Years of lobbying and activists’ efforts have succeeded in establishing community-based care as a keystone of the Caucasus country’s health care system.
Psychiatrist and mental health reformer Giorgi Geleishvili was working at a psychiatric hospital in Tbilisi, a traditional, closed institution, when he established the first community-based mental health center in Georgia, with a holistic approach to treatment and rehabilitation.
“It was like a vicious circle, the patient was lost between home and hospital,” he says of the conditions he observed before opening the center in 2012. At that time, there was no counseling available on a 24/7 basis for patients leaving mental hospitals.
Two decades after the collapse of the Soviet Union, its methods still ruled: Most people who struggled with serious mental health issues were locked up in institutions, sometimes for life, and faced deeply rooted stigmas and discrimination on the outside, says Jana Javakhishvili, president of the European Society for Traumatic Stress Studies.
The Evidence Based Practice Center opened in 2012 and moved to the first floor of a building in the Nutsubidze Plateau district of Tbilisi in 2017. It occupies a three-bedroom apartment. There is a television in the living room, which is always busy with clients coming to the center to watch TV, play chess, or engage in group therapy. The office is located on the same premises. Here team members meet daily to talk over client treatment plans and other activities. Individual care and sessions take place in clients’ homes.
A Client-Centered Approach
Twelve specialists work at the Evidence Based Practice Center: two are psychiatrists, while the others include a social worker, psychologist, occupational therapist, and nurses. There is also a junior doctor and a peer educator – someone who assists clients in the recovery process based on their own experience, or a family member’s, with a mental health condition.
Irakli, 36, is a peer educator and a former client at the center. The history of his mental health problems began with a physical injury. At the age of 15, he slipped on a rock while diving into a river and badly injured his spine. The injury had serious consequences. Since then, Irakli has dealt with mental problems and has been hospitalized several times.
He describes the time spent in a psychiatric institution as difficult. The staff were very rude, and patients lived under severe restrictions, he said. Today, Irakli is not only a beneficiary of assertive treatment, but also an employee who helps doctors work with other clients. “Coming here is like coming home – it feels like home,” he says.
Assertive community treatment, or ACT, is a form of mental health care that began in the United States in the 1970s. As a multidisciplinary approach, ACT combines social, psychological, and medical care to help patients function better in the community. ACT is an alternative to traditional hospital-based treatment for patients who require prolonged, intensive care for severe psychiatric conditions such as bipolar disorder and schizophrenia. It is provided in a non-hospital setting and is available to clients at all times. Research studies have shown ACT to be effective in reducing the number and duration of hospitalizations and improving the employment prospects of clients.
According to Geleishvili, assertive community care is for those patients who need prolonged and intensive treatment (see sidebar). Care at the Evidence Based Practice Center is provided by mobile teams who visit clients who do not or cannot use out-patient services. Center staff visit the 100 or so clients on a daily basis, sometimes two or three times a day. They can provide medicines and other supplies, give advice, and monitor client adherence to drug regimes and other issues.
Crucial to the center’s work is also the training of mobile teams. The center developed a special training module with the support of People Encouraging People, a mental health and social services NGO in the U.S. state of Maryland, and later received certification in Georgia. Overall, more than 150 community mental health specialists have been trained for the different regions of the country.
According to Geleishvili, research and observation shows that, on average, the duration and frequency of hospitalization has dramatically decreased for clients of the Evidence Based Practice Center.
Until 2016, the service was entirely funded by the U.S.-based Open Society Foundations (OSF), but later on state and municipal funding was raised through an advocacy campaign initiated by supporters of community-based care, some media, and other interested stakeholders. Geleishvili and others lobbied parliament, the Health Ministry, and other government bodies to advocate for community-based mental health care and fund mobile teams.
Their efforts met with success: In 2015, the state funded just three community mental health teams, but by 2018, the number had increased to 11 teams serving clients in Tbilisi and four other cities. The 2021 budget allocates 2.8 million lari ($850,000) to fund 32 mobile teams serving more than 1,000 clients.
According to Eka Chkhonia, head of the Georgian Psychiatrists’ Association and a co-author of a study conducted by the Alliance for Better Mental Health in 2020, the total mental health budget has risen by 11.5 million lari over the past three years, with the bulk of the increase allocated to community outpatient or walk-in clinics and community mobile services. However, community mental health care should normally serve 3 percent of the population, Chkhonia says, and Georgia has a ways to go before reaching this level.
The same study reports that community outpatient clinics and mobile teams served about 64,000 clients in 2020.
Along with increased financing, the state now embraces community-based outpatient services, mobile team service, and crisis intervention services, says Chkhonia. The proportion of the budget going to inpatient mental health treatment has fallen in recent years from 71 percent to about 60 percent.
The approved 2021 state budget allocates 28.9 million lari ($8.8 million) for mental health services. The largest single program still is hospital care for adults (15.6 million lari), followed by community outpatient services (7.4 million) and community mobile teams (2.8 million, as noted above).
“Although state support for mental health care has doubled over the past seven years, its share of total health spending has risen more slowly due to inflation and is still very low by European standards at 2.4 percent,” says Vano Tsertsvadze, an economist at the Georgian Institute of Public Affairs.
Scarce funding is reflected in the assertive service team members’ salaries, which is on average around 1,100 lari a month – less than $350. “Team members cannot take a proper vacation on that income, even if just for a week,” Geleishvili says. Lobbying efforts have achieved state financing for 75 percent of the mobile teams, but even so, he says they are “on the edge of existence.”
Overcoming Official Skepticism
The transition from a hospital-only system to community care in Georgia was not easy, says Irma Khabazi, public health program manager at the Open Society Georgia Foundation. The process owed much to the energy of local health activists – “champions,” as she calls them.
“In 2010, some in the psychiatric community realized that the most important issue was to target people that were imprisoned in institutions, and it was really important to get them out of there,” Khabazi recalls. Activists working toward community-based services also needed to gain support from local and international donor organizations. This long-term financial and technical support in the first five years later helped drive systemic change in Georgia’s mental health care system, she says.
Khabazi explained the systemic nature of the changes. Advocates of reform within the professional community joined forces to develop a working document, she said, which later provided the basis for drafting a national mental health program and action plan. Those initiatives had the primary goals of recognizing the utility of community-based treatment and making public discussion of mental health issues more acceptable.
It was not easy to bring officialdom to accept the need for community services, Khabazi says. Health Ministry representatives and parliamentarians were invited on field trips to Europe and the United States, funded by the Open Society Foundations, to observe community mental health services in operation.
In 2014, the government approved a strategy document and action plan for the development of mental health services from 2015 to 2020. Governments at the central and local levels also began funding innovative mental health services previously supported by OSF.
According to Khabazi, at the initial stage of the reform, although mental health policy was not on the government agenda, the Health Ministry took some steps that indirectly promoted the development of mental health services. Khabazi also recalls a government initiative to reach out to expatriate Georgians to mobilize their forces in support of the home country. At one meeting,Archil Abashidze and Nino Abdushelishvili, two U.S.-based mental health specialists, offered to lend a hand to their colleagues in Georgia.
“It was a lucky moment, a tipping point that brought many actors together,” Khabazi says.
Abashidze, a psychiatrist who left Georgia in the 1990s, is affiliated with People Encouraging People, the same U.S.-based group mentioned above that helped the Evidence Based Practice Center develop a special training module. Together with his wife, Abdushelishvili, they served and helped clients to become accepted and productive members of the community in the United States.
Abashidze explains that assertive care offers tangible results for not only clients, but also for organizations that provide it, thanks to its cost effectiveness compared to older methods. These experiences moved the couple to go door to door to convince Georgian officials of the need to finance a similar service, but in the beginning, a decade ago, all doors were closed to them.
However, implementing community services had to find not just financial and administrative remedies, but also fend off criticism. Disapproval of the assertive community center from the beginning was directed toward its cost, as it was considered an expensive method that was not suitable to Georgia’s overall social and economic development.
Geleishvili and his team have also had to deal with negative public opinion and the stigma around mental health. When the center moved to its current home, some residents of the building complained about noise and the presence of strangers smoking and laughing outside, the magazine Liberali wrote in 2018. In general, the residents were not against deinstitutionalization; they simply preferred that clients stay out of sight, Liberali said.
Next Steps: Providing Care to All Who Need It
A systematic survey of community-based mental health services in 2018 revealed how much work remains to be done in order to extend care to those who could benefit from it. The survey found that the number of people receiving care, 49,789, was less than half the total of officially registered cases (102,977).
The stigma attached to mental illness, combined with inadequate quality of services and the financial and geographic obstacles to obtaining needed mental health care, all contribute to driving away many who could potentially benefit, Chkhonia says.
According to mental health reformers Nino Makhashvili, who was recently appointed as a special member of the World Psychiatric Association, many individuals in Georgia who require treatment for psychological conditions still do not receive it. Monitoring is needed, Makhashvili believes, to keep the authorities accountable for continuing the work of deinstitutionalization.
Since Georgia became independent, new generations of mental health professionals have invested their efforts into overcoming the Soviet-era inertia in the field, Javakhishvili of the European Society for Traumatic Stress Studies says. Beyond moving people out of big, closed institutions and overcoming the stigma around mental health disorders, reform should be directed toward empowering patients to participate in making decisions about their lives, she said. Javakhishvili also advised building an infrastructure of community-based services, increasing accessibility of services for people in need, changing hospital-financing models and, finally, implementing evidence-based approaches and methods.
“We are not there yet, but the main thing is that we are on the right path,” she comments.
Deputy Health Minister Tamar Gabunia stresses the success in embedding community mental health care in the national health system. According to Gabunia, a new mental health policy document will guarantee consistent development and evaluation of community-based services.
The document has been drafted and will now be fine-tuned after further consultations with patient groups, professionals, and other stakeholders. “An important step will be to agree on a clear vision of where we are going, what pace we are taking, and how long it will take to implement specific measures,” Gabunia states.
Georgia has made significant progress in developing community-based services when compared with other countries in Eastern Europe, according to Ugne Grigaite, a program manager with the Human Rights Monitoring Institute in Lithuania and a doctoral fellow at the Lisbon Institute of Global Mental Health. Grigaite is part of a regional project to evaluate achievements and challenges in implementing mental health care and social service reforms in several Eurasian countries, including Georgia.
“Some community-based services [in Georgia] especially surprised and impressed us with their quality and uniqueness, especially when compared to situations in other countries, including our own home country Lithuania,” she says. She attributes much of that progress to the work of local activists and non-governmental and donor organizations.
According to Maia Shishniashvili, a mental health specialist and a co-founder of Movement for Changes, a coalition of parents of children with intellectual disabilities, the recognition and establishment of new treatment models and raising trust in community services are major landmarks in establishing a more humane mental health system, but much work remains to be done.
“We have set precedents with the establishment and development of community-based services such as mobile teams, assertive community care, and community housing … But a number of crucial changes need to be made to make the deinstitutionalization irreversible and sustainable,” Shishniashvili says.
Tina (Tiko) Tsomaia, MD, is a professor at the Caucasus School of Journalism and Media Management (CSJMM) of the Georgian Institute of Public Affairs (GIPA). She also runs www.femicide.ge, a collaborative project to inform the public about crimes against women. She is also the chair of Baltic to Black Sea Alliance Georgia, an NGO which, among other projects, supports community mental health centers.
Ia Shalamberidze is a multimedia storyteller with more than 10 years of experience and a researcher at Baltic to Black Sea Alliance.