Region; and the availability of new evidence and guidance to support enhanced country-level action, such as Guidelines on mental health promotive and preventive interventions for adolescents: helping adolescents thrive, which provides evidence-based guidelines and an implementation toolkit on evidence-based approaches to better mental health promotion and protection.
9. In the area of mental health of older adults, the Region has a rapidly ageing population, which places ever greater demands on health and social care systems. Yet many countries in the Region remain under-prepared or ill-equipped to meet the health and social needs of older
adults. As a result, dementia has become a leading cause of morbidity and mortality in many European countries. WHO/Europe has worked closely with WHO headquarters and European partners such as Alzheimer Europe on implementation of the Global Action Plan on the Public Health Response to Dementia 2017–2025, including through increased participation in the Global Dementia Observatory (GDO) and intercountry policy and planning events.
10. In the area of suicide prevention, significant efforts have been made to develop and implement national suicide prevention strategies that incorporate best practice and combine a universal approach with activities protective of vulnerable groups. There is now a national suicide prevention strategy in 26 countries in the Region, which represents a significant improvement on 2014, when only 16 countries reported having such a strategy. Nineteen of the 26 countries reported having developed or updated their national suicide prevention strategy since 2013. Such progress is reflective of the many awareness-raising events and policy dialogues that have taken place in and across countries of the Region. At the regional level, WHO/Europe is moving forward with implementing an evidence-based package on suicide prevention (LIVE LIFE) and has also facilitated the establishment of a self-harm surveillance system in the Russian Federation. Nevertheless, much remains to be done if the Region is to reduce its still-high rate of suicide and achieve the global Sustainable
Development Goal target of a one-third reduction by 2030.
11. Human rights are a core principle and priority objective of the European Mental Health Action Plan, not only because mental health is a human right in itself, but also because people living with mental health conditions and psychosocial disabilities often find themselves deprived of their rights. The United Nations Convention on the Rights of Persons with Disabilities and the United Nations Convention on the Rights of the Child provide important international frameworks against which the protection of rights can be measured.
Accordingly, assessment of the extent to which national mental health policies and laws are aligned with international human rights covenants has been directly incorporated into WHO Mental Health Atlas surveys; in terms of promoting and protecting human rights, recent results indicate that a third of the countries in the Region have both mental health policies and legislation that are not fully compliant.
Mental health service development, treatment and care (objectives 3 and 4)
12. Objectives 3 and 4 emphasize a community-based model of care whereby mental health services are accessible, affordable and available to those in need. Since the endorsement of the Action Plan in 2013, several countries have engaged in systemic reforms to their mental health service model, as indicated by the following examples. WHO/Europe has played a consultative and advisory role in such reform efforts and has also been an implementation partner on aspects ranging from multisectoral dialogue to capacity-building and evaluation.
(a) Belgium: In response to the need for improved people-centred care and support for people with mental health conditions, nationwide reforms in Belgium have led to a substantial decrease in the number of psychiatric inpatient beds as well as the strengthening of community-based services with a focus on social rehabilitation and user recovery. Twenty-two multisectoral mental health care networks were established in 2017, and more than 50 mobile teams are now offering outreach, prevention,
inpatient and outpatient mental health, primary care, day care, and vocational, housing and social care services.
(b) Bosnia and Herzegovina: Mental health care reforms date back to 1996 and have led to large improvements in the quality of mental health services. Seventy-four community mental health centres have now been established and integrated with primary health care, their services fully covered by health insurance schemes. Over 700 mental health professionals have received training in case management, and since 2014, service users have been surveyed regularly, which has shown significant progress towards recovery in 87% of users.
(c) Czechia: A comprehensive mental health reform programme is being implemented that is focused on addressing stigma and discrimination against people with mental health conditions, as well as shifting the locus of care away from large psychiatric hospitals towards a network of 30 community mental health centres. WHO/Europe has been actively assisting and advising the Ministry of Health and National Institute of Mental Health on a monitoring and evaluation framework for the reforms, as well as building capacity in mental health and human rights through application of the QualityRights Tool Kit.
(d) Turkey: WHO/Europe is supporting the government to implement a large-scale project to provide community-based care services and promote social inclusion for people with mental health conditions and intellectual disabilities. Since 2015, 185 community mental health centres have been opened and around 50 small residential homes, called Houses of Hope, were established for people with long-term support requirements.
Training has been implemented for specialist mental health professionals and non- specialists such as family doctors and social care staff.
13. Significant reforms have also been taking place across several countries in Europe and central Asia, including the development of a network of community-based mental health services in the Republic of Moldova and Slovenia, and integration of mental health into primary health care in Kazakhstan and Turkmenistan. WHO’s Mental Health Gap Action Programme (mhGAP) intervention guide has generated significant new national capacity in the identification and management of mental health conditions in non-specialized care settings. The guide provides clinical decision-making algorithms for a set of priority mental, neurological and substance-use disorders, including for children and adolescents.
14. Serious concerns have been raised by Member States and nongovernmental bodies alike about the very poor conditions and widespread human rights violations in institutional care. In response, WHO launched its QualityRights initiative to improve standards of care and promote rights for adults with psychosocial and intellectual disabilities. A large-scale assessment exercise carried out by WHO/Europe in 2017 (with 98 institutions assessed in over 20 countries) concluded that long-term institutional care for people with psychosocial and intellectual disabilities in many European countries was far below quality standards.
A significant proportion of the assessed institutions were found to be violating the rights of people with psychosocial and intellectual disabilities, including in relation to their legal
capacity, autonomy, dignity, liberty, physical and mental integrity and freedom from torture and ill treatment. Since 2018, WHO/Europe has provided technical support to a number of Member States aiming to build capacity in transforming services and promoting human rights in line with the United Nations Convention on the Rights of Persons with Disabilities, for example through advanced training workshops on strategies to end the use of seclusion and restraint.
Mental health services integration, intersectoral collaboration and information systems (objectives 5, 6 and 7)
15. Redesigning health systems and services towards more integrated and person-centred care for people with mental health conditions and other chronic conditions remains a
significant ongoing challenge. The need for such a transition is borne out by the high degree of comorbidity that exists between mental health conditions and communicable diseases such as HIV and tuberculosis, as well as with noncommunicable diseases.
16. Building on the momentum created in September 2018 by the political declaration arising from the third high-level meeting of the United Nations General Assembly on the prevention and control of noncommunicable diseases, the WHO European High-level Conference on Noncommunicable Diseases: Time to Deliver (Ashgabat, Turkmenistan, 9–10 April 2019) provided an important forum to discuss and share pathways towards better integration of mental health across population-level, community-based and health care delivery platforms. In addition to a report on these pathways to integration, WHO/Europe published a report on comorbidity between mental disorders and major noncommunicable disease as well as policy briefings on the links between mental health conditions and harmful use of alcohol, physical inactivity and tobacco use, respectively.
17. A further key resource and support mechanism for well-functioning mental health systems relates to the availability of timely and relevant information that enables implemented actions to be monitored and improvements in service provision to be detected. WHO/Europe participated in a study carried out in Bulgaria, Czechia, Hungary and Serbia to develop and test quality indicators for mental health, and contributed to the Organisation for Economic Co-operation and Development’s mental health system performance benchmarking project.
Among Member States of the European Union (EU), EU-Compass for Action on Mental Health and Well-being provided a valuable opportunity and platform for the intercountry exchange of data, information and good practices in mental health.
18. International surveys were also administered across the Region on specific topics, including adolescent mental health as part of the Health Behaviour in School-aged Children study; dementia policy, services and resources (via GDO); and the impact of COVID-19 on mental, neurological and substance-use services. The latter survey, which was carried out in the third quarter of 2020, found that close to three out of four European Member States included mental health and psychosocial support in their national COVID-19 response plans, and just over half possessed a multisectoral coordination platform for their activation.
19. Feedback was also elicited from Member States on the value, relevance and uptake of the European Mental Health Action Plan (2013–2020) itself. Out of 31 responding countries, 47% stated that the Action Plan was highly relevant; but only 23% considered it highly (as opposed to somewhat) influential in shaping national health policies and practices. In terms of its implementation, 30% reported receiving substantial support from WHO for policy
development, advocacy and training activities, but only 17% for monitoring and evaluation.
Another 30% of responding countries reported no support. 52% considered that a new action plan or implementation framework was highly needed, and a further 40%, somewhat so.
Proposed areas of renewed focus included stronger coordination and partnerships, greater involvement of service users and protection of their human rights, further emphasis on mental health promotion and protection, and continued development of community-based mental health service capacity.
Final report on the WHO European Declaration and Action Plan on the Health of Children and Young People with Intellectual
Disabilities and their Families
20. In resolution EUR/RC61/R5, which endorses the WHO European Declaration and Action Plan on the Health of Children and Young People with Intellectual Disabilities and their Families – better health, better lives, Member States recognize the urgency of ensuring that the human rights of children and young people with intellectual disabilities are respected and accept the responsibility to plan, adopt and implement policies that progressively realize the 10 priority action areas set out in the Declaration (see Table 2).
Table 2. Priority action areas of the WHO European Declaration on the Health of Children and Young People with Intellectual Disabilities and their Families
Priority action area Description
1 Protect children and young people with intellectual disabilities from harm and abuse 2 Enable children and young people to grow up in a family environment
3 Transfer care from institutions to the community 4 Identify the needs of each child and young person
5 Ensure that good quality mental and physical health care is coordinated and sustained 6 Safeguard the health and well-being of family carers
7 Empower children and young people with intellectual disabilities to contribute to decision-making about their lives
8 Build workforce capacity and commitment
9 Collect essential information about needs and services and assure service quality 10 Invest to provide equal opportunities and achieve the best outcomes
21. A 2016 WHO mid-term report noted, among others, the following examples of progress:
Investing in Children: the European Child and Adolescent Health Strategy 2015–2020 (EUR/RC64/12), which incorporated mental disorders and disabilities in young people;1 and Investing in Children: the European Child Maltreatment Prevention Action Plan 2015–2020 (EUR/RC64/13), which identified that children with a disability or behavioural problems and children in institutional care may be at increased risk of maltreatment. In the same year, the World Health Assembly adopted a resolution (WHA67.8) that requests Member States to give appropriate recognition to the specific needs of individuals with autism spectrum disorders and other developmental disorders. The 2016 mid-term report stressed the importance of continued working relations with UNICEF in this area, as well as with the European Commission on progress in deinstitutionalization and with the United Nations Office of the High Commissioner for Human Rights on human rights in institutions.
1 Further information is available in a background document prepared for the 71st session of the Regional Committee, Child and adolescent health in Europe: Report on progress in 2021.
22. For this final progress report, relevant information was collected using a key informant methodology in collaboration with independent researchers commissioned by WHO/Europe.
Key informants from across Europe were identified through existing networks and previous contributors to the Declaration, as well as through online searches of organizations working in this area, both at national and local levels.
23. In general, progress appears to have been mixed across Europe. Many countries reported efforts to incorporate the principles of the United Nations Convention on the Rights of Persons with Disabilities into policy and legislation in order to stimulate change, but progress is varied, and many respondents reported no substantive change over the last decade. Key themes, as relevant to the priorities of the Declaration and data collected, are described below.
Equal opportunities (priority action areas 4, 7, and 10)
24. As recognized in the Declaration (priority action area 7), one way in which to combat inequalities in opportunity is through empowering children with intellectual disabilities to contribute to the decisions affecting their lives. Between 2011 and 2013, the Turning Words into Action project led by Lumos brought together children and young people with
intellectual disabilities, their parents, policy-makers, and health and educational professionals in Bulgaria, Czechia and Serbia, with the aim of bringing the “Better health, better lives”
Declaration to life through meaningful and effective child participation activities and
outcomes. The project, entitled Hear Our Voices and coordinated by Inclusion International, in which partners have developed mechanisms to support children with intellectual disabilities to participate in their communities, including decision-making processes, is more widely implemented across Europe.
25. Despite these examples, many countries reported little to no action in empowering children with intellectual disabilities and their families in decision-making processes.
Respondents reported a lack of participation by and representation of people with intellectual disabilities and their families in local, national and regional planning and decision-making.
Renewed efforts are therefore required to empower children and young people with intellectual disabilities, advance equal opportunities and respond to the stigma and myths connected to people with intellectual disabilities.
Safety and safeguarding (priority action areas 1, 3, 6 and 7)
26. In order to live a healthy and happy life, all children need to live in an environment safe from harm and abuse. Children with intellectual disabilities are particularly vulnerable to abuse, with evidence showing this to be particularly true if they live in an institution. In 2015, the European Union Agency for Fundamental Rights (FRA) developed a comprehensive report, Violence against children with disabilities: legislation, policies and programmes in the EU. Member States of the EU reported that those with intellectual disabilities were more likely to be bullied and abused than those with more “visible” physical disabilities.
Respondents also reported that abuse against children who communicate in a non-traditional way was less likely to be prosecuted.
27. As of 2015, a number of Member States had established policies addressing the rights of persons with disabilities and their protection from violence: Austria, Czechia, Finland, Germany, Italy, Portugal, Slovenia and Spain. In the United Kingdom of Great Britain and
Northern Ireland, a new policy group was established to combat hate crime against people with learning (intellectual) disabilities and autism, with legislation also under review.
28. Progress is being made, but challenges remain, including a lack of specialized support for children with intellectual disabilities; limited knowledge and awareness of protection and prevention measures; lack of family support; and insufficient professional capacity and funds.
Community care (priority action areas 2, 3, 4 and 5)
29. Early childhood interventions are the subject of wide attention, focusing on reducing the impact of factors associated with developmental disability, pre-empting behavioural
challenges and improving parent–child interactions. The 2018 WHO publication, Nurturing care for early childhood development: a framework for helping children survive and thrive to transform health and human potential, proposes an evidence-based framework and roadmap for action to bring together parents and caregivers, national governments, civil society groups, academics, the United Nations, the private sector, educational institutions and service
providers to ensure the best start in life for all children.
30. However, children with intellectual disabilities in many countries are often separated from their families, and live in large residential institutions that cannot meet their needs. In 2015, an estimated one million children lived in institutions of this kind across Europe, and according to UNICEF, across eastern Europe and central Asia, children with disabilities are almost 17 times more likely than other children to be institutionalized.
31. Children with intellectual disabilities, autism and those who present behavioural challenges are reported to be the most likely groups to be living in large residential
institutions. Very few respondents in this study reported progress in deinstitutionalization, with many actively citing this area as a major challenge to be addressed going forward.
32. Child protection reforms are currently being implemented in Bosnia and Herzegovina, Bulgaria, Croatia, Estonia, Latvia, Lithuania, the Republic of Moldova, Romania and
Ukraine, with the support of national strategic frameworks on deinstitutionalization and the development of community care-based services provided through multisectoral collaboration.
Several alternatives to institutionalization have been increasingly promoted across the Region;
for instance, legislation on foster care and on the protection of families with children was adopted in Belgium and Bosnia and Herzegovina in 2017, and in Croatia and Greece in 2018.
Health and social care (priority action areas 5, 6, 8 and 9)
33. Information on health outcomes and health care provision for children with intellectual disabilities is generally limited, with respondents reporting a lack of reliable data. The data that do exist show that children with intellectual disabilities experience higher mortality, morbidity and health care inequalities than children without intellectual disabilities.
34. To support the Declaration and initiatives across the Region, the Regional Committee adopted resolution EUR/RC64/R6: Investing in children: the European child and adolescent health strategy and the European child maltreatment prevention action plan 2015–2020, which incorporates support for children with disabilities. The Framework on Early Childhood
Development in the WHO European Region (2020), developed from resolution
EUR/RC64/R6, provides Member States with guidance on helping children to reach their full potential. Actions and guidance are provided for the support of children with disabilities and developmental disorders, including children with intellectual disabilities. In terms of
developing more connected, inclusive and sustainable health systems, innovation and digitalization can also exert an important influence.
35. As well as support for child health, it is important to recognize the ongoing support needed for family members and caregivers. WHO has developed the Caregiver Skills Training programme for families of children with developmental delays and disorders. This
programme supports caregivers in promoting children’s learning, social communication and adaptative behaviour, and also aims to increase the skills and confidence of caregivers, helping to reduce stress and improve their well-being.
Conclusion and way forward
36. These two final progress reports demonstrate not only the scale of the challenges faced by countries of the European Region, but also the scale of efforts made by parties to these action plans to confront and address these challenges. There have been many important developments that have enabled better care and better lives for children, adults and families at risk of or living with mental health conditions or a psychosocial, cognitive or intellectual disability, such as stronger legislation, more accessible services or better understanding and awareness. But for most users of services, there has been a wholly unsatisfactory lack of progress in service access, quality or standards. Investment in mental health promotion, protection and care remains inadequate relative to the needs of the population, services remain fragmented, and stigma continues to affect public attitudes and blight opportunities for
affected individuals and families. Thus, while the Member States of the Region have the resources, knowledge and capability to provide dramatically better service standards and quality as well as better opportunities for affected individuals and families, there remains a substantial gap in political commitment, financial investment and effective service coverage that must be attended to.
37. The outbreak of COVID-19 across the Region that began in 2020 has served to underscore the importance of mental health as a vital element of individual and collective well-being; it has also served to exacerbate the pre-existing level of psychiatric morbidity and psychosocial disability in the population, and to highlight the weaknesses or inadequacies of health and social care services for people with mental health conditions and psychosocial, cognitive and intellectual disabilities. Addressing the impact of COVID-19 on mental health has been a priority for WHO/Europe since the pandemic began. Building on their knowledge and experience of previous recessions and public health emergencies, WHO, United Nations agencies and the international mental health and psychosocial support community have developed and disseminated a range of risk communication, policy guidance and practical intervention materials to enable and support the integration of mental health into countries’
COVID-19 response and recovery efforts.
38. As the Region begins to adjust to and recover from the wide-ranging impacts of
COVID-19, renewed attention to the mental well-being of affected vulnerable populations as well as the public at large will be crucial. There is a unique opportunity to “build back better”, and to that end, the newly established pan-European Mental Health Coalition – a flagship initiative within the European Programme of Work, 2020–2025 – can play a catalytic role in
bringing forward much needed investment in, reform of and improvements to mental health and social care services across the Region. The pan-European Mental Health Coalition seeks to increase public understanding of mental health and tackle stigma and discrimination; to galvanize and expedite efforts to enhance access to services and support at the community level; and to mobilize investments in mental health and advocate for service reforms that promote and enable rights-based, person-centred care. Its establishment provides an overarching structure for interpartner exchange between Member States, international organizations and non-State actors, including nongovernmental organizations, academia, philanthropic organizations and the private sector. Specific proposed areas for prioritized action are set out in the companion document submitted to the 71st session of the Regional Committee on a WHO European Framework for Action on Mental Health 2021–2025 and the new Mental Health Coalition.
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