社会精神卫生法：对非洲的思考外文翻译

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1、社会精神卫生法：对非洲的思考Peter Bartlett, Rachel Jenkins, and David Kiima精神卫生系统国际期刊2011,5:21摘要：新的联合国残疾人权利公约创建了精神卫生法立法的新模式，这种新的立法模式将原来的那种以制度关怀为重点的模式发展成为现在的以社区为基础的精神病关怀服务。本文的写作目的在于思考这种模式在非洲国家的具体实施。依传统而言，精神卫生立法在国内和国际上都是以机构关怀为焦点，尤其以精神病制度关怀为焦点。从这个角度而言，精神卫生法的作用在于确立合适的实体和程序标准而非通过立法的方式强制精神病患者住院。就最新的精神卫生法而言，它的作用在于确立精神病患

2、者入院后的医疗看护标准。就历史角度而言，这种立法方法与政策相对应。政府对比较严重的精神病人都会给予精神护理，由精神病收容所对精神病人进行长时间的看护。这种精神卫生立法模式从保护精神病人利益的角度考虑显然是不够的。近几十年来，政府对待相对较严重的精神病患者的政策的重点已经从制度关怀发展到社会对人的关怀，这种转变从新的联合国残疾人权利公约可以看得出来。与先前的国际文件（如联合国精神病指导原则）不同，联合国残疾人权利公约不仅仅是一个指导原则，它是一部国际法，它拥有正式的法律渊源，签署该公约的国家应当遵守该公约的约束。联合国残疾人权利公约将法律的焦点从法律对精神病患者的强制发展成为对精神病患者的社会服

3、务上，并将残疾人的权利与社会相融合。显而易见，社会生活制度化的立法模式与国际立法发展的趋势相背。对于这种新的国际精神卫生立法，非洲国家得到了特别的机遇和挑战。与国际发达国家相比，非洲国家将联合国残疾人权利公约所规定的内容制度化并实施的概率很低（见附录文件一中的表1）。在经济发达的国家，制度模式的关怀向社会关怀模式的转变是伴随着分散的以社区为基础的精神卫生保健的发展而形成的。在1980年，英联邦每100000人中就有一名心理医生；而发展到1990年，这种比例已经发展成为50000：1；到了2010年，在英联邦每10000人中就1人是心理学家。然而，大规模的心理学专家提供的精神病服务并不是符合非洲

4、发展实际的模式。在非洲，大部分国家的人均国内生产总之低于2000美元每年，而且这些国家的心理咨询师，心理学家，精神科护士，社工等的数量都相当有限。精神科专家提供的社区服务往往是在省级或者市区级的社区单位里，这些服务由热心的致力于为精神病患者提供服务的专家提供。然而，这种由专家提供的社区服务只能满足很小一部分的精神病患者需求。一些非洲国家，例如坦桑尼亚，肯尼亚，马拉维，赞比亚，正在尝试将心里健康融入初级保健制度的立法。这种立法模式，将可以将专家的比例调整为每250000人一个心理学护士，每1000000人一个心理医生。本文着眼于新的精神卫生法律立法模式在非洲国家可能表现形式。这种立法模式刻意不注

5、重对精神卫生机构的监管。当然这些精神卫生机构在非洲国家也存在，他们一般都处于省会城市。这些机构在精神病患者的准入和医疗看护方面的做法和标准都导致许多人权问题的发生。把整个国家的社会立法当作一个整体，无论是否通过首要关怀或者其它的方式，都不能使人们被允许进入这些被忽视或者遗忘的机构。但是，这些担忧已经吸引了国际社会的关注。这篇文章的焦点在于依靠一些独特的问题，比如如果精神卫生立法的焦点超出了机构的范围，那么它将是什么样子的。同时该篇文章焦点也在于依靠社区和首要的关怀服务。然而残疾人权利公约所规定的新的立法模式又使这一相关问题国际化，本文将社区环境中的精神卫生立法所存在的问题和非洲服务发展中存在的

6、特殊问题结合起来予以阐述。 非洲国家的精神卫生关怀立法正如表格显示，在非洲国家资源有限的问题是不可避免的。人均国民生产总值在2000美元以下是很普遍的。然而非洲联盟的成员国已经确定了在卫生上花费15%的财政预算的目标，许多国家在近些年是不太有可能达到这一目标的。政府每年在卫生上的人均支出一般低于50美元，并且在某些情况下每年甚至会低于10美元。通过比较，发达国家的政府每年在卫生上的人均支出一般在1500美元到2000美元不等。在非洲，卫生经费通常提供给一些少部分的国家医院，给远离主要城市中心的医疗服务提供了很少的经费。例如，在肯尼亚，在内罗毕的国家医院消耗了近90%的国家卫生支出。反过来，精神

7、卫生的预算仅仅是全体卫生预算的一部分。在2000年，精神卫生在全球疾病的负担中所占的比例是12%，预测到在2020年将会增长到15%。在国际上对精神卫生的预算往往都没有达到这一比例。但是这一比例在非洲国家却惊人的低通常情况下低于卫生预算的1%，并且整个卫生预算每年可能仅仅在人均10美元左右。在如此低的卫生预算的背景下，结果就是仅有及其少的资金用于精神卫生服务。产生这种情况的原因是医院职工的工资很低以及可用于住院的病床有限所致。例如在肯尼亚，40万的人口却只有少于1000的病床可供使用，而且在这些病床中，内罗毕占绝大部分。每个省有4到5万的人口，却只有20个精神科住院病床。每个区有25万人口，却

8、只有1到2个精神科护士，而且有精神科住院病床的区域不足10%。在一些非洲国家，并不存在国家投资的精神服务的存在。 结果是最低限度的精神卫生服务。根据2005年世界卫生组织的研究表明，尽管马拉维已经聘请了心理科医生，但在安哥拉和马拉维没有精神科医生。一般来说，在非洲1万个人中才有一个心理医生，并且这种情况已大大加剧了人才外流。在肯尼亚有23卫心理医生为40万人口提供公共服务。在马拉维有13位心理医生为42万人口服务。心理科护士，社会工作者和心理医生的工资待遇都很低。在肯尼亚有250名心理科护士开设了精神病学，但是产出的比例是远远低于退休的比例，从而导致了大量的人才外流。进一步来说，在2009年，

9、肯尼亚在所有接受培训的12人之中，仅仅为国家培养了一名精神科护士，但是绝大部分的人是来自于其它非洲国家。近些年来，由于学生没有足够的支付课程的费用，精神科护士的学生人数不断的下降，但是在2010年这一人数很幸运的重新增长起来。 地理因素加剧了这些问题。在南非共和国之外，撒哈拉以南的非洲地区，其每名精神科医生所在的平均面积范围是不同的，斯威士兰是每17,000平方公里一名医生，而刚果则是每342,000平方公里一名精神科医生。在相同背景之下，澳大利亚的相应数据是2600平方公里，而美国是230平方公里，法国和英国是每40平方公里一名精神科医生。当然，对于这方面的平均水平，我们必须要小心求证。实际

10、上，精神卫生专业人员（特别是精神科医生）可能都集中在城市地区。对于这些城市的人来说，他们比市区以外的人更容易得到专业服务。而对农村地区的人来说，专业服务集中在城市稀疏的初级保护覆盖范围（每一万人口有一个诊所）意味着最近的医疗设施可能确实都需要走很长的路，而有限的公共交通基础设施更加剧了困难。 现有的治疗方法是有限的。由于价格原因，新一代抗精神病和抗抑郁药物是不太可能在公共部门中得到的，而且尽管他们有更好的作用，但也不是在任何情况下都能取得更好的结果。如果政府和客户之间都会分担成本的话，那么老年人的药物一般是由两者共同支付的。但是，即使是这样也经常出现供不应求，而公共分配也会出现各种问题，这是因

11、为国外采购比较困难，且质量较差，而进口的药品也缺乏质量管理，分配机制又在不断变化，如在肯尼亚的卫生设施就由药物包推式系统转变为拉式订购系统。这不仅造成精神卫生设施的缺乏，而且造成抗疟药的短缺。新的心理疗法的培训（如CBT）是有限的。研究表明，如果新的心理疗法培训的实施是有效的，它就需要持续的监督。因此，只有密切监督的时间足够长才能使得这种培训成为更有效地一般心理技能，从而支持CBT和其他特殊疗法的实施。Mental health law in the community: thinking about AfricaPeter Bartlett, Rachel Jenkins, and Davi

12、d KiimaInternational Journal of Mental Health Systems 2011, 5:21Abstract: The new United Nations Convention on the Rights of Persons with Disabilities creates a new paradigm for mental health law, moving from a focus on institutional care to a focus on community-based services and treatment. This ar

13、ticle considers implementation of this approach in Africa. Traditionally, mental health law at both domestic and international levels has focused on institutional care, and particularly psychiatric hospitalisation. In this vision, the role of mental health law has been to ensure appropriate substant

14、ive and procedural standards prior to involuntary admission, and, more recently, to ensure standards of institutional care following admission. Historically, this approach to legislation corresponded to the policies regarding the psychiatric care of people with relatively severe mental illness, whic

15、h had a central focus on detention in psychiatric asylums, often for extended periods. This paradigm of mental health law can however be seen as increasingly insufficient. The political emphasis in recent decades has moved from institutional to community care for people with relatively severe mental

16、 illness, and this shift is reflected in the new UN Convention on the Rights of Persons with Disabilities (CRPD). Unlike many previous international documents such as the UN Mental Illness Principles, the CRPD is not mere guidance: it is international law, with a formal review body to which countrie

17、s that have signed the convention will be held accountable. The CRPD moves the focus of law away from detention and compulsion, to the provision of community services and the right of a person with disabilities (a term which expressly includes mental disabilities) to integration into the community.

18、Clearly, a legislative focus on institutionalisation to the exclusion of community life is now out of step with the developing international law. Africa presents particular opportunities and challenges for this new legal paradigm. Its rates of institutionalisation tend to be very low by internationa

19、l standards: see additional file 1, table 1. In rich countries the move from an institutional model of care to a community model of care has been achieved through the development of decentralised community-based dedicated mental health care alternatives provided by specialist professionals in liaiso

20、n with a strong primary care infrastructure. In 1980 there was around 1 psychiatrist per 100,000 population in the UK; by 1990 this had increased to 1 per 50,000 and by 2010 this ratio is around 1 psychiatrist per 10,000. However, large-scale specialist mental health care provision is not a practica

21、l general model for Africa, where per capita GDP is often less than US$ 2000 per year, and where consultant psychiatrists, psychologists, psychiatric nurses, and social workers are strictly limited (see further table 1). A little specialist community provision is often found in the close neighbourho

22、od of psychiatric provincial and district units, practised by enthusiastic specialists who devote some time to following up clients in the community-however, logistically such a specialist delivered community service can only cover a tiny fraction of those in need. Some African countries eg Tanzania

23、, Kenya, Malawi, Zambia are making systematic efforts to integrate mental health into primary care settings with support and supervision supplied by district level mental health staff, who where they exist, tend to be psychiatric nurses. Such approaches make major logistical sense in the context of

24、only 1 psychiatric nurse per 250,000 population, psychiatrist per million population, and often no psychiatric social workers or psychologists. This paper looks at what the new paradigm of law might look like in African contexts. It deliberately does not focus on the regulation of institutions. Such

25、 institutions do of course exist in some African countries, generally in the capital cities, and the practices and standards concerning admission to them and care within them raise important human rights issues. A focus on community provision across the country as a whole, whether through primary ca

26、re or some other method, must not result in the people admitted to these institutions being forgotten or ignored, but such concerns have already attracted some international attention. This article focuses instead on the specific question of what mental health law looks like if it focuses outside th

27、e institution, and instead on community and primary care services. While the new legislative paradigm enshrined in the CRPD makes this a relevant question internationally, this paper couples the issue of mental health law in community environments with the practical issues of service development in

28、Africa.Mental Health Care Provision in Africa As table 1 shows, the problem of limited resources is unavoidable in an African context. Per capita GDPs of less that US$2000 per year are common. While members of the African Union have affirmed their objective of spending fifteen per cent of their nati

29、onal budgets on health, many countries are unlikely to reach that target in the near future. Government per capita expenditures on health are often less than US$50 per year, and in some cases are less than US$10 per year. By comparison, governments of developed countries generally spend in the range

30、 of US$ 1500-2000 per capita per year on health. In Africa, health funding is often focused on a small number of national hospitals, leaving little for health care provision outside major urban centres. In Kenya, for example, the national hospitals in Nairobi consume 90% of the national health budge

31、t. Mental health budgets in turn are a small part of the overall health budget. The share of mental health of the global burden of disease was roughly 12 per cent in 2000, expected to rise to 15 per cent by 2020. Health budgets devoted to mental health internationally often do not reach this proport

32、ion, but the proportions in Africa can be startlingly small - often less than one per cent of the health budget, and the overall health budget itself may only be around $10 per capita per year. In the context of such small health budgets overall, the result is miniscule funding actually available fo

33、r mental health services. This is largely devoted to staff salaries and a small number of inpatient beds. Kenya for example has less than 1000 beds for a population of roughly 40 million, and of these, most are in Nairobi. Each province of around 4-5 million population has only 20 psychiatric inpati

34、ent beds. Each district of 250,000 has 1-2 psychiatric nurses, and less than 10% of districts have any inpatient psychiatric beds. In some African countries, there would appear to be virtually no state investment in specialist mental health services. The result is minimal specialist mental health se

35、rvices. According to the WHO in 2005, (WHO, Mental Health Atlas, 2005) there were no psychiatrists in either Angola or Malawi, although Malawi has since successfully recruited a psychiatrist. On average, there is roughly one psychiatrist per million people in Africa, and this situation has been grea

36、tly aggravated by brain drain. Kenya has 23 psychiatrists in the public service for 40 million population; Tanzania has 13 for 42 million. Psychiatric nurses, social workers and psychologists are in similarly short supply. Kenya has 250 psychiatric nurses deployed in psychiatry in the country, but t

37、he rate of production is far less than the rate of loss to retirement, mortality and brain drain (both overseas and internal). Indeed, in 2009, Kenya produced only one psychiatric nurse for the country. 12 were trained that year, but most were from other African countries, to which they returned. Nu

38、mbers of Kenyan student psychiatric nurses fell in recent years since students now have to pay course fees, but in 2010 numbers are fortunately rising again. These problems are exacerbated by geography. Outside RSA, the average area per psychiatrist in sub-Saharan Africa ranges from roughly 17,000 k

39、m2 per psychiatrist in Swaziland, to 342,000 km2 per psychiatrist in the Congo. To put that in context, the comparable numbers for Australia is 2600, the United States 230, and France and the UK are 40 km2 per psychiatrist. Averages in this context must of course be approached with care. In practice

40、, mental health professionals, and psychiatrists in particular, are likely to be concentrated in urban areas. For these urban populations, specialist services will be considerably more accessible than for people outside these urban areas. For people in rural areas, the concentration of specialist se

41、rvices in cities and the sparse coverage of primary care (1 clinic per 10,000 population) means that the nearest medical facilities may be a very long way away indeed, a difficulty exacerbated by limited public transportation infrastructure. Available treatments are limited. New generation anti-psyc

42、hotics and antidepressants are unlikely to be available in the public sector because of price, and in any event do not achieve better outcomes although they do have better side effects. Older medicines are generally affordable by both governments and by clients if they have to cost share, but even t

43、hese are often in short supply, and public distribution is often problematic because of difficulties in procurement from other countries, poor quality and lack of quality control of imported medications, and changes in distribution mechanisms, such as a shift in Kenya from a push system of drug kits

44、 for health facilities to a pull system of ordering by the health facilities. This has led not only to lack of psychotropics in health facilities but even of antimalarials. Training in new psychological therapies such as CBT is limited, and research suggests it needs continued supervision if its implementation is to be effective. Training may therefore be more effectively devoted to general psychosocial skills until such time as close supervision is sufficiently widespread to support implementation of CBT and other such specific therapies.