The Situation of People with Mental Health Problems and People with Intellectual Disabilities GEORGIA. Needs Assessment Report

The Situation of People with Mental Health Problems and People with Intellectual Disabilities GEORGIA Needs Assessment Report Written by Manana Shar...
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The Situation of People with Mental Health Problems and People with Intellectual Disabilities GEORGIA

Needs Assessment Report

Written by Manana Sharashidze, Jan Vorisek, Nino Giguashvili and Nino Sanikidze

Edited by Judith Klein and Camilla Parker

Tbilisi 2005

© Georgian Association for Mental Health 2005 All rights reserved. Information provided in the report may be quoted with appropriate reference. Georgian Association for Mental Heath (GAMH) is a non-profit organization, which unites people with mental disabilities (users, ex-users), their relatives, mental health professionals and concerned civilians. GAMH’s vision is that people with mental disabilities must be integrated into society and provided with all the opportunities to live in dignity. GAMH seeks to promote Mental Health Care reforms in Georgia through developing community-based approach. In order to accomplish its mission, GAMH carries out the following activities: advocating and lobbying for reforms in mental health care in Georgia, raising the public awareness, facilitate the mental health policy development, updating the Georgian Law on Psychiatric Care, protection of rights of people with mental disabilities, empowering and providing support to the patients’&relatives’ organizations, adaptation of modern methods of psychosocial rehabilitation to the context of Georgia, and training of Georgian mental health professionals in psychosocial rehabilitation methods. Georgian Association for Mental Health 30 Vazha-Pshavela Ave. Tbilisi 0177 Georgia Tel +99532 312 070 Fax +99532 311 080 Email [email protected]

Open Society Mental Health Initiative (MHI) is a program of the Open Society Institute (OSI). OSI is a private operating and grant making foundation which aims to shape public policy, to promote democratic governance, human rights, and economic, legal, and social reform. On a local level, OSI implements a range of initiatives to support the rule of law, education, public health, and independent media. At the same time, OSI works to build alliances across borders and continents on issues such as combating corruption and rights abuses. MHI seeks to ensure that people with mental disabilities (mental health problems and/or intellectual disabilities) are able to live as equal citizens in the community and to participate in society with full respect for their human rights. MHI promotes the social inclusion of people with mental disabilities by supporting the development of community-based alternatives to institutionalization and by actively engaging in policy based advocacy. MHI is both a grant making and an operational program, providing training and technical assistance to its partner organizations. MHI operates in Central and Eastern Europe and the former Soviet Union. Open Society Mental Health Initiative Open Society Institute H-1051 Budapest Oktober 6 u. 12 Hungary Tel +361 327-3100 Fax + 361 327-3101 Email www.soros.org/initiatives/mhi

Forward At least one in four people in the world are affected by mental health problems at some point in their lives. Around 450 million people currently suffer globally from such conditions, placing mental disorders among the leading causes of disability worldwide, as stated by the World health Organization. Depressive disorders are already the fourth leading cause of the global disease burden, and by 2020 mental health problems are expected to rank second, behind ischemic heart disease, but ahead of all other diseases. The rapid social and economic changes which have taken place in former Soviet countries in recent years have caused the spread of stress-related, psychosomatic and depressive disorders. Suicide rates have also significantly increased in certain countries. In Georgia, civil war and armed conflicts have deepened social and economic crises. This has resulted in a drastic decrease in government financing for health care services, including mental health services. Yet, there is no justification for the fact that people with disabilities, including people with mental disabilities, are the poorest and most vulnerable groups in Georgia. The general public turns its back on the problem, as if these people do not exist at all. None of us is immune from mental disorders which can be caused by social factors, biological disposition, aging, or trauma related to traffic accidents which have been increasing in Georgia in the last years. It has been said that the level and quality of mental health services and services for people with disabilities, the most vulnerable members of society, is a reflection on the society itself. This report provides an overview of the general situation of people with mental health problems and people with intellectual disabilities in Georgia. It analyzes the relevant legislation and policy, and identifies the major gaps, assesses the availability of communitybased services and makes concrete recommendations for improving policy, legislation and practice to support the social inclusion of people with mental disabilities. The report emphasizes that the government needs to develop community-based services as alternatives to institutional care. Despite limited resources, this is possible. What is needed is a real commitment. Our hope is that this report will not simply be shelved. Coupled with other initiatives, it intends to contribute to improving the existing situation. We have made the recommendations as realistic as possible to increase the likelihood that they will be implemented. As one philosopher said, Soviet thinking is a poison - once it affects the mind, it destroys our ability to think and those who do not think precisely, fall pray to “evil.” Georgian society is in the process of restoring its ability to think, and it is well known that the soviet mentality cannot be overcome in one day, nor in one decade. It will take generations, but the process has begun. Manana Sharashidze Georgian Association for Mental Health Chairperson of the Board

Acknowledgements This report was written by Manana Sharashidze, Jan Vorisek, Nino Giguashvili, and Nino Sanikidze, and edited by Judith Klein and Camilla Parker. Authors would like extend the special gratitude to Ketevan Abdushelishvili, who made an invaluable contribution in developing the present report. The research was conducted by the Georgian Association for Mental Health and financially supported by the Open Society Mental Health Initiative and The Open Society Georgia Foundation. The report contains information from many sources, and the authors would especially like to thank the following individuals for their contributions: Temuri Silagadze, Simon Surguladze, George Naneishvili, Nino Okribelashvili, Ketevan Gelashvili, George Bezarashvili, Nino Makhashvili, Nana Zavradasvili, Grigol Giorgadze, Marina Kuratashvili, Archil Begiashvili, Dodo Duduchava, Nino Agdgomelashvili, Veta Lazarishvili, Tamar Amzashvili, Tatia Pachkoria, David Gzirishvili, Vakhtang Megrelishvili, Nato Xonelidze, Teona Kacheishvili, Manana Tsintsadze, Maya Kereselidze, Tamta Golubiani, Nunu Sukhishvili, Tinatin Tsomaia, Irma Khabazi, Maya Bibileishvili, Salome Janelidze, Vaniko Bokeria, Taduli Kekenadze, Marina Chelidze, Nana Iashvili, and Nana Tsartsidze. Authors would like to thank Lasha zaalishvili and Lika Giorgadze for the administrative support. Cover design – Tamar Naskidashvili.

TABLE OF CONTENTS FORWARD .................................................................................................................................................. 3 ACKNOWLEDGEMENTS .............................................................................................................................. 4 ABBREVIATIONS ......................................................................................................................................... 6 EXECUTIVE SUMMARY ............................................................................................................................... 7 RECOMMENDATIONS ................................................................................................................................ 11 DEFINITIONS ............................................................................................................................................ 14 1. COUNTRY OVERVIEW AND BACKGROUND .......................................................................................... 16 POPULATION OF GEORGIA....................................................................................................................... 16 SOCIO-ECONOMIC SITUATION ................................................................................................................. 16 STATISTICAL AND DEMOGRAPHIC INFORMATION ON PEOPLE WITH MENTAL DISABILITIES ................... 17 MENTAL HEALTH CARE STAFF ................................................................................................................ 21 2. THE GENERAL SITUATION OF PEOPLE WITH MENTAL DISABILITIES ...................................................... 22 DISABILITY STATUS.................................................................................................................................. 22 INTELLECTUAL DISABILITY: DEFINITIONS, DIAGNOSIS AND ASSESSMENT ............................................... 22 MENTAL HEALTH PROBLEMS: DEFINITION, DIAGNOSIS AND ASSESSMENT ............................................. 23 SOCIAL WELFARE BENEFITS ................................................................................................................... 23 INTERNALLY DISPLACED PERSONS AND REFUGEES AND THEIR ENTITLEMENT TO SERVICES AND BENEFITS THE ROLE OF INTERNATIONAL DONORS ................................................................................................. 24 3. LEGAL AND POLICY FRAMEWORK ....................................................................................................... 24 A. THE KEY DECISION MAKERS IN MENTAL HEALTH AND DISABILITY .................................................... 24 B. THE POLICY FRAMEWORK ................................................................................................................... 25 SOCIAL WELFARE POLICY ........................................................................................................ 26 POLICIES TARGETING CHILDREN .............................................................................................. 29 STAKEHOLDER INVOLVEMENT IN POLICY DEVELOPMENT............................................................ 29 C. LEGAL FRAMEWORK ............................................................................................................................ 30 GUARDIANSHIP........................................................................................................................ 30 MENTAL HEALTH LEGISLATION: DETENTION AND COMPULSORY TREATMENT .............................. 31 ACCESS TO JUSTICE ................................................................................................................ 32 THE ROLE OF THE OMBUDSMAN ............................................................................................... 33 4. INSTITUTIONS FOR PEOPLE WITH MENTAL DISABILITIES .................................................................... 33 PSYCHIATRIC HOSPITALS ........................................................................................................................ 33 INSTITUTIONS FOR ADULTS WITH INTELLECTUAL DISABILITIES .............................................................. 34 INSTITUTIONS FOR CHILDREN WITH MENTAL DISABILITIES ..................................................................... 34 FORMAL DETENTION IN INSTITUTIONS .................................................................................................... 35 CONDITIONS IN INSTITUTIONS ................................................................................................................. 36 COMPLAINTS PROCEDURES .................................................................................................................... 36 ADVOCACY SERVICES ............................................................................................................................. 37 5. ACCESS TO EDUCATION ...................................................................................................................... 37 GENERAL SITUATION................................................................................................................................ 37 CHILDREN WITH DISABILITIES .................................................................................................................. 38 INCLUSIVE EDUCATION ............................................................................................................................ 38 6. ACCESS TO EMPLOYMENT .................................................................................................................. 39 UNEMPLOYMENT ...................................................................................................................................... 39 UNEMPLOYMENT OF PEOPLE WITH MENTAL DISABILITIES ..................................................................... 40 7. PROGRESS TOWARDS SOCIAL INCLUSION ......................................................................................... 40 INCLUSION IN SOCIETY ............................................................................................................................ 40 THE NEED TO DEVELOP COMMUNITY-BASED SERVICES ........................................................................ 40 THE DEVELOPMENT OF COMMUNITY-BASED SERVICES IN GEORGIA .................................................... 41 PUBLIC AWARENESS ABOUT PEOPLE WITH MENTAL DISABILITIES......................................................... 43 GLOSSARY OF TERMINOLOGY ................................................................................................................. 46 HUMANITARIAN SITUATION AND TRANSITION TO DEVELOPMENT 2006, DEVELOPED BY UNITED NATIONS HUMANITARIAN AFFAIRS TEAM ................................................................................................. 55

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Abbreviations APNSC CORDAID DFID EDPRP GAMH GEL GIP IDP MoLHSA MoES NGO OXFAM SDS SUSIF UNICEF USAID WHO

Association of People in Need of Special Care Catholic Organization for Relief and Development, Netherlands UK Agency for International Development Economic Development and Poverty Reduction Program Georgian Association for Mental Health Georgian currency (Lari) Global Initiative on Psychiatry Internally displaced person Ministry of Labor, Health and Social Affairs Ministry of Education and Science Non-governmental organization International Development and Relief Agency State Department for Statistics of Georgia State United Social Insurance Fund United Nations Children’s Fund United States Agency for International Development World Health Organization

Executive Summary Background and Introduction Social exclusion, stigma and discrimination are issues for people with mental disabilities, 1 who are among the most marginalized groups globally. The situation of people with mental disabilities in Georgia is characterized by poverty, lack of access to appropriate health care, and other support services, virtually no alternatives to institutionalization, and extremely limited or no access to education and employment. Following the Rose Revolution in 2003, there is a new hope for reform in Georgia. In the health, social welfare and education sectors reforms are already underway. On the positive side, Ministries are beginning to involve a range of stakeholders, including non-governmental organizations, as they develop new programs and policies. However, in order for reforms to have a real and positive impact, the government must also allocate adequate resources to implement new programs and policies. The system for collecting data on people with mental disabilities needs to be significantly upgraded. Appropriate policies that meet real needs cannot be developed in the absence of information on how many people are at issue, what their living situation is, and what their needs are. Better data collection would also improve the accuracy of statistical information that is currently available on morbidity, mortality and suicide that is attributable to mental disability in order to enable policy makers to strategically address these issues.

Resource Allocation With nearly half the population still living below the poverty line, government spending on health care is about 2% of the GDP, one of the lowest in the Eastern European region. Only 2.7% of this amount, that is €1.6 million, is allocated to mental health care annually. People with disabilities are entitled to receive social welfare benefits, and the amount of the benefit is the same regardless of the disability, about €12.2 monthly. While additional allowances are available in special circumstances, the total benefits package is much less than the monthly subsistence minimum (€56.5). Only 2% of people with disabilities lived above the poverty line in 2003, with most people with disabilities still living in extreme poverty, as social welfare benefits are often their only source of income. These people are in most cases supported by family members and other relatives.

Mental Health and Social Welfare Policy The Ministry of Labor, Health and Social Affairs began the first reforms in the health care sector in 1995, which resulted in the development of a Ten Year Strategic Health Plan and National Health policy documents in 1999. However, these reforms did not correspond to the realities in the country: there is a major problem with a lack of available training for professionals who would implement the plan, the plan did not provide for the development of community-based services, and resources were not allocated for implementation. Having realized that this policy and strategic plan needed reworking, in 2002 the Ministry assigned leading psychiatrists to elaborate a more realistic plan for 2002-2005. While this plan included some essential reforms in terms of data collection, monitoring and research, to date, no financial resources have been allocated for implementation. Having lost patience with the Ministry’s efforts to elaborate a realistic mental health policy, the NGO sector 1

Definitions regarding terminology used in this report are provided in the “Definitions” section.

initiated the development of a policy and presented it at a conference at the Ministry in 2004. This NGO-initiated policy has not received the Ministry’s endorsement, and therefore, at this writing, policy making in mental health is at a standstill in Georgia. While there are annually budgeted state social welfare programs for disabled people and a special unit for people with disabilities within the Ministry of Labor, Health and Social Welfare, as well as a Board of people with disabilities established by the Ministry in 2005, the national social welfare policy that specifically address the needs of people with disabilities in the long-term has not been yet developed.

Mental Health Care Staff There is an urgent need to improve the quality, the quantity and the range of professionals who work in mental health in Georgia. There are a very limited number of qualified psychiatric nurses and psychotherapists; qualification of psychiatrists and clinical psychologists needs updating. There are virtually no social workers or occupational therapists. Training for professionals, including the introduction of new courses to train professionals, the revision of curricula and updating textbooks and other materials at the university level must also be brought in line with international standards.

Children with Intellectual Disabilities and Education There is very little opportunity for children with disabilities to receive an education, to be outdoors or to live in the community. There are no ramps or sloping walkways for people with physical disabilities anywhere in the country. Where education is available to children with disabilities, it is of extremely poor quality (using an outmoded Soviet era “defectology” curriculum), and does nothing to prepare the child for mainstream school, though this is the stated objective of the special school. Children who finish special schools receive no training in any skills that would enable them to live more independently as adults. In the past, there were two medical pedagogical commissions in Georgia. The decision of these commissions was required for the placement of children with disabilities in either special boarding schools or internats (long stay residential institutions), with children diagnosed as “uneducable” being sent to internats. As a result of the trend toward inclusive education, these commissions have been disbanded and no alternative has been established to replace them yet. There is an urgent need for the Ministry of Labor, Health and Social Affairs to work with the Ministry of Education and Science to develop multidisciplinary expert teams to assess children who are thought to have developmental disabilities, and to recommend appropriate educational services for them. Because very few mainstream schools are ready to accept children with disabilities, and the special education system is in ruins (there is only one special non-residential school in the country), there is an urgent need to develop educational services in mainstream schools across the country that will include children with mental disabilities. The Ministry of Education is currently seeking international funding to implement a pilot inclusive educational project for children with disabilities in 10 pilot schools in Tbilisi. This project follows the Ministry’s educational reform plan which emphasizes the need to develop inclusive education. The plan is to work in collaboration with NGOs which will prepare these schools to include children with disabilities, and then to replicate the project nationwide. The Ministry of Education and Science has shown its willingness to work with a coalition of NGOs in implementing its reforms.

Access to Employment There is no statistical data on the employment rates of people with mental disabilities, but considering that there is no system of vocational training or rehabilitation in the country, and most people with mental disabilities have no access to quality education, it is safe to say that the vast majority of people with mental disabilities are unemployed. NGOs have succeeded in establishing a small number of employment initiatives that operate as pilot projects. While the Ministry of Labor, Health and Social Affairs has expressed interest in these initiatives and has committed to providing some financing to them once other donor support ends, it is also essential for the Ministry to develop employment programs for people with disabilities that include appropriate services for people with mental disabilities, including vocational training and re-training programs.

Guardianship There is no data available on how many people with mental health problems and people with intellectual disabilities are under guardianship, but it is clear that the current system of guardianship is extremely problematic: there is only plenary guardianship, and guardians are appointed by the Guardianship and Curatorship Agency upon written request. When a person is detained in a psychiatric hospital and their legal capacity is at issue, the court hearing on the matter generally takes place in about ten minutes and in the absence of the person in question. There is no analysis of the facts of the case, and the person’s needs and wishes are not considered. There is potential for widespread abuse of power by guardians, and there are many examples to show that these abuses take place, particularly a guardian selling or using the ward’s property without permission. Patients who are detained in psychiatric hospitals are generally completely unaware of their rights and therefore vulnerable to abuse. If a patient is hospitalized involuntarily, there is no right to legal representation, nor is there any impartial body that reviews the lawfulness of the detention.

Institutionalization In Georgia, there is a major problem of inappropriate institutionalization of people with mental disabilities. In the vast majority of cases, institutionalization is the only solution because alternatives to it simply do not exist. There is also a severe lack of the range of community-based alternative services which could provide support to people with mental disabilities so that they could be included in society. In the 21st century, segregating people in remote institutions, where many people begin and end their lives, solely on the basis of a disability label demonstrates a blatant disregard for human rights and is a disgrace to civil society. Judging by the situation of people with mental disabilities in the eight new Central and Eastern member states of the European Union, it has become clear that membership in, or candidacy for membership of, the European Union has done nothing to improve this situation. Conditions in all long stay institutions in Georgia are appalling. Buildings are generally in severe states of disrepair, poorly heated and without essential technical and material resources. This problem is even worse in rural areas where there is often also a shortage of electricity, gas and water. In institutions (orphanages and supplementary boarding schools) for children, admissions procedures are not followed, so children with all types of disabilities and conditions are

housed together, without any regard for whether the institution meets their needs. There is very little, if anything, available in terms of education or rehabilitation. In psychiatric hospitals, there is a severe lack of basic necessities such as food and medicines, as well as a lack of qualified staff. Other than one service operated by an NGO, there is no patient advocacy service in any closed institution in the country.

The Role of International Donors One of the aims of this report is to help international donors understand where the greatest needs and gaps are in the provision of services for people with mental disabilities in Georgia. This research has revealed that there is an urgent need to develop community-based alternative services. Without such alternatives, the outlook for people with mental disabilities in Georgia will continue to be extremely bleak. Currently, people with mental disabilities are either housed in long stay institutions or isolated at home with virtually no support services. For the fortunate few who live in the capital city and in other larger towns, there are some community-based services, but these are not enough in number to meet real needs. International donors can have a major impact on this situation by making it their policy to make investments not in improving institutions, but in the alternatives to them, thereby having a role in promoting the social inclusion of people with mental disabilities in Georgia. There is enormous scope in Georgia for international donors to work both with each other and with the government on co-financing initiatives aimed at including people with mental disabilities in society.

Conclusion Given the current situation of people with mental disabilities in Georgia, it is essential that a concerted effort is made to ensure that the government recognizes that there are frequent violations of human rights in closed institutions; and that mental disorders represent a major contributing factor to disability, loss of economic productivity and mortality. Thus there is an urgent need for the government to declare mental health a priority and increase financing for the development of community-based services as alternatives to institutions. Without such work, people with mental disabilities will continue to be excluded from society. It is also essential to ensure that the people who have the most severe and profound mental disabilities have access to the alternative services that are developed in the community. NGOs, families and consumers of services must be involved as real stakeholders in policy development. With these general points in mind, this report makes a series of recommendations aimed at encouraging positive change in Georgia.

Judith Klein, Director Open Society Mental Health Initiative H-1051 Budapest October 6. u. 12 Hungary

Recommendations Recommendations to the Ministry of Labour, Health and Social Affairs (MoLHSA): 1. The MoLHSA should elaborate a Strategic Plan for mental health care development which sets out concrete steps that will be taken in order to facilitate the development of community-based services for people with mental disabilities. In elaborating the Strategic Plan, the MoLSHA should take into consideration the 2005 WHO documents: the Mental Health Declaration for Europe and its accompanying Action Plan. 2. The MoLHSA should take steps to promote the involvement of stakeholders including NGOs, consumers of services, and consumers’ families in the Expert Board 2 created by the MoLSHA. Expanding the membership of the Expert Board, which to date includes only senior psychiatrists, will ensure both the active involvement of all relevant stakeholders and availability of all information relevant to policy development to the Ministry, as it elaborates its Strategic Plan. The Strategic Plan should include provisions for promoting the social inclusion of both people with intellectual disabilities and people with mental health problems. 3. The MoLHSA should significantly improve its capacity to collect accurate data on the situation of people with mental disabilities in Georgia including carrying out a one-time, baseline epidemiological survey on mental disorders with the assistance of international experts and in collaboration with interested mental health organizations. Reliable data on mental health problems, intellectual disabilities and suicide is necessary in order for the MoLHSA to be in a position to develop evidence-based strategic policies, prevention programs and appropriate services for people with mental disabilities. 3. The MoLHSA should ensure that adequate resources are allocated to mental health services and should make mental health a higher priority within the field of public health. The total annual health care budget is very small itself (about € 56.5 million) and only about € 1.6 million is allocated annually to mental health care. 4. The State Program for Psychiatric Care and the State Social Program for Promotion of Social Adaptation of the Disabled should be expanded. The MoLHSA should ensure sufficient resource allocation to guarantee a comprehensive system, using a “continuum of care” philosophy. The MoLHSA should emphasize the shift towards community-based care within these programs. 5. The MoLHSA should revise existing medical standards to promote quality medical care and treatment, with the assistance of the Expert Board. 6. The MoLHSA should develop employment programs, including vocational training programs geared toward people with disabilities, which include appropriate adaptations for people with mental disabilities. 7. The MoLHSA should develop legislation that sets out a framework for advocacy services within closed institutions. Patients who are involuntarily admitted to institutions must have the right to legal representation, the right to a hearing and the right to an

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An Expert Board (which includes only psychiatrists) was created by the MoLHSA in 2004 to assist the Ministry in developing its mental health policy, though its duties and responsibilities have not clearly defined by the MoLHSA.

independent and impartial tribunal, which has the power to order the patient’s discharge from detention if the tribunal finds that grounds for detention are not met. 8. The MoLHSA should improve the existing system of postgraduate and continuing medical education for mental health professionals. Specifically, continuing medical education programs and licensing requirements for psychiatrists should be updated. Education and training programs for psychiatric nurses should also be developed. 9. The MoLHSA and MoES should work closely together to create multidisciplinary expert teams to assess children with intellectual and other developmental disabilities and to refer these children to appropriate educational services rather than to special boarding schools. Such assessment teams should be accessible nationwide. The two medical pedagogical commissions that existed in the country have been disbanded, and no alternative service coordinating the referral of children to appropriate services has yet been created to replace them. While creating new multidisciplinary assessment teams, the MoLHSA should work with the MoES to ensure that appropriate schools near the children’s homes are ready to enroll them. 10. The MoLHSA should take steps to ensure that mental health, which formally is included in the national primary health care program, meets real needs. This includes urging donors supporting this program (the European Commission, The UK Department for International Development, and the World Bank) to include funding for training primary healthcare physicians on mental health and disability issues. 11. The MoLHSA should take steps to ensure the development of community-based alternatives to institutional, segregated care for children and adolescents with mental disabilities. This includes setting out a clear policy in favor of deinstitutionalization. The MoLHSA should look to existing models of best practice in community-based services operated by NGOs and should assist in disseminating these models nationwide. 12. The MoLHSA should work with the Ministry of Justice to evaluate existing laws that are relevant to people with mental disabilities and bring them in line with international human rights standards such as the European Convention on Human Rights (ECHR). For example, the laws relating to guardianship and involuntary admission to institutions must be reformed so that they comply with the standards set out in the ECHR. 13. The MoLHSA should work with its Expert Board to develop and consistently apply mental disability terminology that is unified, non-stigmatizing and in line with internationally accepted standards in all legislation and policy documents. To the Ministry of Education and Science (MoES): 14. The MoES should take steps to ensure that appropriate financial resources are allocated to implementing its educational reform program, which includes the development of inclusive education for people with mental disabilities.

To the Ministry of Justice: 3 15. The Ministry of Justice should ensure real access to the legal aid services for people with mental disabilities. To the International Donor Community: 16. International donors should support NGOs to develop networks of communitybased alternatives to institutions for people with mental disabilities. Other than providing humanitarian aid to save lives, donors should not make investments in improving the conditions in institutions for people with mental disabilities. 17. International donors should support activities geared toward training medical and other professional staff, users of services and their families in awareness of the users’ human rights. 18. International donors that provide funding for educational programs should support activities that are in line with the Ministry of Education and Science’s inclusive educational reforms. 19. International donors that provide funding for children’s programs should support NGOs to develop early intervention programs targeted at maximizing the potential of children with mental disabilities in early childhood. 20. International donors should support NGOs to launch public awareness activities that are geared toward ending stigmatization and promoting the social inclusion of people with mental disabilities. To the Parliament of Georgia: 21. The Parliament of Georgia should accelerate the process of adopting the New “Law on Psychiatric Care.” In order to ensure the law’s effectiveness, the Parliament should assign responsibility for developing a full package of regulatory documents and supervision of the implementation of the new legislation to the MoLHSA.

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This report does not cover issues concerning forensic psychiatry, prison mental health and psychiatric expertise. The Global Initiative on Psychiatry developed a series of recommendations on these issues which it has submitted to the Ministry of Justice.

Definitions Many terms used in mental health are considered to be stigmatizing. Accordingly, the authors use the terms “mental health problems” and “intellectual disabilities” in this report because these are regarded as less stigmatizing than other terms. This report considers issues relevant to both people with “mental health problems” and people with “intellectual disabilities.” While some individuals are diagnosed with both intellectual disabilities and mental health problems and while many of the problems faced by both these groups of people are similar – such as serious human rights abuses, social exclusion, stigma and prejudice - there are also significant differences between the two groups. The term “intellectual disability” (also described as “learning disability” or “mental retardation”) refers to a lifelong condition usually present from birth or which develops before the age of 18. It is a permanent condition that is characterized by significantly lower than average intellectual ability and results in significant functional limitations in intellectual functioning and in adaptive behavior as expressed in conceptual, social and practical adaptive skills. A person with an intellectual disability usually requires support in three or more of the following areas of major life activity: self-care, receptive and expressive communication, and economic self-sufficiency. People with intellectual disabilities generally need a combination of special, interdisciplinary, or generic services, individualized support, or other forms of assistance that are of lifelong or extended duration and are individually planned and coordinated. When applied to infants and children, “intellectual disability” refers to an individual from birth to age nine who has a substantial developmental delay or specific congenital or acquired condition. He or she may be considered to have an intellectual disability without meeting three or more of the above criteria if the individual, without services and supports, has a high probability of meeting those criteria later in life. The term “mental health problems” describes a broad range of mental and emotional conditions. Mental health problems are different from other mental impairments such as intellectual disability, developmental disability, organic brain damage, and learning disability. The term “mental health problems” is used when an individual’s mental condition significantly interferes with the performance of major life activities such as thinking, communicating, learning and sleeping, among others. Someone can experience mental health problems over many years. The type, intensity and duration of symptoms vary broadly from person to person. Symptoms can come and go and do not always follow a regular pattern, sometimes making it difficult to predict when symptoms and functioning will worsen. Mental health problems are typically treated through some combination of psychotherapy, social support, medication and hospital care. Unfortunately, the inappropriate use of some of these treatments, such as long-term hospitalization, is still common. Generally, the ICD-10 Classification of Mental and Behavioral Disorders 4 is used to diagnose mental disabilities in Georgia. The ICD-10 terminology uses the term “mental disorders” rather than “mental health problems,” and “mental retardation” rather than “intellectual disabilities.” The terms “mental illness” and “mental disability” are not used in the ICD-10. Diagnosis and assessment procedures as well as legislation and relevant policies in Georgia cover both people with mental health problems and people with intellectual disabilities. Accuracy of Data: In order to formulate policies and establish services that meet the needs of people with mental disabilities, governments and other decision-makers must have accurate statistical data and other information as to the numbers of people with mental 4

International Classification of Diseases and Related Health Problems, 10th Revision, World Health Organization, 2003

disabilities, where they live and what services they currently receive, if any. The absence of reliable data makes targeted policy- making and service delivery very difficult or impossible to achieve. Statistical data provided in this report should be treated with caution. Although the authors have sought to consult the most valid sources of information, even data obtained from official sources such as the State Department for Statistics, the Ministry of Labor, Health and Social Affairs’s Center for Disease Control and Medical Statistics and the Ministry of Education and Science are not necessarily accurate because data reporting in the country is very poor, particularly in rural areas.

1. Country Overview and Background Population of Georgia According to the latest census data provided by SDS in 2002, the population of Georgia was approximately 4.4 million people. 5 According to the 1989 census, the population of Georgia was 5.4 million people. The decrease in the population during the years 1989-2002 is the result of the country losing some of its territory, a decrease in the birthrate, an increase in the mortality rate and large-scale emigration. According to official statistics, the population is almost equally distributed between rural and urban areas (52.4% urban and 47.6 % rural). 6 The population disaggregated by age and gender is presented in Annex 1.

Socio-economic Situation Despite minor improvements in the economic situation, Georgia still remains a poor country. The standard of living has not improved, and about half of the population lives below the officially determined poverty line (€56.5/month). The average monthly salary is GEL138 (€60). The GDP per capita is GEL 2,093 (€910). Reforms in health care and social security have not brought about the expected results. The fact that the government doubled monthly pension payments from GEL14 (€6.1) to GEL28 (€12.2) is touted as a major success, though its effect is merely symbolic. The government spends only about 2% of the GDP on health care, which is one of the lowest numbers in the Eastern European Region. Only 2.7% of this small budget, or about €1.6 million annually, is currently allocated to mental health. Based on the analysis of the Laws on State Budget of Georgia for the years 2003-2005, it can be concluded that, despite some increase in state financing of the social welfare and health care sectors during last two years, this trend is not reflected in public spending on mental health services. Thus, the current level of public funding is woefully inadequate for the provision of quality and appropriate mental health care.

5 6

Population of Georgia, Statistical Abstract, SDS, Tbilisi, 2003 Ibid.

Statistical and Demographic Information on People with Mental Disabilities Issues concerning data collection 7 The data provided by the MoLHSA should be treated with great caution. Mental health professionals argue that official rates of mental disorders (presented in Annex 2, Tables 2.1 and 2.2) are likely to be largely underestimated, especially for new cases (e.g. while the incidence of ICD-criteria schizophrenia in most countries varies between 20-54 per 100,000, in Georgia it is reported as only 9.5). The most significant reasons for this (along with the general problem of an inadequate disease registration/surveillance system in the country) are as follows: The official statistics is primarily based on the number of referrals to mental health institutions and reflect the extent to which people refer to psychiatric services rather than actual morbidity from mental disorders which would be obtained from population-based epidemiological studies. Legislative changes: Since 1995, legislation (the “Law on Psychiatric Care”) gives patients the freedom to choose whether or not to register as psychiatric patients. During the Soviet period, registration of mental disorders was mandatory and under particularly strict control. Extremely low referral rate to mental health specialists: Because of individuals’ inability to pay and mistrust in the health services (that lack resources to provide quality care), referral rate to mental health facilities is low among Georgian population. In case of mental disorders, this problem is further aggravated by stigma: people avoid reporting psychiatric symptoms to medical specialists and often prefer self-treatment. Misdiagnosis: as mentioned above, because of stigma, people with mental health problems avoid mental health professionals and refer to them in extreme cases only. However, even when they do go to psychiatrists, they often do not describe their symptoms fully; they try to “put them mildly”, thus increasing the possibility of incorrect diagnosis. Non-registration: Again because of stigma, people with mental health problems prefer to go to private doctors if they can afford it. Cases treated on a private basis are not publicly registered. Where a person has sought assistance from a public clinic, s/he often asks the provider not to include them in the official register of people with mental illnesses. Thus, as long as this register represents the official source of information for medical statistics, the statistics will underestimate actual morbidity due to mental disorders. Miscoding of diagnosis: Because state psychiatric program covers the cost of treatment for only limited types of mental disorders (i.e. for those included in the BBP - Basic Benefit package), a phenomenon similar to “DRG shift,” 8 has also become a major reason for inaccurate statistics in Georgia. Mental health service providers tend to miscode diagnoses in order to “adjust” them to the state covered BBP, making patients who cannot afford treatment eligible for state subsidized health services. Thus, for example, mild depression

7

Detailed data about people with intellectual disabilities in Georgia is scarcely available. This is partly due to the existing uniform system of social benefits for disabled people (which represents one of the sources for the official statistics), which issues social benefits irrespective of the specific medical diagnosis (health condition which caused the disability). Most of the official data does not differentiate between people with intellectual disabilities and people with mental health problems. Therefore, the information provided in this section refers to both groups, and separate data on people with intellectual disabilities is provided wherever available. 8 "DRG (Diagnosis related group) shift" - refers to the phenomenon of the documented diagnosis indicating more serious conditions than the actual condition, for the purpose of receiving higher level reimbursement from the health insurance agency.

may be documented as a major depressive disorder because the treatment for the latter is paid for by the state. Absence of mass screening programs for mental and intellectual disabilities: The Georgian public health system does not include any mass screening programs for any type of mental disability. Morbidity: mental and behavioral disorders Since 1990, official statistics show a significant decrease in morbidity from mental and behavioral disorders. Despite the major socio-economic crisis in Georgia since its independence in 1991, the officially reported incidence of mental and behavioral disorders fell significantly. It was the lowest during 1990-1992 and began rising again in 1992. This ascending trend continues today. According to the official statistics, there has been a threefold increase in incidence and twofold increase in prevalence of mental disorders since 1992 in Georgia (See Annex 2, figures 1-4). It is widely recognized that the decrease in officially reported rates of mental disorders during the early 1990s was largely due to the virtual collapse of the disease registration and surveillance system in the country as well as extreme reductions in public funding for healthcare in general and psychiatric care in particular. Patients had to cover all the costs of their psychiatric treatment out of pocket; because very few could afford such treatment, people did not refer to mental health facilities and, hence, were not officially registered or treated. The rise in officially reported psychiatric morbidity since 1992 can be partially attributed to the relative improvement in the disease registration system as well as to the introduction of a state-funded psychiatric program (which was introduced under the 1995 healthcare reforms as a part of the mandatory health insurance program). The state program covered a limited package of psychiatric services that resulted in an increase in referral rates to mental health facilities. However, the above factors do not fully explain the rise in official morbidity from mental and behavioral disorders, and the ascending trend reflects the rising burden of mental health problems in the country. It is important to stress that, although improved, the disease registration system as well as public funding allocated for mental health care is still far from adequate, and a vast number of cases are not detected, treated or officially registered. The official statistics on morbidity from mental disorders reflects the number of people recorded in a special register of mental disorders produced by psycho-neurological, narcological dispensaries and general out-patient clinics. 9 For the year 2004, a total of 106,921 persons with mental disorders were officially registered by these facilities (prevalence 2,445.8 per 100,000 of population). Among these, 68,993 people were registered at psycho-neurological dispensaries, 31,417 people were registered at narcological dispensaries and 6,511 - at general out-patient clinics. The figure (106,921) for 2004 included 7,637 newly diagnosed cases (incidence 174.7 per 100,000), and 1,290 of these new cases were children (incidence 140.8 per 100,000 children). The number of people with mental disorders officially registered at psycho-neurological dispensaries in 2004 was 68,993 (prevalence 1,578.2 per 100,000 of population). Of this number, 3,206 were newly diagnosed cases (incidence 73.3 per 100,000).

9

Statistical Reference Book on Health Care, Georgia, the MoLHSA Center for Disease Control and Medical Statistics, Tbilisi, 2003-2004

Of 68,993 people with mental disorders registered at psycho-neurological dispensaries, 20,536, that is, 30% were people with intellectual disabilities (prevalence 469.8 per 100.000 of population). Among these, 1,039 were newly identified cases in 2004 (incidence 23.8 per 100.000). Of the total number of people with intellectual disabilities, 8,732 were registered as having mild intellectual disabilities (prevalence 199.7 per 100,000) with 365 cases newly identified in 2004 (incidence 8.3 per 100,000). The number of discharges from psychiatric hospitals in 2004 was 3,782. Admissions to psychiatric hospitals were 3,598. Of this number, 18 people were under the age of 18. For the year 2003, of the total number of people with mental disorders, 14,904 were registered as disabled (i.e. have the officially assigned status of “having restricted ability”). Among these, 4,258 were people with schizophrenia, and 3,583 were people with intellectual disabilities. Of the total number of people with intellectual disabilities, 3,583 were officially recognized as “having restricted ability.” 544 people of these 3,583 were under the age of 15. 10 Mortality rates The overall mortality rate (from all causes) in Georgia was 1,063.7 per 100,000 of the population in 2003. 11 Precise data on mortality from mental disorders is not available: people who die from mental disorders outside hospitals are rarely (if ever) registered. Mortality is particularly high among institutionalized patients. Mortality in psychiatric hospitals increased significantly during 1991-1995, the most difficult years for Georgia because of decoupling from the soviet economic system. Civil war left Georgia in a state of economic collapse, with drastically reduced resources for the health sector. 12 It is suggested that more than 800 psychiatric patients died at psychiatric hospitals during this period due to lack of food, medications, heat and lack of care. However, this number is unreliable because of the inadequate registration system and may be underestimated. Since the introduction of the State Funded Program for Psychiatric Care in 1995, mortality from mental disorders began to decline partially because the basic conditions in institutions, including the provision of food and medication, has started to improve. According to the MoLHSA statistics, 84 patients died in psychiatric hospitals in 2003 and 73 in 2004. The number of people who die from mental disorders outside hospitals is unknown. If calculated from the number of inpatient deaths, the mortality rate from mental disorders per 100,000 of the population constituted 1.95 in 2004. Based on above official data, inpatient mortality from mental disorders constitutes about 2% (i.e. 2 deaths per 100 hospital admissions). The data on inpatient mortality obtained directly from two psychiatric hospitals in Tbilisi is presented in Table 1 below:

10

SUSIF data. Similar data is not yet available for the year 2004. Data on mortality rates for the year 2004 is not available. 12 Heath Care Systems in Transition, Georgia, Gamkrelidze at al, European Observatory on Health Care Systems, Copenhagen, 2002. 11

Table 1. Inpatient Mortality in Psychiatric Hospitals Zurabashvili Tbilisi Psychiatric Hospital (Gldani)

Asatiani Scientific-Research Institute of Psychiatry

Year

N of admissions

N of deaths

Inpatient mortality

N of N of admissions deaths

Inpatient mortality

1989 1990 1991 1992 1993 1994 1995 1996 1997

2813 2085 2074 1429 1434 730 550 664 610

51 51 75 86 126 124 25 33 34

1,80% 2,40% 3,60% 6,00% 8,80% 17,00% 4,50% 5,00% 5,60%

2388 1801 1347 1102 1195 1116 1132 1281 1304

11 5 11 14 32 22 22 15 11

0.5% 0.3% 0.8% 1,30% 2,70% 2,00% 1,90% 1,20% 0,80%

1998

600

39

6,50%

1426

19

1,30%

1999 2000 2001 2002 2003 2004

526 421 403 375 550 543

43 32 19 31 25 32

8,20% 7,60% 4,70% 8,30% 4,50% 5,90%

1307 1377 1284 1266 1255 1227

16 12 11 16 16 12

1,20% 0,90% 0,90% 1,30% 1,30% 1,00%

However, it should be noted here that data obtained directly from hospitals does not accurately reflect the situation of inpatient mortality because of the following common practice: when the health condition of the patient in a psychiatric hospital becomes lifethreatening, s/he is either moved to another (general) hospital for treatment or discharged (with the “explanation” that his/her condition is untreatable); in these cases, these deaths are not registered by the psychiatric hospitals. As Table 1 shows, the trend of inpatient mortality (increasing since 1990, the highest in 1993-94, and decreasing since 1995) in these two psychiatric hospitals in Tbilisi is similar and corresponds to the overall mortality trend in the country (as reflected in the official statistics from the MoLHSA). However, mortality rates between these hospitals differ significantly, with the rate being much higher in Gldani Psychiatric Hospital. This difference can probably be explained by the fact that the Gldani Psychiatric Hospital is located in a remote district of Tbilisi (Gldani), which is difficult to access (due to damaged roads) and is considered extremely non-prestigious. At the same time, less attention is paid to this hospital by the health authorities. These circumstances result in the following: ƒ

Admission to this hospital of predominantly people with lower socio-economic status who may have higher prevalence of general health risk factors;

ƒ

The patients at this hospital suffer more from the lack of adequate care because a) better qualified medical staff has left the hospital; b) due to lower socio-economic conditions and poor access to the hospital, family members cannot provide adequate medicines, food and care for their hospitalized relative.

Suicide rates As stated in the MoLHSA 2000-2002 annual reports, and in the 2000-2009 Strategic Health Plan, in the last decade the suicide rate has significantly increased. Rapid socio-economic

changes, poverty, unemployment and internal displacements of the population are thought to be the key contributing factors to the increase in suicide rates in Georgia after its independence. However, information provided by SDS states the contrary: that the suicide rate decreased between 1989 and 2003 from 4.6 to 3.1 per 100,000 of the population (135 cases in 2003). This difference is another example of the unreliability of the official statistics. It has been suggested by experts that the cases of suicide and suicide attempts are not registered as such but as an “accident.” Due to stigma, religious convictions and unwillingness to proceed with a criminal case, family members tend to hide the fact of a suicide, saying that the victim “shot him/herself with a gun by accident” or “s/he fell out of the window by accident.” The fact of suicide is more difficult to hide in the capital, Tbilisi, but in the outlying regions, law-enforcement bodies fail to investigate these cases adequately. Also, suicide cases are sometimes not registered as such in medical institutions, e.g., in the case of poisoning the immediate cause of death can be acute renal failure and is documented as such, or in the case of heavy cranio-cerebral trauma following jumping out of a building, the medical records may reflect this latter as the cause of death. Therefore, with regard to the suicides, SDS is sometimes provided with inaccurate information from medical institutions and from the civilian registry office. Mental Health Care Staff There are currently 250 licensed psychiatrists in the country (235 adult and 15 child psychiatrists). This works out to 1 psychiatrist per 17,500 people. 13 There are about 900 psychiatric nurses who are trained in general nursing with no special training in psychiatry. Also, there are 1,200 “assistant psychiatric nurses” in Georgia who are more commonly referred to as “aides” in former Soviet countries. Their duties are to provide basic patient care, ward cleaning and tidying. There are virtually no social workers or occupational therapists, except at services operated by NGOs. Curriculum of the social worker is just now being developed at the state university level. Although the number of psychotherapists and psychiatric nurses in the country may be sufficient, their qualification is extremely inadequate. The qualification of psychiatrists and clinical psychologists also needs updating. The reform of the postgraduate educational system for medical doctors was initiated in 1999. A 3-year residency program in psychiatry was introduced which includes four subspecialties: general psychiatry, child and adolescent psychiatry, alcohol and drug abuse and psychotherapy. Certification examinations and the credit hour system for medical doctors have also been introduced. However, the residency program is not working effectively due to the lack of qualified trainers and appropriate funding. Despite some progress, the existing system of professional training does not meet the requirements of a modern public health system. For example, a curriculum for continuing education in psychiatry is still based on outmoded textbooks. A questionnaire which psychiatrists must complete in order to obtain a licence also needs to be significantly improved.

13

In the UK, there is 1 psychiatrist per 50,000 people.

2. The general situation of people with mental disabilities Disability Status Disability status (for both children and adults) is defined by medical-social expertise bureaus administered by the State United Social Insurance Fund (SUSIF) on the basis of “restricted capability.” (“Restricted capability” is measured by the ability to care for oneself, movement, orientation, communication, self-control, education and employment.) However, in practice, disability assessment is almost entirely focused on a person’s clinical diagnosis while the person’s abilities, adaptive behavior and quality of life are not considered. Standardized procedures or methods for assessing and diagnosing disability do not exist. Mental disability status is defined by specialized psychiatric medical-social expertise bureaus, which function in 6 major regions of the country. Depending on the disability status, terms of repeated examinations as well as rehabilitation measures are defined and recommendations on employment are made. 14

Intellectual Disability: definitions, diagnosis and assessment In Georgia, the term “mental retardation” is used to describe “intellectual disability” and is defined according to the ICD-10: “A condition of arrested or incomplete development of the mind, which is especially characterized by impairment of skills manifested during the development period, skills which contribute to the overall level of intelligence, i.e. cognitive, language, motor and social abilities. Retardation can occur with or without any other mental of physical condition.” 15 Degrees of mental retardation are estimated by using standardized intelligence tests which are supplemented by social adaptation scales. When parents detect signs of disability in their children, they first turn to pediatricians and neurologists (due both to stigma and low public awareness about mental disability) and only after to psychiatrists. Also because of stigma, parents either take the child to be treated privately or register him/her at a psycho-neurological dispensary for diagnosis and treatment. After registration at the psycho-neurological dispensary, the child is sent to the specialized psychiatric medical-social expertise bureau, where his/her disability status is defined and the pension is issued. The status of “child with restricted capability” is given to the persons under the age of 18. Very often the incentive for registering the child is to have access to the disability pension. In the past, two medical pedagogical commissions functioned in Georgia which referred children with disability status to specialized institutions such as boarding schools and internats (long stay residential institutions). The consent of parents (or guardians) and the commission’s assessment as to whether a child was “educable” was required in order to place the child in an institution. Following the trend towards inclusive education, these commissions have been disbanded, and currently the MoES is working on the development of a better alternative service to coordinate the referral of children to appropriate services.

14

Recommendations on employment are merely a formality due to the absence of rehabilitation and vocational services in the country. 15 ICD-10 Classification of Mental and Behavioral Disorders, WHO Geneva, 2003.

Mental Health Problems: definition, diagnosis and assessment Mental health problems are classified and clinical decisions made according to the definition and categories of mental disorders provided in the ICD-10 (categories F80-98 for children). In practice, children are very rarely diagnosed with schizophrenia. There is no data on the frequency of autism or autism spectrum disorder. As in case of intellectual disability, the rate of referrals and disease detection depends on the severity of the mental health problem, with the most severe conditions detected earlier.

Social Welfare Benefits The benefits system for people with mental health problems and for people with intellectual disabilities is the same. A person with a mental disability is diagnosed at a psychoneurological dispensary or at a psychiatric hospital. A special “benefits form” (form IV-50) is completed and sent to the medical-social expertise bureau administered by SUSIF, which defines disability status as well as the degree and the cause of the disability. Social welfare benefits are granted on the grounds of disability. These benefits are much less than the monthly subsistence minimum and are not sufficient either for food or for housing. Generally, the amount is the same irrespective of the degree of disability: GEL28 (€12.2) per month. The legislation governing benefits envisages additional allowances in certain cases. For example, if a disabled person lives alone, s/he receives an additional GEL22 (€9.6) per month; additional benefits are provided to people whose mental disability was caused by an employment-related accident or illness, nuclear accident, or while serving in the armed forces and participating in armed conflicts.

Internally Displaced Persons and Refugees and their Entitlement to Services and Benefits There is no significant difference in the status of internally displaced persons and refugees in terms of entitlement to social benefits. The armed conflict in Abkhazia was the major conflict in Georgia and resulted in the internal displacement of about 250,000 people. Also, about 2,500 Chechen refugees live in the Pankisi Valley, in northeast Georgia, having fled from neighboring Chechnya. The social and economic rights of the refugee population as well as their rights to healthcare and education are regulated by Georgian law and enforced mainly by UN agencies operating under the auspices of the United Nations High Commission on Refugees (UNHCR). Refugees enjoy the same rights as other residents of Georgia except for the right to participate in political activities and to work as civil servants. 16 According to the latest data provided by the Ministry of Refugees and Accommodation of Georgia, 250,000 internally displaced people (IDPs) were registered in January 2005, constituting about 6% of the total population. Women make up more than 55% of all IDPs. 17 IDPs enjoy the same rights as other citizens of Georgia; however, efforts to enforce the political and civil rights of IDPs have long been neglected mainly due to political 16

The principal legislation is the Law of Georgia "On Refugees" of 1998; refugees' rights are also stipulated by the International Convention of the Rights of Refugees of 1951. 17 The overwhelming majority (over 95%) of all IDPs are ethnic Georgians who were displaced due to two ethnically fueled conflicts in South Ossetia (1989-1991) and Abkhazia (1992-1993).

considerations. 18 IDPs are entitled to certain state benefits including social benefits (such as pensions for the elderly, social allowances for veterans and multi-child families), access to free secondary education and a package of free medical care. 19 About 42% of IDPs reside collectively in “centers of collective resettlement” (buildings of former hotels, schools, kindergartens, and hospitals) mainly in the capital city, Tbilisi, and in western Georgia. The majority of the remaining 58% of IDPs live with host families (relatives) or in rented apartments. State benefit allowances from the central budget are GEL14 (€6) per person/per month for IDPs living in private accommodation and GEL11 (€4.9) per person/per month for those people living in collective centers. In addition to these state benefits, IDPs are entitled to free public transportation and receive discounts on public utilities. 20 This state allowance is often the single source of stable income for the majority of IDPs and is far below the officially defined subsistence minimum (see above). Thus, IDPs largely lack basic financial resources, have inadequate living space, poor access to employment and medical care and are stigmatized.

The Role of International Donors The largest donors operating in Georgia are the United States government operating through the United States Agency for International Development (USAID), the World Bank, the European Union, and the International Monetary Fund (IMF). These organizations make up about 70% of total foreign donor assistance. Other significant donors include the European Bank for Reconstruction and Development, UN agencies and the German government. 21 (For more detailed description of donor activities in Georgia see Annex 3). Mental disability-focused projects have been supported by the following foreign donors: CORDAID/Netherlands, MISEREOR/Germany (various activities of the mental health NGOs: GIP Tbilisi, GAMH, APNSC, Ndoba, etc.), Open Society Mental Health Initiative and the Open Society Georgia Foundation (grant making to mental disability NGOs and a public awareness program on advocating for the rights of people with mental disabilities), the European Commission (protection of the human rights of torture victims), The Global Initiative on Psychiatry (GIP - (assisting mental health NGOs in various activities such as service user involvement, monitoring psychiatric institutions, and reforming psychiatric expertise); Eurasia and Oxfam Foundations (rehabilitation of victims of domestic violence), Hamlet Trust/UK, (mental health users' advocacy), Mercy Corps (public education in mental health), the World Bank (integration of people with mental disabilities), and American Friends of Georgia Foundation (improvement of psychosocial assistance to the elderly population).

3. Legal and Policy Framework a. The Key Decision Makers in Mental Health and Disability The key people who influence policy making and practice in Georgia are the president, the prime minister, other government ministers, the chairman of the parliament, heads of parliamentary committees, leaders of relevant parliamentary factions, leaders of major 18

The principal legislation is the Law of Georgia "On Internally Displaced Persons - Persecuted" of 1996. Study on IDP Rights, UN OCHA, 2003. 20 Reference Book for IDPs, Ministry of Refugees and Accommodation of Georgia/UNHCR, 2003. 21 EDPRP, Tbilisi, June 2003 19

political parties and a number of influential MPs. Mental health and disability policy development and implementation are influenced by the Parliamentary committee for Health and Social Affairs and the Ministry of Labor, Health and Social Affairs (MoLHSA) departments for health policy and for social policy. A National Coordinator for the State Program of Psychiatric Care was appointed in November 2004 under the MoLHSA in order to manage the development and implementation of the state psychiatric program. An Expert Board (which includes only psychiatrists) was created by the MoLHSA in 2004, though its duties and responsibilities have still not been clearly defined.

b. The Policy Framework Healthcare Reforms and the State Program for Psychiatric Care Since 1991, due to an intensive social and economic crisis, the Georgian health care system has faced extreme difficulties. Psychiatry has been left the furthest behind, with the mortality rate in psychiatric hospitals rising drastically due to the lack of basic conditions such as food, heating and medicines. In order to overcome the crisis in the healthcare system, preparatory work for launching healthcare reforms was planned by the MoLHSA in 1993. In the development of the health care reforms, an assessment was made of what essential basic services could be covered by the state, and as a result, reform plans were developed with the assistance of the World Bank and other external contributors. A Basic Benefits Package (BBP) was designed to provide all citizens with a minimum health care package. Initially, the BBP consisted of nine state-funded and five municipal health programs. 22 The “State Program for Psychiatric Care” was designed as part of the state-funded health programs. The need for such a program was recognized given the extreme vulnerability of people with mental disabilities, necessity for long-term or lifelong treatment, and the critical conditions in psychiatric institutions. 23 In 1999 with the assistance of the WHO, a National Health policy document was prepared; it was then followed by the Ten Year Strategic Health Plan developed by the MoLHSA. While the input of the international community was significant, due to the limited contribution of citizens, consumer organizations and local NGOs, there are fears that some concerns of the population were not fully addressed. 24 Both these documents (the National Health Policy and the Strategic Plan) include mental health and outline the necessary measures for reducing suicide, self-injury and mental disorders among children, adolescents and adults (See Annex 4). Neither of these documents provides any concrete information about the need to develop strategies to make the shift to community-based mental heath services. Implementation of the plan is hampered by the fact that resources have not been allocated. There are also problems with lack of training for professionals in the provision of community-based care and very low public awareness about the need for such alternatives to institutions. Thus, the policy and the strategic plan seem to exist in a vacuum, in no way corresponding to existing resources and realistic possibilities in the country. Having recognized that the existing policy and strategic plan do not work given the realities of Georgia, the MoLHSA assigned leading psychiatrists to elaborate a more realistic 22

Heath Care Systems in Transition, Georgia, Gamkrelidze at al, European Observatory on Health Care Systems, Copenhagen, 2002. Available on website: http://www.euro.who.int/document/E75489.pdf. 23 Georgian National Health Policy, Tbilisi, 1999 24 D. Gzirishvili, G. Mataradze, Healthcare Reform in Georgia, 1999, UNDP Country Office.

strategic plan for 2002-2005, taking into consideration the situation in the country. Such assignments were made by the former Minister of Health in 2001 at a meeting with senior representatives of the various healthcare fields, including mental health. The resulting document in the mental health field, entitled “The Main Directions of Psychiatry Care Development in Georgia, 2002-2005,” was approved by the Ministry in 2002. 25 The document sets out fifteen main objectives such as: improvement to, and expansion of, the State Program for Psychiatric Aid; creation of a psychiatric service monitoring system; conducting epidemiological research; and creation of a single database for information on psychiatric patients. Unfortunately, no resources have been allocated by the state for implementation of any of these objectives. A long-term mental health policy does not exist. The field is managed by a State Program for Psychiatric Care, which has been functioning in Georgia since 1995. This program envisages a very limited package of psychiatric treatment free of charge. The program applies to: ƒ ƒ ƒ ƒ

Patients who committed crimes and were sentenced to compulsory treatment by a court; In-patient treatment of people in emergencies and people in acute psychotic states; Patients with long-term psychiatric disorders who are prone to frequent relapse; Out-patients with psychotic diagnoses.

The program covers in-patient treatment of 1,045 patients and about 13,000 outpatient visits monthly. In 2000-2004, GEL3.5 mil (€1.6 mil) was disbursed annually to fund the program. 26 Involvement of NGOs in mental health policy development Because, to-date, the MoLHSA has not made any efforts to elaborate a comprehensive and realistic mental health policy, the NGO sector has stepped in. The policy development process was initiated by the Georgian Association for Mental Health (GAMH). 27 The mental health policy that was elaborated was based on the Georgia Mental Health Country Profile 28 and information obtained from stakeholders including the MoLHSA. GAMH elaborated this policy at its own initiative and presented it at a conference at the MoLHSA in July 2004. Significant lobbying will be necessary to ensure that the policy is actually implemented, particularly because the policy stresses the importance of developing strong inter-sectoral links between relevant ministries and other responsible agencies. Unfortunately, the MoLHSA has not expressed its intent to implement this policy. Implementation will also be a challenge because the ministry is still in the process of reorganization following the Rose Revolution in 2003.

Social Welfare Policy Overview According to the information provided by the MoLHSA, social policy development and reforms are among the top government priorities in Georgia. However, the existing social security system (health insurance, pension, social benefits systems) is largely ineffective both in safeguarding individuals against lifetime health and social risks and in reducing 25

A summary version of the document is given in Annex 5. Organization of Psychiatric Care in Georgia. Facts, Documents, Analysis, George Naneishvili, Teimuraz Silagadze, Tbilisi, 2004 27 GAMH worked closely with Professor Rachel Jenkins, WHO Collaborating Centre, London Institute of Psychiatry, Kings College, UK. 28 Georgia Mental Health Country Profile, International Review of Psychiatry, Volume 16, Number 1-2, February/May 2004 26

poverty. The transition in Georgia from a planned to a market economy has inflicted a heavy burden on the social welfare system, which faces three types of problems: conceptual, administrative and financial. These problems are strongly related to, and aggravated by, political and economic problems. The government should take steps to build a new social welfare system that takes into account the country context as well as relevant experience of other Eastern European countries that have faced the difficulties of transitional economies. 29 To date, no consistent national social welfare policy has been developed and implemented in Georgia. The major policy document is the Economic Development and Poverty Reduction Paper for Georgia (EDPRP), approved in June 2003, which broadly outlines major principles and directions in social welfare as a part of an overall country development strategy. However, the implementation of the EDPRP policy has been hindered by the major political changes, in particular the Rose Revolution and the continuing changes in government as a result of it. At present, the MoLHSA, the MoF and the SDS are working closely on the elaboration of a new social welfare policy and program. As a first step in the reform process, the government has initiated a process to identify potential beneficiaries of social welfare benefits. The “State Agency for Social Aid and Employment” was created in January, 2005 as a legal successor of the “State Employment Agency” under the MoLHSA. The agency aims to “ensure the realization and promotion of State policy in the field of social security and employment and implementation of Social security and employment activities.” 30 However, as mentioned above, no consistent “State Policy” is in place at this writing. The agency has recently developed the “State Program for Identification, Assessment of Socio-economic Status and Formation of a Data-base of Households Living Below the Extreme Poverty Line” (assessment methodology adopted in May, 2005). The main goal of the program is to more effectively target people in the greatest need and thus shift away from social category-based assistance to needs-based assistance. The program aims to distribute state social welfare benefits to households in the most need, which will be identified as having the lowest “Welfare Status.” Such households will be identified through the establishment of “communication centers” throughout the country staffed with trained “social agents” who will examine households’ “Welfare Status” after receiving written requests for social welfare assistance from them. The assessment of the applicants’ Welfare Status will involve in-depth interviews and direct observation of the household conditions, assets etc., as well as verification of other official sources of information. A database of these people will be formed on the basis of their identity cards, and funding will be distributed among the population with the lowest “Welfare Status” score. The database formation process has already begun, and the payment of benefits is planned to begin in 2006. Social welfare benefits Georgian healthcare authorities have not developed any policies that define concrete strategic action to address the needs of people with mental disabilities. All people legally recognized as “disabled” are eligible for social welfare benefits, regardless of what condition 29

The legislative basis for the social protection of people with disabilities is comprised of: ƒ The Law of Georgia "on Social Protection of the Disabled,” 1995 ƒ The Law "On Medical and Social Expertise,” 2002 ƒ The Presidential Decree "On Establishing a National Council to Support Activities of NGOs Focused on Persons with Limited Abilities,” 2002 ƒ The law "On Veterans of War and Armed forces,” 1995 ƒ The law "Social Care for those Who Suffered and Became Invalid While Liquidating Results of Chernobyl and Other Nuclear Disasters,” 2000. 30 Provision of the State Agency for Social Aid and Employment, January 2005.

caused the disability. Thus, while these programs do not specifically target people with mental disabilities, they are eligible for benefits if deemed “disabled” by the medical-social expertise bureau administered by SUSIF. State-funded health and social welfare programs that exist for people with disabilities have been implemented rather inconsistently. These programs are within the framework of mandatory health insurance and social welfare programs operated by SUSIF. While the range of health and social welfare benefits provided by these programs has changed frequently over time, the benefits have always been largely insufficient to meet the needs of the disabled population. Currently, one of the state social welfare programs, “Social aid for vulnerable families,” envisages a very small pension, GEL22 (€9.6) per month, for disabled children (under the age of 18) and for people with 1st degree blindness. In addition, SUSIF operates several programs designed specifically for “people with disabilities.” The list of these programs and their budgets for 2005 (according to the Law on the State Budget, 2005) is presented in the table below. Table 2. State Programs for Disabled People, 2005

Program Social aid for temporary disability Supporting social adaptation of disabled people: 1. Social integration of disabled people 2. Institutional care for disabled people 3. Subsidies for NGOs for disabled people (unions of people with visual, hearing and speech impairments) 4. Rehabilitation of disabled children 5. Provision of accessories (wheel-chairs, etc.) for disabled people

Budget

Budget

thousand GEL

thousand €

3.850

1.674

4.485 586, 9 2.563,1 365

1.950 255,2 1.114,4 158,7

600 350

260,87 152,2

According to 2003 estimates from the MoLHSA, only 2% of the disabled population has income that brings them above the poverty line. Thus, the significant burden of care for people with disabilities (financial, physical and psychological) is almost wholly imposed on their families. The MoLHSA department for disabled people estimates that the only source of income for 17% of the disabled population is social welfare benefits, which are extremely low (GEL28 / €12.2 per month), causing these people to live below the extreme poverty line (which is GEL60, or €26.1 per month). Another 81% of people with disabilities have additional sources of income, but their total income still does not reach the officially defined subsistence minimum (i.e. the general poverty line ~ GEL130 / €56.5 per month) meaning that, in practice, they live in poverty. Policies and programs concerning disabled people In 1994, a “department for protection of invalids” was established under the Ministry of Social Affairs and was tasked with developing a national policy to address the needs of the disabled population. After the merger of the ministry of health and the ministry of social affairs in 1999, the department was transformed into the department for people with disabilities. However, a national policy was never developed. At present, the Department for Social Policy Issues is functioning at the MoLHSA and is supervised by the Deputy Minister for social issues. This department is in the process of

developing a social policy document. However, all of the work at the MoLHSA is delayed due to the prolonged process of reorganization and re-staffing of the Ministry following the Rose Revolution. Thus, while government programs seem to address the needs of disabled people on paper, in practice, neither financial nor human resources are allocated to implement these programs. This lack of implementation is made worse by the extremely poor management of these programs. For example, the lack of an efficient and accurate system for identification/registration of people eligible for governmental benefits, 31 and a lack of coordination of services, which would be necessary for continuity of care, have been pervasive problems until recently.

Policies Targeting Children In February 2004, Parliament adopted an advocacy act for disabled children, which includes children with mental disabilities. This policy document, entitled “Main directions of State policy on disabled children of Georgia,” was developed by the NGO Horizonti Foundation by order of the parliamentary committee on health and social issues, whereby the highest political authorities expressed their will to support disabled children. The Parliament assigned the MoLSHA and the MoES to work on this document. MoES has started working in this direction, but the MoLSHA has yet to become involved. In June 2003, UNICEF developed a National Action Plan for Aid to Children 2003-2007 which broadly addresses issues such as social integration, rehabilitation, deinstitutionalization, and inclusion of disabled children into society. Though it is called an “action plan,” the document is rather general and does not contain any concrete plans for action. This program has not been implemented to date, perhaps because its budget is high: GEL400 mil (€174 mil). UNICEF continues to lobby for implementation of this action plan. Studies by international organizations and local NGOs have found that there is very little access for children with disabilities to education, to be outdoors, or to enjoy life in the community. There are no ramps or sloping walkways anywhere in the country for people who have physical disabilities. In addition, the majority of families with a disabled child have insufficient resources to secure effective medical treatment or special educational services, purchase prosthesis or a wheelchair, or meet their child’s special needs in any other way. 32

Stakeholder Involvement in Policy Development NGOs, families, and consumers have not been involved in policy development. Prior to the Rose Revolution in 2003, the former government did not take any steps to promote stakeholder involvement. While the post-revolution health officials are willing to involve and consult all stakeholders, they do not have experience in doing this. For example, there is no system whereby draft laws and policies are made available for interested stakeholders to comment upon. The Georgian Association for Mental Health (GAMH) has made efforts to promote the involvement of families and consumers in mental health policy development, but this has not been effective due to the absence of such practice at the governmental level. 31

Practices that hindered efficiency included issuance of fake policy cards making someone otherwise be ineligible, then eligible for state benefits; not canceling benefits when a beneficiary died resulting in family members receiving benefits illegitimately, and even the state agencies responsible for issuing benefits receiving those benefits themselves on behalf of deceased beneficiaries. 32 Human Development Report Georgia, 2003-2004, UNDP.

Because there is no tradition of consumers of services and families advocating for their own rights, these groups must be encouraged to speak out.

c. Legal Framework Anti-discrimination Legislation The Constitution of Georgia does not prohibit discrimination on the grounds of disability. However, disability discrimination is prohibited in the Law “On Social Care for Disabled [People]” which states: “Discrimination against people with disabilities is prohibited and is subject to punishment as prescribed by law.” 33 This law introduces the term “disabled person,” defines his/her rights and outlines the state policy towards disabled people to ensure their social protection. 34

Guardianship There is no official data on how many people with mental health problems and people with intellectual disabilities are under guardianship. In Georgia there is only plenary guardianship. According to Article 1276 of the Civil Code, “Guardianship is established over a person who has been declared by a court to be a person without legal capacity by reason of mental illness or mental retardation.” Such decisions are made by Tbilisi district courts and by local courts in regions according to the person’s place of residence. Guardianship and Curatorship Agency Guardianship is established by the Guardianship and Curatorship Agency that functions under the supervision of the local healthcare authorities. The agency's functions are limited to appointing a guardian on the basis of a written request by a person who wishes to obtain guardianship. This is usually a relative of the person in question. According to the data provided by the Guardianship and Curatorship Agency of Tbilisi, for the period between years 2000-2005 guardians were appointed for 97 persons; 20 cases are currently under consideration; 1 person was not appointed a guardian because there was nobody willing to take guardianship responsibilities. There is no public guardianship system in Georgia. Legal capacity and patients detained in hospital If the legal capacity of a person detained in the hospital is at issue, the court hearing on the matter generally takes place without the person in question. The formal procedure lasts about 10 minutes. It does not include analysis of the facts of the case, nor does it consider the wishes, opinions, and needs of the person in question. The lawyer involved in the case represents the interests of the person to be appointed as a guardian for the purpose of determining the disposal of the patient’s property. Once a guardian is appointed, the guardian has complete authority over the ward’s property, including the disposal of the property. The Law prescribes that the guardian must obtain legal permission from the Guardianship and Curatorship Agency regarding disposal of the ward’s real estate. However, in practice there are cases in which a guardian sells the ward's property without obtaining this permission. There is no mechanism for investigating any potential conflict of interest guardians may have, nor is there any monitoring of guardians’ activities. While guardianship legislation provides that a court may revoke a declaration of incapacity if a person’s mental condition improves, this is not applied in practice. 35 33

Law of Georgia "On Social Care for Disabled,” Article 1, adopted on June 14, 1995 For Georgia’s signature/ratification of international instruments see Annex 6. 35 Nowhere to Turn: Creating Guardianship Possibilities for the Mentally Disabled in Georgia, Grigol Giorgadze, Judit Mandl, Marta Schaaf, Human Rights, Law and Development, December 2003 34

Case example of Nino L: Nino L. was declared legally incapacitated by a court decision in 2003 and detained in a psychiatric hospital because of her mental health problems. Her sister was appointed as her guardian. Nino's rights were abused by her guardian, who sold Nino's house during the period of her hospitalization without the consent of the guardianship agency. The proceeds from the sale were not used for Nino’s benefit, e.g. for purchasing a new apartment or providing her with food and medicines while hospitalized. Because nobody was present to claim her when she was to be discharged, 36 Nino turned to the GAMH advocacy project for support. An international NGO facilitated the representation of Nino by a Georgian lawyer who appealed the guardian's activities before the guardianship agency and demanded removal of the guardian. The request was granted by the agency. A further claim was submitted to the court demanding that the agreement to buy and sell Nino's house be voided. The guardian agreed to the deal offered by the judge, which was to purchase the house for Nino at fair market value. This positive outcome is an extremely rare occurrence and can be attributed to the involvement of the international NGO, which supported the local lawyer to represent Nino before the court. Case example of Manana I: Manana I. was declared legally incapacitated due to intellectual disability as well as mental health problems. After the death of her parents, one of Manana's brothers requested and was granted guardianship. When Manana's mental health grew worse in 1997, her guardian had her detained in a psychiatric hospital. After 8 months, Manana's condition became more stable, and the issue of discharge was raised by her doctor. Because nobody had visited her in hospital, hospital staff began looking for her guardian and her residence. It was discovered that the guardian had sold Manana's house, destroyed her identity documents and emigrated abroad. Manana was thus left without the necessary documents for obtaining social welfare benefits, and she had nowhere to go. Hospital staff contacted GAMH’s users’ advocacy project in 2002. After intense efforts, GAMH was able to recover Manana's documents, and she was granted a disability pension. It was not possible to seek compensation for the theft of her real estate, as her guardian and other family had left the country. Advocacy project staff contacted the police for assistance in locating Manana's guardian, but to no avail. Manana still lives in the psychiatric hospital.

Mental Health Legislation: Detention and Compulsory Treatment The Law of Georgia “On Psychiatric Care” 37 envisages two forms of involuntary hospitalization: “emergency hospitalization” (Article 9) and “compulsory treatment” (Article 10). In both cases, the patient enjoys the same constitutional rights as other citizens unless s/he is found to be “incapacitated.” For example, the Law “On Psychiatric Care” states that the patient is guaranteed respectful and humane treatment; psychiatric care under the least restrictive conditions; information about his/her disease and the treatment methods applied; and has the right to refuse the treatment offered if s/he has legal capacity to make decisions. 38

36

In the Soviet period, legislation mandated the presence of a relative or a guardian when a patient was discharged from psychiatric hospital. Today this remains an informal rule that is not enforced. 37 Law of Georgia "On Psychiatric Care,” adopted on 21 March, 1995. See Annex 7. 38 See Annex 7, Article 3, Paragraph 2.

Decisions about emergency hospitalization are made by a medical commission, which examines the patient within 48 hours after hospitalization and makes a decision as to whether hospitalization is warranted. 39 The decision as to whether a patient is legally incapacitated is made by the court. (See “Legal Capacity and Patients Detained in Hospital” in the section on Guardianship above.) Either the patient’s relatives or the hospital administration (if the patient is hospitalized) must submit a written statement to the court, asking the court to recognize the person as legally incapacitated. The Court convenes a forensic psychiatric examination to advise on the patient’s capacity and makes its decision based on the conclusions of the examination. 40 Social Integration/Rehabilitation Legislation There is no separate law on social integration and rehabilitation, nor is there separate legislation regarding people with mental health problems and people with intellectual disabilities. However, Chapter III of the Law “On Social Care of Disabled [People]” refers to the medical, professional and social rehabilitation of disabled people, which includes people with mental disabilities.

Access to Justice The right to legal representation People with mental disabilities have the right to access the legal system. However, in practice, there is no mechanism to exercise this right. There are no publicly funded legal aid organizations which provide free legal consultancy and/or legal representation to people with mental disabilities. However, the law “On State Duties” 41 provides that disabled people are not required to pay court costs when submitting a civil complaint. Civil as well as criminal procedure legislation provides for court-appointed legal counsel free of charge for persons who can show their inability to pay, but the decision to appoint counsel is made by a judge based upon the severity of the case. It is well-known that, in general, court-appointed attorneys fail to advocate effectively for their clients. Patients detained in psychiatric hospitals Patients detained in psychiatric hospitals are generally unaware of their rights and, being isolated from outside world, are exposed to abuse of their human rights. In the case of involuntary hospitalization, a patient does not have the right to a legal representative. The Law “On Psychiatric Care” does not provide for court hearings in cases of involuntary detention, nor does it provide for an independent and impartial tribunal, which would examine involuntary admission cases. These omissions violate the European Convention on Human Rights (ECHR). Article 5 of the ECHR (the right to liberty) provides that individuals who are detained “shall be entitled to take proceedings by which the lawfulness of his detention shall be decided speedily by a court and his release ordered if the detention is not lawful.”

39

Ibid. Article 9, Paragraph 5. The Code of Civil Proceedings, Articles 322-327. 41 "Disabled people as well as public organizations and unions of disabled people are exempted from state duties when submitting complaints to the courts". Law of Georgia "On State Duties" (adopted on 29 April, 1998), article 5, paragraph 1, subparagraph "l". 40

The Role of the Ombudsman A state ombudsman’s office has been functioning in Georgia since 1996, but to date it has largely failed to address mental disability. However, since recently the state ombudsman’s office has actively been collaborating with NGOs working on rights of people with mental disabilities. After preparatory work, a Public Council for Carrying out Motoring of Human Rights in Closed Medical Institutions was created under the Ombudsman’s office, which includes NGOs working in the fields of mental health and human rights. A special Memorandum was signed on 13 November, 2005 by the Minister of Labour, Health and Social Affairs and the State Ombudsman. These activities are in-line with the requirements of harmonizing the efforts directed to the protection of patients' rights envisaged in the National program of the Government of Georgia. 42 Some efforts are being made by NGOs; namely, the Georgian Health Law and Bioethics Society and the Welfare Foundation to work on the protection of patients' rights by offering health ombudsman services. These activities are supported by an international donor organization (Oxfam Great Britain) and are implemented as pilot projects. Some other NGOs, namely, The Georgian Young Lawyers' Association and 42nd Article of Constitution, provide free consultation and advocacy services to vulnerable groups, including people with mental disabilities, for example, by representing them in court. Although people with mental disabilities, along with other vulnerable groups, are eligible for all of the above-described services (provided by NGOs), none of the services specifically target people with mental disabilities. Nor do they do anything to specifically solicit clients with mental disabilities. Thus, though eligible, very few people with mental disabilities use these services.

4. Institutions for People with Mental Disabilities43 Psychiatric Hospitals In Georgia there are 7 psychiatric hospitals, 15 outpatient clinics and 4 outpatient departments at psychiatric hospitals. 44 Since the 1990s, the number of psychiatric beds in the country has been reduced from 5,000 (1 per 1,000 of the general population) to 1,000 (1 per 5,000 of the general population) due to the prevailing shortage of resources. The state finances these 1,000 beds in psychiatric hospitals as well as 45 beds in 3 outpatient clinics. In addition, 50 beds are available at the general hospital under the penitentiary department of the Ministry of Justice. There is only one special geriatric ward for 15 patients at the Asatiani Scientific Research Institute of Psychiatry. This ward was opened in 2003 with the financial support of a foreign donor, “American Friends of Georgia.” Soviet style vocational rehabilitation workshops were functioning in large psychiatric hospitals until the 1990s, but currently there are no vocational programs available.

42 National program of the Government of Georgia on Harmonization of Georgian Legislation with the European Legislation, Tbilisi, 2003 43 For a complete list of Institutions for people with mental disabilities see Annex 8. 44 Organization of Psychiatric Care in Georgia. Facts, Documents, Analysis, George Naneishvili, Teimuraz Silagadze, Tbilisi, 2004.

Institutions for Adults with Intellectual Disabilities For adults with intellectual disabilities, there is one special ward in Zurabashvili (Gldani) Tbilisi psychiatric hospital with 70 beds, 45 and only one separate institution - “House for People with Intellectual and Physical Disabilities” - for 55 people in Dzevri village in Western Georgia.

Institutions for Children with Mental Disabilities Today in Georgia there are no medical institutions (children's departments in psychiatric or general hospitals, day care centers) that provide services to children with mental health problems or to children with intellectual disabilities. There are 44 institutions for children in Georgia (orphanages, boarding schools, supplementary schools (special education schools), rehabilitation centers, and specialized nursery schools) which serve about 4,800 children nationwide. 46 Of these, 31 institutions serve children with disabilities. 47 Children with intellectual disabilities can be found in all 44 institutions because admittance procedures are not followed, though generally these children are placed in supplementary boarding schools. Specifying the exact number of children with intellectual disabilities in the above-mentioned institutions is impossible due to the poor record-keeping system. Specifically for children with intellectual disabilities, there are 8 institutions in the country seven supplementary boarding schools and one supplementary special school in Tbilisi. Two houses (Senaki and Kaspi) serve children with severe intellectual and physical disabilities, and there are two houses for infants with intellectual disabilities. 48 Also, until 1993, departments for children with mental disabilities were functioning at the Asatiani scientific research institute of psychiatry (Tbilisi) and at the Batumi psychiatric hospital (western Georgia). After the severe economic crisis, which seriously affected the quality of care in hospitals, these children were taken out of these institutions by their parents, and the departments were closed. Among the problems identified with regard to institutions for children with intellectual disabilities are a permanent lack of medicines, food and educational materials; outmoded educational curricula; and a chronic lack of qualified staff. There are no proper procedures for admitting children to institutions, and they are often admitted contrary to regulations. 49 Generally, children with mental and physical disabilities from neighboring regions are placed together at the same institution, regardless of whether the institution is suitable for providing care to the child. Also, children with intellectual disabilities are commonly placed at the school for children with speech impairments despite the fact that this school is not specifically designed for serving children with intellectual disabilities. This is because conditions in this school are better compared to the

45

Because there are only two institutions specifically for adults with intellectual disabilities in the country, they sometimes are placed in psychiatric hospitals. This is especially likely when the person with intellectual disabilities also has a mental health problem. Up until the 1990s, the presence of people with intellectual disabilities in psychiatric institutions was quite common. However, due to the economic crisis that affects the health care system, their numbers have been significantly reduced. Since 1995, the State Psychiatric Program has been in force, which provides public funding for institutional care of people with intellectual disabilities who are in acute psychotic states, or who have long-term psychiatric disorders and are prone to frequent relapses. 46 Study on Children's Institutions, Situation analysis, NGO Child and Environment, Tbilisi, December 2004 47 Main Directions of the State Policy on Protection of Rights of Disabled Children, Horizonti Foundation, Tbilisi, 2002 48 Data of the MoES. The complete list of these institutions is presented in Annex 8. 49 Research on Childcare Institutions, Situation analysis, NGO Child and Environment, Tbilisi, December 2004

supplementary special school where there are children with intellectual disabilities, children with physical disabilities and children who are socially disadvantaged. Funding of institutions The MoLHSA is responsible for funding institutions for people with mental disabilities. It designs the State Program for Psychiatric Care and defines its budget while the financing for institutions is administered by SUSIF. International donors have made significant contributions to these institutions. The Red Cross supplied medicines to psychiatric hospitals as part of a special project that ended in April 2000; The United Nations World Food Program provided psychiatric hospitals with food until 2004. 50 Financing for supplementary special schools for children with intellectual disabilities as well as for orphanages is administered by MoES. Location of institutions Institutions for people with mental disabilities are dispersed countrywide, though the majority of them are located in urban areas (See Annex 9). The main problem is that institutions are generally located far away from families. Some institutions are barely accessible because of very poor road conditions, limited public transport and poor economic conditions of relatives, who can barely afford even the transportation expenses. This problem is particularly acute in rural areas, resulting in relatives visiting hospitalized family members extremely rarely. Length of stay in Institutions The length of stay in psychiatric hospitals depends on the diagnosis but on average is 70 days. 51 However, some people with mental disabilities stay at institutions for years because they have nowhere else to go. Relatives are not willing to take them because they are unable to provide adequate home care, and there is no community-based supported housing in the country. Very limited state financing and the absence of a developed health insurance system allows for hospitals to cover only very basic costs, while medication and additional food supplies are provided by relatives.

Formal Detention in Institutions According to the Law “On Psychiatric Care,” two types of detention are relevant to people with mental disabilities: ƒ

About 200 of all the hospitalized people with mental disabilities (20% of 1,000 patients countrywide) are under compulsory treatment. 52 These are people who have committed a criminal offence and are receiving court-ordered compulsory treatment on the basis of the conclusions of a forensic medical examination commission.

ƒ

There are a significant number of people with mental disabilities involuntarily hospitalized, though there is no statistical data available. This “emergency hospitalization” occurs when a person is deemed to be socially harmful (i.e. their aggressive behavior creates physical danger or threat of material damage to themselves or others). 53

50

Other donors and NGOs such as Premiere Urgence/France, UMCOR/US State Department and ACTS Georgia have supplied psychiatric hospitals with medications.

51

The length of stay for people who have been involuntarily detained is regulated by the court. Organization of Psychiatric Care in Georgia. Facts, Documents, Analysis, George Naneishvili, Teimuraz Silagadze, Tbilisi, 2004. 53 See Annex 7, Article 9, Paragraph 1. 52

Conditions in Institutions Since the Soviet period, all state facilities serving people with mental disabilities are in terrible states of disrepair. There is a permanent lack of material and technical resources and of adequate sanitary and heating systems. The situation in the rural regions is even worse, with electricity, gas and water shortages. Conditions are also severe in Georgian psychiatric hospitals; buildings are old and often in remote locations, distant from patients’ families. The hospitals receive GEL 6.70 (€3) per patient/day to cover all treatment and operating costs. There are hygiene issues, and there is a serious problem with lice. The quality of care is low, and there is a lack of funding for even basic necessities such as food and heat, let alone active treatment and rehabilitation services. The supply of medicines is insufficient, there is a lack of qualified staff, and staff salaries are extremely low. The structure of mental health institutions remains very similar to the way it was during Soviet times: wards are divided only by gender at psychiatric hospitals (and not by any other criteria, such as age or diagnosis). Because of the extreme reduction in public funding since 1993, this problem has become even more severe, resulting in the closure of the children’s and neuroses’ wards in above-mentioned hospitals. Due to the prolonged social and economic crisis, socially vulnerable groups, including people with mental disabilities and their relatives, have developed a nihilistic attitude about the possibility that their situation will improve. Complaints of people with mental disabilities who are hospitalized are not appropriately addressed by hospital administrators, who argue that the severe lack of financing makes it difficult to meet even minimum requirements for staff. Inhuman and degrading treatment, including physical abuse of people with mental disabilities by both hospital staff and relatives, is also a pervasive problem. In 2003-2004, the Advocacy group of the Georgian Association for Mental Health, established in collaboration with mental health service users, carried out the project “Users' Advocacy” at the Asatiani psychiatric hospital. The project collected details on the nature of complaints made by institutionalized patients. The breakdown is as follows: ƒ ƒ

ƒ ƒ ƒ ƒ

Poor food - 56% Problems with discharging patients - 27% (due to the absence of relatives or a guardian willing to take a patient home, the lack of appropriate social services and/or lack of means to live outside, hospitalization period is extended beyond what would be necessary for medical purposes) Lack of contact with the external world (impossibility of sending letters, making phone calls, walking in the yard, taking short-term leaves) - 9% Psychological abuse by attendants - 4% Lice - 4% Requests for changes in medication - 2%.

Complaints Procedures It is important to note that, except in rare cases, patients do not make formal complaints about their care and treatment in institutions because: ƒ They have no information about who to address and how; ƒ They do not believe that the situation will change as a result of the complaint; ƒ They fear that the complaint will result in worse care or treatment on the part of administration and medical staff.

The majority of complaints to the MoLHSA in 2004 were submitted by relatives asking for placement of their family members with mental disabilities in psychiatric institutions for the long-term because: ƒ ƒ ƒ

Relatives are unable to provide them with food and medication; Relatives lack space in the household; The person with mental disabilities is in conflict with other relatives.

There is no independent body in any institution that addresses complaints of people with mental disabilities who are hospitalized. Verbal complaints made to the heads of departments or hospital directors are common. Written complaints are registered in the special journal of incoming correspondence which is reviewed by the director who reacts to the complaint at his/her discretion. The majority of complaints by relatives and patients are now addressed to the newly appointed National Coordinator for Psychiatric Care (see above). However, this method is ineffective because the Coordinator is not authorized to handle complaints and does not have the appropriate financial or human resources to do so.

Advocacy Services GAMH operates an innovative project on users' advocacy. The project was established with the initial purpose of developing mental health advocacy in psychiatric institutions. It was the first attempt to develop an advocacy initiative where ex-users of mental health services are involved as peer advocates. The project has operated at Tbilisi Asatiani psychiatric hospital since 2002. Its activities include visiting patients in wards; listening to complaints and working with patients on solutions to their problems; assisting patients in arranging meetings with medical staff, relatives, and neighbors; providing patients with information about their rights; carrying out legal consultations, and dissemination of informational leaflets. Despite success in rendering assistance to certain patients, there are very serious issues that remain. For example, the hospital’s budget allocation, food rations, sanitary conditions, and management are all cause for concern but are outside the capacity of the NGO to address. There is an urgent need for legislation that sets out a framework for advocacy services within closed institutions.

5. Access to Education General situation Because primary and secondary education is fully state-funded in Georgia, in theory all children have access to public education at the primary and secondary levels. According to official data provided by SDS, 99.7% of children receive at least primary education, and the majority at state schools. Of those children, 12.6 % end their education with primary school. The percentage figures of those children who complete primary, secondary and higher education are set out in Table 3, below. 54

54

SDS 2002 data.

Table 3. Percentage of the population receiving Primary and Secondary Education in Georgia No education Primary or higher education Including: primary education only complete secondary education only Primary vocational education only Secondary professional education only Incomplete higher education only Higher education Total

0.3% 99.7% 12.6 % 39% 3.2% 17% 3.6% 24.3% 100%

However, these official figures may be inaccurate, and it has been suggested that a larger number of children do not receive primary or secondary education. Many children do not attend school because of factors such as: geographical inaccessibility (especially in rural areas), poor condition of schools (schools are poorly equipped, not heated etc.), and poverty (families cannot pay costs related to transportation, educational materials, and even clothing). Also, many children do not attend school because they have to work to financially support their families (selling and begging in the streets, at markets, etc.)

Children with Disabilities For children with physical and intellectual disabilities, there are state-funded special boarding schools (internats) nationwide; in each region there is at least one such institution. There is only one special non-residential school in the country, in Tbilisi, for children with intellectual disabilities. Special boarding schools (internats) provide housing rather than education to children. The educational programs, materials and curricula available are from the Soviet period and seriously outmoded. In a special boarding school, a child follows a Soviet-era “defectology” curriculum which does nothing to prepare the child for study in a mainstream school, although this is the stated objective of the special school. There are no accurate records kept on individual children who study in special schools - they do not receive assessments of their abilities, there are no individual educational plans, and they are not taught independent living skills. The future for children who finish special educational institutions in Georgia is bleak they receive no training in skills that would enable them to obtain employment. Because diagnostic and assessment practices are so outdated, it is common for children who should be attending mainstream schools to attend special schools.

Inclusive Education Inclusive education for children with disabilities is only taking place on a very small scale in the country and is operated by NGOs that tend to focus on children with physical, rather than mental, disabilities. These pilot activities have been supported by Mercy Corps, OXFAM GB, and World Vision. The major donor in the field is UNICEF, which supported the NGO Child

and Environment to prepare 10 schools in Tbilisi for implementing the inclusive education model. In order to improve coordination and better target needs, a coalition for Education of Disabled People, which unites 12 local NGOs that are working on integrated and inclusive education, was established in 2004. The coalition works closely with MoES, which declared its new goal 55 of reforming the educational system in Georgia with an emphasis on inclusive education. The MoES, the MoES Education Project and the Coalition for Education of Disabled People have developed a joint project with the aim of providing disabled children with education in mainstream schools. Inclusive education will be introduced at 10 Tbilisi-based schools which have already been prepared by NGOs. These schools will serve as models for replicating inclusive education nationwide. Due to extremely limited state financing for implementing this project, MoES is currently negotiating with the Norwegian government for co-financing. Street Children The issue of street children has grown more acute in the last decade. There is no exact quantitative statistical data available on street children; however, their number has significantly increased since 2002, when 2,500 street children were registered in Tbilisi. 56 Street children are often involved in illegal activities such as theft and prostitution (which is sometimes a source of income for them and their families). High-risk behavior, including unprotected sex and intravenous drug use, is common. There is no information available on the mental health condition of these children. There are several NGOs that provide support to street children, but they do not provide mental health services (including assessment and treatment).

6. Access to Employment Unemployment According to SDS data from 2003, 14.1% of the population in the labour force is unemployed based on the International Labour Organisation’s (ILO) “mild criteria.” 57 According to the same data, the overall unemployment rate is the same among women and men. However, the actual unemployment rate is thought to be higher than the figure officially reported. UNDP’s Human Development Report suggests that the actual unemployment rate for 2004 is about 25%. 58 Many people do not report that they are unemployed and do not register with employment agencies because they do not believe that this will help them get employed. Unemployment primarily affects people between 15-24 years of age according to the official statistics, with about 25% of this age group being unemployed. In this age group 55

The legislation which serves as grounds for these changes are: ƒ State policy guidelines for protection of disabled children's rights in Georgia, approved by the parliament of Georgia, February 2004. ƒ Law of Georgia on General Education, adopted on April, 2005. 56 Children of Georgia: Rights for Better Future, UNICEF, 2004 57 According to the ILO (International Labor Organization) "strict criterion,” a person is considered unemployed if s/he registers with the State employment agency with purpose of seeking employment. However, in countries where the labor market is underdeveloped, it is recommended to use "mild criterion". According to the «mild criterion,” a person is considered unemployed if s/he gave up looking for job through the state employment agencies (because s/he gave up hope). According to ILO "strict criterion,” the unemployment rate in Georgia, as reported by SDS, was 12% in 2003. 58 National Human Development Report Georgia 2004, UNDP 2004.

the unemployment rate is 1.3 times higher among men than women. Unemployment is also a severe problem for people between 25-34, 17% of whom are officially registered as unemployed.

Unemployment of People with Mental Disabilities There is no statistical data on the numbers of people with mental disabilities who are unemployed. However, given the situation, the likelihood is that unemployment of this group is close to 100%. There are no employment programs for people with mental disabilities, nor is there a system of rehabilitation or vocational training targeting this group of people. There are no sheltered workplaces or social enterprises for people with mental disabilities or for people with disabilities generally. The great majority of people with mental disabilities are isolated at home or in hospitals without any opportunity for vocational rehabilitation, employment or inclusion in society. Mental health NGOs have created a small number of employment opportunities, which operate as pilot projects, for people with mental disabilities. After familiarizing itself with these projects, the MoLHSA has expressed an interest in developing employment programs for people with mental disabilities. According to the deputy minister for social issues, the national social policy to be developed by the MoLHSA will cover these issues. Specifically, the state has committed to co-financing employment services for people with mental disabilities. Currently, employment services are operated by local NGOs and are financed by external donors; the MoLHSA will begin co-financing once this external financial support ends.

7. Progress towards Social Inclusion Inclusion in Society There is no state policy that envisages the integration of disabled people into society. The existing Health Policy and the document “Main Directions for Development of Psychiatric Care” do not promote the shift from institutional to community-based care. However, a growing number of mental health NGOs are putting serious effort into advocating for the shift towards community-based care. NGOs have organized conferences, discussions and meetings with representatives of central health authorities to discuss this issue. Several community-based projects are being piloted by these organizations with the support of international donors. The CORDAID-supported psychosocial rehabilitation unit for in-patients has been functioning for 3 years at Gldani psychiatric hospital; a GIP-supported unit was opened at Asatiani Scientific Research Institute. Art and ergo therapy groups are functioning in these units, as are programs aimed at restoring social skills.

The Need to Develop Community-based Services People with mental disabilities living at home do not receive any state-financed support services. Services providing home-based care to people with mental disabilities have not yet been developed in the country. The State Program for Psychiatric Care envisages only one visit per year/per patient. This visit should be made by medical staff of the psychiatric dispensary (outpatient clinic). However, the state fails to finance even this very simple type of service. Due to the very limited budgets of psychiatric dispensaries, which do not cover

transportation expenses, in most cases they are not able to carry out even these one-time visits. On average, the amount spent for outpatient care per patient/ month is as low as GEL5,5 (€2,4). GEL2 (about €1) out of this amount is earmarked for medication. It is clear that such a package of services is far from being adequate. Since the supply of medicines is also insufficient, patients do not bother to attend the dispensary until they relapse. It is also clear that with such a limited budget, an outpatient clinic cannot provide adequate support services for mentally disabled people living at home. This situation is more acute in regions where people with mental disabilities living in high mountainous villages cannot reach dispensaries due to the lack of financial means for transportation. There are no resources for dispensary staff to make home visits. Hence, a great majority of the population is left without any support. Only one outpatient clinic, namely, Gotsiridze psycho-neurological dispensary in Tbilisi, has managed to obtain grants from several donors (Open Society Georgia Foundation, Global Initiative on Psychiatry, American Friends of Georgia) to provide home care service for about 70 elderly people with mental disabilities. This program includes one home visit monthly by a nurse to the elderly person, provision of medication, and a visit by a psychiatrist or therapist in case of need. A psychiatric nurse provides social work services to the patient such as facilitating communication with a lawyer and various administrative organizations and assisting the patient to receive his/her monthly pension. On the basis of observations made by the medical staff of psycho-neurological dispensaries, many people with mental disabilities are in need of home-based care. The reasons for this are: because of their condition, some patients do not leave homes; some are unable to leave home because they also have physical disabilities and/or are bed-ridden; the great majority of people do not have money for transportation. Community-based alternatives to institutionalization for people with mental disabilities are operated as demonstration projects mainly by NGOs. The majority of these services are based in Tbilisi with very few examples functioning in other parts of the country.

The Development of Community-Based Services in Georgia Set out below are some examples of community-based projects for people with mental disabilities which are being implemented in Georgia: Psychosocial Rehabilitation Centre A noteworthy example of a successful community-based mental health care project is the one implemented by GAMH - a non-governmental organization, founded in 1991 and uniting mental health professionals, users, their relatives and concerned civilians. This project has been providing community-based services since 1998 when the Psychosocial Rehabilitation Centre for people with mental health problems was established. About 40 people with mental health problems attend the centre daily and are provided with psychosocial rehabilitation based on modern methods such as the Social Independent Living Skills and Integrated Psychological Therapy. Cognitive-behavioral psychotherapy is at the stage of being studied and introduced. Art, ergo, and psychotherapy groups are functioning, as well. When working with mental health service users, the staff uses the case management method. The MoLHSA representatives were familiarised with the project activities and, beginning in 2003, the centre is co-financed by State. Although the healthcare officials are aware of, and acknowledge, the significant need for such services, they state that currently it is impossible to establish similar centres in other parts of the country, mainly due to the lack of financial resources.

However, a major success is that a psychosocial rehabilitation component was included in the State Program for Psychiatric Care. As a result, the outpatient clinics (psychoneurological dispensaries) based in 3 major regions of Georgia will receive small-scale state financing for carrying out psychosocial rehabilitation programs. At present, the functions of these dispensaries are limited to diagnosing, prescribing and providing medication. Once they receive state financing, these regional out-patient clinics will also provide rehabilitation service to people with mental health problems. The medical staff at these clinics as well as other specialists working in various state and non-governmental organizations that have a mental health mandate are trained in modern rehabilitation methods in a special training program developed by GAMH, which is based on the unique experiences of the psychosocial rehabilitation centre in Tbilisi for the last decade.

Rehabilitation and Integration of Adults with Intellectual Disabilities The Association for People in Need of Special Care (APNSC) implements a project called Rehabilitation and Integration of Adults with Intellectual Disabilities. This project began in 1990 by creating social-therapeutic working communities. Later a social therapy day center was established for 40 beneficiaries, which continues to be a model organization in this sphere. The project aims at social inclusion of people with intellectual disabilities. The beneficiaries of this project work following a well-designed schedule of art and cultural activities. APNSC periodically organizes fairs of the products made by beneficiaries and presents drama performances and concerts, with the participation of people with intellectual disabilities that are aimed at raising public awareness. A training workshop was also organized for specialists who work with people with intellectual disabilities.

Association of Psychosocial Assistance Ndoba The project, Centre for Crisis Intervention and Mental Health, implemented by the NGO Ndoba, is also noteworthy. The project provides professional, multidisciplinary psychosocial assistance to the public. The crisis center serves 800-1000 people with mental and psychosocial problems (children, adults and families) annually. The team consists of a psychiatrist, a psychologist, and a social worker who provide medical-psychological, social and legal assistance that make early identification of mental health problems, timely intervention, and prevention of suicide and other psychosocial deviations possible. The increased number of referrals (40%) proves the success of the project. 79% of consumers report a significant improvement in health and state that their problems have been solved. Some consumers are prepared to pay for these services. Since 2003, the organization has introduced a series of trainings and consultations on new approaches in mental health to the newly developing system of primary health care at family medical centers. Guidelines and an annex for the provision of mental health care for family doctors were published in the Georgian language in line with chapter V of the ICD-10.

Resource Center for Integrated and Inclusive Education A Resource Center for Integrated and Inclusive Education (IMEDI) serves pre-school-aged children with mild and moderate intellectual and physical disabilities. The Center was established with the assistance of the NGO Child and Environment and has been functioning since 2002 with the financial support of UNICEF and World Vision International. The Center is located on the premises of a kindergarten and is attended daily by 25 beneficiaries with disabilities. Children are served by a multidisciplinary team on an individual basis and are

involved in art, music and various entertainment activities together with children without disabilities. The Center prepares children for inclusive education in mainstream schools.

Parents’ Bridge In 2004, the Global Initiative on Psychiatry supported a parent’s organization, Parents’ Bridge, to establish a day center for children with intellectual disabilities on the premises of the supplementary special school in Tbilisi. Currently, the center serves 29 children. Groups of music, art, occupational and drama therapies are functioning, in addition to physical therapy. After one year of working, children who had not even seen a paintbrush before now independently produce paintings and make objects from clay. Exhibitions of children’s work and joint concerts and sporting events of children with and without disabilities are organized. At the initiative of the parents, a playground was built, on a square adjacent to a mainstream school, where children with and without disabilities play together.

Rehabilitation and Corrective Center The Rehabilitation and Corrective Center Aisi for children with intellectual disabilities serves 30 children between the ages of 3-18 with moderate intellectual and physical disabilities. Each child is assessed by a multidisciplinary team composed of psychologists, special educators, a doctor, and occupational therapists. On the basis of this assessment, an individual rehabilitation and educational program is developed for each child. The goal is to refer the children to mainstream schools. Center for Free Pedagogics The center includes a kindergarten for 10 children and St. Michael School for 86 children with various degrees of intellectual disabilities. Medical and pedagogical activities of the multidisciplinary team is based on Waldrof’s anthroposophy approach.

The First Step Foundation The First Step Foundation works with children who reside at Senaki disabled children’s institution in western Georgia. The project staff took 24 orphans with intellectual and physical disabilities from this institution and arranged sheltered housing for them by creating a familylike environment – nurses called “mothers” and “aunts” take care of children. A multidisciplinary team works on developing children’s social skills. A special school is also functioning, where individual educational programs are developed for each child. Children are also provided with medical care. Two social workers are working at the Senaki institution with the aim of re-integrating children into society by trying to reunite children with their biological families. First Step has also established two inclusive classes in mainstream schools - one in Tbilisi and another one in Zugdidi in western Georgia.

Public Awareness about People with Mental Disabilities Level of stigma and discrimination faced by people with mental disabilities There has been no survey studying the public attitude towards people with mental disabilities. However, on the basis of information gathered from various sources including governmental and non-governmental organizations, mental health service users and public officials, it can be said that in Georgian society there is a high degree of stigma and prejudice against people with mental disabilities. People with mental disabilities feel shame and fear; they avoid talking about their problems because of the fear that their friends and

relatives will stop communicating with them; those who are employed fear losing their jobs. Many people with mental health problems hide the fact that they are seeing a psychiatrist. Generally, people are afraid of marrying someone with a mental disability, or someone who has a relative with a mental disability, because they think that the disability is inheritable. The same feeling is common among family members of a person with a mental disability – they try to forget that they have such a relative, which is why it is common for relatives to initiate the institutionalization of family members with mental disabilities. Violation of the property rights of persons with mental disabilities who are placed in institutions is very common. There is a widespread assumption that these people do not need private accommodation and because they are “asocial” and “unable to look after themselves,” they should be admitted to the institution forever. The following case is typical: two brothers inherited an apartment after the death of their parents. One of them was placed in a psychiatric hospital because of a mental health problem, and in the meantime the other became the sole owner of the property. Unfortunately, there is no remedy in Georgian legislation for this type of rights violation. People with mental disabilities are labeled with terms like “mad,” “sick,” and “moron.” The majority of the general population thinks that people with mental disabilities are aggressive and avoid them. The general public lacks the knowledge that in most cases this is pure myth and that, in fact, there is no increased risk of aggression in people with mental disabilities when compared with the general population. People with mental disabilities often have low self-esteem and low self-confidence; as a result, they avoid social contacts and are consequently isolated from the rest of society. This situation is worsened by the absence of community-based psychiatry and social services in the country. The Role of the Media A free Georgian media is only just developing and is focused on other political and social issues. Mental disability issues are rarely addressed by the media, and when they are, the coverage tends to be sensational. There have been a number of television programs and newspaper articles that portrayed people with mental disabilities negatively - focus is placed on the fact of the disability and the diagnosis, regardless of whether the story was about disability. The vast majority of journalists lack knowledge about how to responsibly cover mental health and disability issues. However, progress has been made since there have been public awareness campaigns launched on or around World Mental Health Day. For the last few years, tens of articles covering the problems of people with mental disabilities were published. Poor financing of state mental health institutions and the appalling conditions in them were highlighted. Articles describing activities of the NGOs working in mental health are becoming more frequent, journalists are beginning to show interest in innovative approaches, and they report about community-based approaches. Since 1993, both the government and NGOs have started launching public awareness campaigns on mental disability issues, and these campaigns are covered by the mass media. In 1993-1995, when the country suffered an economic crisis, the main purpose of the campaign was focusing the attention of society and government to the most severe situation that existed in psychiatric institutions.

NGO Public Awareness Campaigns The World Federation for Mental Health, of which some Georgian NGOs are members, provides guidelines, recommendations and materials for operating successful public awareness campaigns. A series of trainings on how to develop a successful media campaign, carried out by The Open Society Mental Health Initiative, has contributed to the organization of well-staged campaigns annually. The topics of these campaigns have been mental health and human rights, stigma and discrimination, children and mental health problems, and mental health and employment. In the framework of these campaigns, there are various events and activities carried out such as arts and crafts exhibitions and joint concerts with users and popular artists. Representatives of the MoLHSA, MPs, people with mental disabilities, family members, NGOs and staff of mental health institutions attend meetings held by NGOs implementing pilot projects for demonstrating alternative community-based services. In the framework of these campaigns, press conferences are arranged, trainings and seminars for students and journalists are conducted and lectures on mental health and disability issues are held in schools, with interviews printed in newspapers and broadcasted on television and radio. During a television talk-show dedicated to the World Mental Health Day in 2004, people with mental disabilities talked publicly about their problems, without shame and fear for the first time. The NGO SOCO, operated by the first lady of Georgia, carried out a broad nationwide public awareness campaign in 2003 against stigma related to AIDS, Tuberculosis, mental and neurological disorders. Despite the fact that mass media coverage during these campaigns was rather extensive, it is clear that a sustained effort will be necessary to effectively raise the public awareness about these issues. Mass media intensifies its activities during special focused events such as World Mental Health Day, but the problems are quickly forgotten by society. In order to have a positive effect on the public attitude, it is important to attract public attention to these issues on a regular basis by, for example, arranging for TV and radio programs to address them, publishing articles in print media, and stressing that these issues can also affect wellknown public figures.

Glossary of Terminology Community-based services – A community-based service assists individuals to live independently in natural community settings of their choice and to prevent hospitalization, out of home placement, or placement in a more restrictive environment. Community-based services include mental health services, educational and employment services, and housing services, among others. Disability benefits (also referred to as “disability pensions”) – Financial support provided by government to individuals to help them meet the extra costs of living with a disability or longterm illness. Individuals will only receive such benefits if they can show that they fall within the definition of “disability” set out in the relevant national legislation. Guardianship - Many countries have a system of “guardianship” in which the court appoints an individual or program (the “guardian”) to exercise certain legal rights in the best interest of an individual who is found by the court to be incapacitated (the “ward”). Although the precise requirements and procedures will vary from county to country, generally it will be necessary for the court to find that the individual is substantially unable to provide for his or her physical, emotional, medical and residential needs. Intellectual disability is not, by itself, a sufficient reason for the court to rule that a person is incapacitated. A person may be deemed “incapacitated” if he or she is not able to make “informed decisions” with regard to these needs. The Court authorizes the guardian to make decisions on behalf of the ward, and by giving such rights to a guardian, these rights are taken away from the ward. Because guardianship involves such serious deprivation of liberty and dignity, the law in some countries requires that guardianship be imposed only when other less restrictive alternatives have proven to be ineffective. In some countries, a guardian's authority may be limited in some cases to those areas of decision-making for which there is evidence to indicate that a person is incapacitated. This is “partial guardianship.” Some persons deemed by the court to be incapacitated are able to make responsible decisions in some, but not all, areas of their lives. Some individuals may require a guardian who has the responsibility for both the person and the estate. The primary responsibility of the guardian with duties pertaining to the person is to provide consent for issues such as medical treatment and living situation. A guardian of the estate is responsible for managing some or all of the property and/or income of the ward. Incidence rate - The number of new cases of a disease occurring in a population per 100,000 people during a specified period (usually 1 year). Inclusive education - Inclusive education refers to a philosophy of education which recognizes the right to education for all people and addresses the educational needs of all learners in a non-threatening, supportive learning environment, including learners who were formally disadvantaged and excluded from education for various reasons. The practical implementation will vary from context to context, but inclusive education occurs in mainstream schools. The form Inclusive Education takes will depend on human resources, fiscal resources, the state of development of the educational system related to the extent to which the concept has been debated and the value attached to human dignity. Inclusive education generally operates using the following criteria: ƒ Acknowledging that all children and youth can learn and that all children and youth need support. ƒ Accepting and respecting that all learners are different in some way and have different learning needs which are equally valued and an ordinary part of our human experience. ƒ Enabling education structures, systems and learning methodologies to meet the needs of all learners.

ƒ ƒ ƒ ƒ ƒ

Acknowledging and respecting differences in learners whether due to age, gender, ethnicity, language, or disability. Changing attitudes, behavior, teaching methodologies, curricula and the environment to meet the needs of all learners. Maximizing the participation of all learners in the culture and the curricula of educational institutions and uncovering and minimizing barriers to learning. Empowering learners by developing their individual strengths and enabling them to participate critically in the process of learning. Acknowledging that learning also occurs in the home and community and within formal and informal modes and structures.

Institutionalization - Refers to the practice of segregating individuals with disabilities by placing them in long-term residential facilities, often without the individuals’ consent. In many parts of Europe such institutions are situated in remote areas, where access to them is difficult. Mainstreaming (in schools) - Mainstreaming is an educational method that includes many different kinds of learners in the same classroom instead of separating students according to their learning abilities. In a mainstreamed classroom, all children learn together in the same classroom. Mainstreaming is also commonly known as “inclusion.” Prevalence rate - The total number of people in a population who have a disease or any other attribute at a given time or during a specified period per 100,000 of that population. Sheltered workplace - An occupation-oriented facility operated by either a not-for-profit corporation or a standard corporation which, except for staff, employs only people with disabilities. There are three main types of sheltered workplaces (workshops): sheltered workshops financially supported by employment offices; sheltered workshops established by NGOs; and sheltered workshops which are part of a residential institution for people with intellectual disabilities. Social inclusion - A policy designed to make sure that all citizens are able to participate in society regardless of disability, race, culture, gender, etc. In order to achieve this, the barriers to equal access to education, employment and housing in the community must be addressed. Special segregated school - A school that provides education only to children with special needs, often in a residential environment (i.e. special boarding schools). Vocational rehabilitation - The process of supporting an individual in the choice of, or return to, a suitable vocation which includes assisting the person to obtain training for such a vocation. Vocational rehabilitation can also mean preparing an individual to cope emotionally, psychologically, and physically with changing circumstances in life, including remaining at school or returning to school or work.

Annex 1 Table 1. Population of Georgia by Age and Gender ∗ (in thousands)



Age-groups

Male

Female

Total

0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70 and over

127,8 155,3 187,7 179,8 162,6 151,7 144,7 152,0 157,7 134,1 114,6 67,0 111,2 87,4 128,1

115,8 147,0 182,4 177,4 164,9 159,4 155,9 171,5 177,7 153,5 132,8 81,9 146,7 115,0 227,9

243,6 302,3 370,1 357,2 327,5 311,1 300,6 323,5 335,4 287,6 247,4 148,9 257,9 202,4 356,0

Census of population of Georgia 2002, State Department for Statistics, Tbilisi 2004.

Annex 2 Statistical Information on Mental Disorders in Georgia 59 Table 2.1 New Cases of Mental Disorders in Georgia, 2004 (in absolute figures) Type Mental disorders - all type

Total N % 3206 100% Among these:

Male 1712

A. Psychotic disorders Psychosis and senile dementia

1216 198

38% 6%

590 97

626 101

59 0

100 1

76 11

830 124

Reactive psychosis 60

134

4%

53

81

1

6

28

87

Schizophrenia

447

14%

234

213

4

9

21

341

Epilepsy with psychosis and mental retardation

122

4%

68

54

26

11

3

61

B. Non-psychotic mental disorders Neurosis

951 249

30% 8%

523 166

428 83

56 1

45 0

102 7

643 142

83

3%

79

4

0

1

10

28

Specific symptoms and syndromes

11

0,3%

9

2

2

4

0

0

Reactive conditions

10

0,3%

6

4

0

2

1

6

Epilepsy with non-psychotic impairments

170

5,3%

94

76

29

11

21

84

Mental disorders caused by cerebrovascular diseases Other disorders caused by organic impairment of central nervous system

33

1,0%

19

14

1

4

0

21

28

0,9%

18

10

2

0

0

24

1039 365

32% 11%

599 257

440 108

297 109

100 34

66 22

505 112

Psychopathy

61

C. Mental retardation of that: mild mental retardation

* Data given in Tables 2.1 and 2.2 are the cases officially registered in psycho-neurological dispensaries

59

MoLHSA Center for Disease Control and Medical Statistics, Diagnoses are given as indicated in the source. Corresponds to F43 in ICD 10 – “Reaction to acute stress and adaptation disorder”. 61 Corresponds to “Personality disorders”. 60

Among these: Female N by age groups 1494 412 245 244 1978

Table 2.2 All Cases of Mental Disorders in Georgia, 2004 (in absolute figures) Type Mental disorders - all type

Total

Among these: Female N by age groups

N

%

Male

68993

100%

39951

29042

1537

1316

3174

52452

41% 4%

15913 1844

12271 1212

255 0

320 1

999 31

22097 1685

931 6533 1101 8570 3952 795 225 199 828 267

5 6 96 268 31 8 56 3 102 7

93 21 65 239 17 2 28 22 67 7

11 490 84 1153 185 90 27 112 54 5

1627 13310 2224 15486 6327 1952 146 342 1741 338

217 8201 2706

10 1014 391

1 757 298

1 1022 303

841 14869 5175

Among these:

62 63

A. Psychotic disorders Psychosis and senile dementia

28184 3056

Reactive psychosis 62 Schizophrenia Epilepsy with psychosis and mental retardation B. Non-psychotic mental disorders Neurosis Psychopathy 63 Specific symptoms and syndroms Reactive conditions Epilepsy with non-psychotic impairments Mental disorders caused by cerebrovascular diseases Other disorders caused by organic impairment of central nervous system C. Mental retardation of that: mild mental retardation

2266 16142 3368 20273 7678 2469 528 625 2185 569

23% 5% 29% 11% 4% 0,8% 0,9% 3,2% 0,8%

1335 9609 2267 11703 3726 1674 303 426 1357 302

1051 20536 8732

1,5% 30% 13%

834 12335 6026

Corresponds to F43 in ICD 10 – “Reaction to acute stress and adaptation disorder”. Corresponds to “Personality disorders”.

Figure 1. Incidence of Mental Disorders in Georgia in 1992-2004* (per 100.000 of population) 174,7 153,9

145,3

135,7 139,6 132,7 139,8 140,8

92,8 61,2 50,2 63,5

61,4

67,7

* Based on cases registered in psycho-neurological, neurological dispensaries and general out-patient clinics

20 0 4

20 0 3

20 0 2

19 9 8

19 9 9

25,6

19 9 7

19 9 6

19 9 3

19 9 4

19 9 5

21,0

65,5

20 0 1

44,3

120,8 106,2

65,1

20 0 0

41,8

19 9 2

200 180 160 140 120 100 80 60 40 20 0

all ages

children

Figure 2. Prevalence of Mental Disorders in Georgia in 1992-2004* (per 100.000 of population)

3000 2500

2445,8 2259,0 2200,9 2354,2 2197,6 2335,9 2120,0

2000 1500 1000

1224,8

1369,3

1533,0 1488,0

1698,3

1909,9

445,9 389,3 426,9 428,6 476,3 542,3 322,6 353,8 400,4

500

* Based on cases registered in psycho-neurological, neurological dispensaries and general out-patient clinics

all ages

04 20

03 20

02 20

01 20

00 20

8

99 19

19 9

97 19

96 19

95 19

94 19

93 19

19

92

0

children

Figure 3. New cases of Mental Disorders Registered in Psychoneurological Dispensaries in Georgia by Types of Disorder in 2000-2003 (per 100.000 of population)

80

73,3

70 60 50

41,0

39,6

39,5

38,0

40 30

21,3

20 10

11,1

19,6

18,7 9,6 10,3

8,6

10,1

27,8 23,8 21,8

19,6 10,8

8,0 10,4

0 2000

2001

2002 All type

Psychotic

2003 Non-psychotic

2004 Mental retardation

Figure 4. All cases of Mental Disorders Registered in Psycho-neurological Dispensaries in Georgia by Types of Disorder in 2000-2003 (per 100.000 of population)

1800 1600 1400 1200 1000 800 600 400 200 0

1529

1525

632

622 447 456

2000

2001 All type

645

624

613 450 447

1578

1520

1491

440 438

2002 Psychotic

445

450

2003 Non-psychotic

464 470

2004 Mental retardation

52

Annex 3 International Donor Activity in Georgia World Bank: ƒ

With the assistance of the World Bank, the Georgia Health care project was launched in 1996. Within the framework of this project, a national medical center was constructed on the grounds of one of the major clinics (Gudushauri hospital), in accordance with international standards.

ƒ

The World Bank Structural Reforms Support project allocated USD 1.52 million for reforming the state pension system, which envisaged development of the legislative basis as well as providing a logistical background for establishing a registration system for pensioners.

ƒ

USD 13.4 million was allocated by the World Bank for reform of the judicial system, which was completed in 2003.

A primary health care reform project is being implemented between 2003-2008, supported by the following three major donors: The World Bank (USD 24 million, partly loan), EU (USD 8 mil) and DFID (UK) (USD 7mil.). USAID also provides assistance for primary health care reform. The International Committee of the Red Cross (ICRC) provides assistance and expertise in the following areas: food, non-food items, medical, water and sanitation, shelter, psychological and legal counseling, orthopedic and orthotic services, TB control program in prisons and promotion of international humanitarian law. Other key partners in combating TB in Georgia include the World Bank, German Technical Cooperation (GTZ), the German Development Bank (KfW), the Royal Netherlands Tuberculosis Association (KNVC), Project Hope, the UK-based NGO MERLIN, and Médecins San Frontières-France. International organization Global Fund carries out TB, AIDS and Malaria prevention programs in Georgia for 2003-2007. UN agencies, which have provided humanitarian aid to Georgia since 1993 include UNHCR, WFP, UNICEF, UNDP, and OCHA. Among others, the UN goals incorporate support to Georgia’s population in the consolidation of country-wide peace, advancement of democracy and human rights, and poverty reduction strategies. More specifically, the UN agencies provide assistance and expertise in the following sectors: human rights, conflict resolution, relief assistance, support to social, health, human rights advocacy and education sectors, children’s issues, economic development, food security, disaster preparedness and response. After the 1996 peak, funding for humanitarian aid had been steadily decreasing annually until 2000. However, after 200 there has been somewhat of a reverse trend Which reflects the recognition by many donors that the hopeful assumptions around Georgia’s development prospects and reducing vulnerability of the late 1990s were too optimistic, and that considerable humanitarian needs had not been met. In 2003, some major donors increased their humanitarian funding, while others announced expansions of programs targeting food and vulnerable households. Other donors, notably USAID, have made a policy shift to development programs, thus significantly reducing the funding for humanitarian programs.

53

Annex 4 Reports that contain information concerning mental health care in Georgia Each of the reports below has been developed in recent years and assess the general situation in mental health care in Georgia. They reveal gaps and outline directions for improving the situation, and are useful in emphasizing the necessity to restructure the old soviet mental health care system. Summaries of the reports are presented here: Georgia Country Profile, Georgian Association for Mental Health, 2002 available at: http://www.mental-neurological-health.net The Georgia Country Profile concerns the mental health of the population, describing context and mental health needs, extrinsic and intrinsic influences on mental health in the country, and health and social services for people with mental disabilities. This report was written with the assistance of a mental health country situation appraisal instrument developed by the International Consortium on Mental Health. Available on the website www.world-mental-health.org

The report stresses that the political, social and economic changes in recent years have led to wide-scale social stress in Georgia, which has resulted in psychosocial and behavioral problems. The report discusses the National health policy document and the fact that its implementation is hampered by the lack of resources, training and low level public awareness. The report also discusses the adoption of the law on “Georgia Psychiatric Care”, and that this legislation is also ineffective due to a lack of financing and appropriate facilities. The authors found that state funding is largely insufficient to ensure adequate care as well as availability of basic vital necessities for people with mental disabilities, and that the quality of care in psychiatric hospitals and living conditions of people with mental disabilities are extremely poor. Georgia Mental Health Country Profile, 2004 (Sharashidze M., Naneishvili G., Silagadze T., Begiashvili A., Sulaberidze B., Beria Z. “Georgia Mental Health Country Profile”, International Review of Psychiatry, volume 16, 1-2, February/May 2004). Available on the website: http://www.ingentaconnect.com/content/routledg/cirp/2004/00000016/F0020001/art00011 The study explores various aspects of the Georgian mental health care system including the scope of mental health coverage in national health policy, provision of public funding, resources in the mental healthcare system, organization and provision of mental health services, relevance of the legislative framework, perceptions of mental illness in Georgian communities, and the role of families. The report concludes that although mental health is stated as one of the health priorities in Georgia’s National Health Policy document (1999), and the Strategic Health Plan for 2000-2009 envisages mental health promotion, prevention, treatment, rehabilitation and stigmatization reduction strategies, resources were not allocated for the implementation of these activities. Moreover, neither the Strategic Health Plan nor the national health policy contains a clear strategy for the shift towards communitybased care. Although publicly funded mental health services are formally accessible to all citizens, state provision of services satisfies only about 30% of the existing need with the most vulnerable populations (especially in rural areas) having poor access to necessary services. The services that exist are poorly planned, with no involvement of stakeholders and they are poorly implemented. It is suggested that many people with mental health problems 54

turn to private doctors for treatment, and an old-fashioned, discriminatory and stigmatizing attitude of the general public towards people with mental health problems prevails. International Covenant on Economic, Social and Cultural Rights (ICESCR), submitted by GAMH in 2002 The report considers the rights to mental health in Georgia, in relation to Article 12 of ICESCR and includes a general overview, information on specific concerns, a conclusion, and a list of suggested questions that the Committee on Economic, Social and Cultural Rights might ask the representatives of the Georgian Government during consideration of its second periodic report. The following conclusions were made: while mental health services are partially free of charge in Georgia, they are not equally accessible to all citizens, especially for the socially vulnerable and rural populations; while the government has adopted the law “On Psychiatry Care”, the absence of relevant regulatory documents and guidelines, as well as appropriate financing make it ineffective; the government does not have sufficient resources to implement large-scale preventive activities in mental health, and this has a negative effect on the mental health of the population. The report also states that it is important to note that the mental health reform process as declared by the Government creates a good basis for implementation of innovative projects by NGOs working in the field of mental health, including psychosocial rehabilitation of people with mental disabilities, crisis centers, users’ advocacy, training of multidisciplinary groups, and day services for people with mental health problems. There is some fear of losing the support of international donors because the Georgian Government has not yet provided financing to make these projects sustainable in the longterm.

Organization of Psychiatric Care in Georgia. Facts, Documents, Analysis George Naneishvili, Teimuraz Silagadze, Tbilisi, 2004 This brochure provides general information on state-supported psychiatric services in Georgia, provides official data on morbidity from mental disorders, describes the state program for psychiatric care 1995-2003, presents draft amendments to the law “On Psychiatric Care” and outlines the main directions for future development of mental health care in Georgia. Humanitarian Situation and Transition to Development 2006, developed by United Nations Humanitarian Affairs Team The document describes and analyses the country’s transitional context and priority areas that would require continued attention from the aid community and the Government. It also intends to assist donor agencies and other international organizations, as well as the Government, in their planning, fundraising, advocacy, and other efforts on behalf of the vulnerable populations in Georgia, spurring professional and public debate, and action on the issues discussed. Three priority areas are identified: enabling transition & effective intervention; vulnerable & beneficiary populations (individuals, households, communities); disaster preparedness & response. The report defines certain categories of the population, namely, the elderly, children and youth in special circumstances and people with disabilities as “vulnerable populations” and makes relevant recommendations for improving the situation of these groups. Children and Women in Georgia: A Situation Analysis, UNICEF, 2003 This report contains information related to the right of a child in need of special protection (CNSP), as well as statistical information on institutions for children with physical and mental disabilities, for severely mentally and physically handicapped children, for children with asocial behavior and for those people who have come into conflict with the law. Enrolment rates for primary and secondary education through grade 11 are also given. The report 55

provides a capacity gap analysis for children in need of special protection. The basic (national level) determinants of the prevalence of CNSP in Georgia are the following: Insufficient funding of state institutions; outdated and failing concepts and policies on CNSP; mechanisms for social protection and prevention of institutionalization are not in place; and gaps in legislation regulating CNSP. Nowhere to turn: Creating Guardianship possibilities for the Mentally Disabled in Georgia, 2003, Grigol Giorgadze, Judit Mandl, Marta Schaaf, Human Rights, Law and Development (unpublished) The report provides a comprehensive description of the guardianship system for disabled people and people with mental disabilities in particular. It outlines the details in Georgian and international legislation and identifies the gaps in the system and in practice.

Situation And Perspectives of Mental Health Service in Georgia, G. Naneishvili, Institute of Psychiatry, Tbilisi, Georgia 2002 (unpublished) The report provides a general description of the Georgian mental health system including its financing and the relevant legislation. Specifically, it states that: The state covers all the expenses of those 30,000 patients, who are registered in various psychiatric institutions and require qualified treatment and care. 70,000 registered patients also requiring psychiatric treatment have been left out of the State Program of Psychiatric Care. According the data, which are not exact, a minimum of 150,000 patients receive private treatment or self-treat. According to these parameters the State Program of Psychiatric Care covers the costs of only 30% of patients requiring psychiatric treatment. The report outlines the gaps and difficulties in the system and provides a description of the main directions of the mental health policy with the overall objective of creating 5 psychosocial rehabilitation centers and 9 offices of psychosocial care for people with mental health problems nationwide. Georgia Trip Report, 2000, Rachel Jenkins, Simon Surguladze, Jo Lucas, Ed Harris (report was prepared for DFID) (unpublished) The report briefly describes the general situation in mental health care in Georgia. Situation Analysis of the Conditions for the Children with Disabilities in Georgia, 2004, developed by USAID-funded Georgian Community Mobilization Initiative http://www.unicef-icdc.org/research/ESP/CountryReports2002/GEO_rep2002_ENG.pdf

The report provides a situation analysis of the general problems related to protection of children’s rights, protection of the rights of children with disabilities, the legal framework, education, medical services and disability assessment. The report also outlines the main directions of the State Policy on Protection of the Rights of Disabled Children including legislative changes, community involvement strategies, institutional changes, social security, education, health care and rehabilitation, and financial security.

56

Annex 5 Excerpt from the Georgian National Health Policy 1999 Mental Health Selection criteria: The difficult economic situation existing in the country adversely affected a very specific field of medicine, psychiatry. The chronic nature of diseases, necessity of long-tem treatment, socially dangerous behaviour of patients and the critical situation in psychiatric institutions necessitated state funding. Psychiatric care is therefore one of the health priorities.

Targets and strategy: Target: reduction of the number of suicides in the population (not more than 10.5 cases per 100,000 of population), and reduction of cases of self-injuries by 15% in the 14-17 years age group. Strategy: • Register cases of suicide and parasuicide; • Process statistical data on suicide and parasuicide cases registered in the country. Identify corresponding risk-factors and risk-groups on the basis of surveillance; • Develop state programs against suicide and parasuicide; • Provide continuous psychological and/or psychiatric care in cases of nonfatal suicides at both acute and later stages by means of patients' monitoring (setting up of sociopsychological care offices for suicide prevention services at psychoneurologic dispensaries with the Centre in Tbilisi and corresponding regional offices); • Support active and direct contact of suicidologists with psychologists, lawyers, teachers of secondary and higher schools and with public organizations and social security institutions; • Timely detect and eliminate conditions potentially causing the risk of suicide; • Early detect suicide trends among certain parts of population (risk-groups); • Solution of suicide and parasuicide diagnostic problems and the application of necessary curative and preventive measures; • Treatment of postsuicide state. To prevent repeated suicide attempts, social rehabilitation of individuals who have attempted to commit suicide; • Carry out wide psycho-hygienic activities among adolescent groups of the population simultaneously with campaigns against drug and alcohol abuse (lecture-discussions with working and study groups, parents, etc.). Target: reduction of mental disturbances in children and adolescents to 10%. Strategy: • Maintain children's and adolescents' mental health; • Strengthen children's and adolescents' mental health resistance against harmful environmental factors; • Elaborate age norms of psycho-physiological development; • Strengthen psycho-preventive activities in high-risk age groups (3,7,12-15 years age groups) for the improvement of psychological defense mechanisms and decrease of frustration level); • Provide educational groups with offices of psychological care; • Prevent deviation and delinquent behavior through psycho-preventive activities among children and adolescents with active participation of teachers and parents; 57

• • • • •

Carry out psycho-prevention of children and adolescents in global stress situation; Provide professional orientation to adolescents; Conduct psycho-physiological testing of children and adolescents in pre-school periods; Carry out mass examination of children and adolescents to detect timely mental and behavioral disturbances in order to avoid changes in personality and development of pathologies; Provide training to school doctors in the field of psychiatry and psycho-hygiene of verging conditions in children and adolescents.

Target: reduce mental disturbances among adult population to 10.7% (except psychotropic substance abuse); decreased share of individuals with serious depressive disturbances to at least 20% with personal and emotional problems; decreased share of individuals of 18 years and over by at least 20% with personal and emotional problems; decreased share of individuals with chronic, mental (long-term) disturbances to at least 30% who participate in Public Assistance Programs; Reduced share of adult population with health deterioration caused by stress situations by at least 35%. Strategy: • • • • • • • • • •

Maintain mental health in adult population; Improve registration of detected mental disturbances; Process statistical data about mental disturbances registered in Georgia, determine contingent of mental patients and its basic structures and identify corresponding riskfactors and risk-groups on the basis of epidemiological analysis; Introduce psycho-preventive and psycho-hygienic education among wide groups of the population for the timely detection and treatment of mental disturbances; Secondary prevention of mental disturbances by psychiatric services for avoiding recurrences and chronification of a disease; Activate crisis care services for adults in conditions of total social and psychological stress situations; Encourage geriatric psychiatric services; Establish material and technical basis for psychiatric services according to modern requirements; Activate psycho-rehabilitation services for patients at psychiatric institutions; Study psycho-social problems of population, identify social stress factors and detect high risk groups.

Implementation strategy: Main responsible bodies in solution of this problem are: Ministry of Health of Georgia, Department of Public Health of the Ministry of Health; Executors are: specialized health facilities, polyclinics, dispensaries, Public Health Centres, etc.; Vertical programs: “Active Detection of Morbidity and Massive Preventive screening", “Psychiatric Care", “Hygienic Normation and State Sanitary Normation for Provision of Population With Safe Environment", etc. Levels of responsibility: 58

o Ministry of Health - strategic planning and program implementation; o Ministry of Health of Georgia, Department of Public Health of the Ministry of Health - planning and program management; o Specialized health facilities, polyclinics, dispensaries. Public Health Centres and staff of these facilities - implementation of programs. Involvement and responsibility of other sectors: o When adopting the Budget, Parliament should adopt the programs for mental health with sufficient funding for implementation of these programs; o Ministry of Finance - should fully and timely fund the programs through Budget transfer in case of incomplete funding of the programs by the State Health Insurance Company (lack of 3%+l% premiums); o Ministry of Social Security must provide social integration and material assistance to persons with mental disturbances; o Ministry of Education must offer special programs for children with mental retardation. Role of non-governmental organizations is very important in psychosocial adaptation and social integration of persons with mental disturbances, especially with mental retardation. In addition, they can partly assume responsibility for emergency psychological care for the population (i.e. „Trust Service (Phone)", etc.). I.

Monitoring

Indicators: • Number of suicides per 100,000 of population; • Percentage of attempts of self-injuries among adolescents of 14-17 years age group; • Percentage of children and adolescents in total number of mental disturbances; • Percentage of mental disturbances (except psychotropic substances abuse) in adult population; • Percentage of persons of 18 years and over with health deterioration caused by stress situations; • Percentage of persons of 18 years and over with chronic psychiatric pathologies who participate in public assistance programs: • Percentage of persons with serious depressive disturbances who undergo treatment; • Percentage of persons of 18 years and over who require assistance for solution of personal and emotional problems: • Percentage of persons of 18 years and over detected with significant level of stress situations and ignoring measures for their reduction and control; • Percentage of the institutions (with 50 and more employees) participating in the implementation of the programs against occupational stress. The Centre of Medical Statistics and Information of the Ministry of Health provides collection and processing of the data required to determine the above-mentioned indicators. Delivery of the data to the Centre is provided quarterly by the institutions involved in the implementation of these priorities. Analysis of the data is carried out by the National Health Management Centre. The Ministry of Health annually publishes obtained data and corrects strategic and implementation plans in correspondence with achieved results. 59

Annex 6 The Main Directions of Psychiatry Care Development in Georgia 2002-2005 Situational Analysis The Georgian Health Care reform launched in 1995 is a complicated and gradual process. The Ministry of Health's “Georgian National Health Policy” considers the mental health care system one of the top priorities. In accordance with this plan the mental health care policy in Georgia should have proceeded in the following directions: 1. De-institutionalization of mental health services; 2. Gradual improvement of the National Mental Health Program and expansion of its scope; 3. Development of psycho-social support system for the mentally ill; 4. Psychiatric services network development and its further perfection for children and adolescents. The existing situation and the protracted economic crisis have made the implementation of the main directions set by the "Georgian National Health Policy" impossible. Consequently, the issue has been raised of designing another, more realistic plan for 2002-2005, the funding of which should have increased by 10-12 % annually. The document, entitled Principal Directions for the Development of Mental Health in 2002-2005, has been drawn up. (See the main directions in the table attached). Situational analysis of the Georgian mental health services shows that there are numerous difficulties, out of which the main are: 1. Epidemiological survey has not been conducted for the last ten years in Georgia in the field of psychiatry, which prevents us from having a comprehensive overview of the situation and analyzing the true state of mental illness spread in the country; 2. A special shelter for the people with long-term mental disorders and disabilities does not exist; the great majority of these people have to stay in psychiatric hospitals for years; 3. The social benefit system for the mentally disabled has not been developed; 4. Psychiatric services system for children and adolescents requires further advancement and structural organization; 5. Professional and retraining system for the psychiatry and mental health care system specialists requires development and improvement. The difficult current situation and protracted economic crisis made it impossible to carry out the principal strategic tasks formulated in the “National Health Care Policy” document. It became necessary to revise the Strategic Plan and define and choose those main components the implementation of which would best contribute to the furtherance of the reform and improvement of mental health services system in 2002-2005. In order to achieve this goal, we think that the following measures should be carried out in the field: 60

1. Further expansion of the State Program on Psychiatric Services (Mental Health), stage-by-stage optimization and improvement of funding, which would reduce the existing significant Program budget deficit and raise the in-patient and out-patient treatment quality for the people with mental problems (2002-2005); 2. Creation of mental health services monitoring system and conducting epidemiological studies, which will make it possible to get a true picture of mental diseases prevailing in Georgia (2002-2003); 3. Further perfection and organization of psychiatric services system for children and adolescents; 4. Creation of re-socialization system for the mentally disabled and launching its operations in main regions of Georgia (2003-2005); 5. Development of the National Strategy for Suicide prevention (2003-2004); 6. Creation of the independent panel of expert psychiatrists in Georgia, organization and improvement of the system for their training and re-training (2002-2005); 7. Establishment of psycho-social services in the capital and other main cities of Georgia and launching their operations (2002-2005).

61

The Main Directions of the Development of Psychiatric Service in Georgia 2002 – 2005 (Year 2002 has not been funded) No

1.

2.

Objective Improvement and expansion of the State Program for Psychiatric Aid

Organization and further development of the shelters of chronically ill disabled patients

Implementing agency The Ministry of Labor, Health, and Social Care, The A. Zurabashvili Society of Psychiatrists, JSC “M. Asatiani Scientific Research Institute of Psychiatry”

Activities

2002

2003

2004

2005

3 730 000

4 045 000

4 420 000

-

200 000

300 000

500 000

-

25 000

30 000

35 000

to be funded by international

25000

30 000

a. Improvement of the State Program of Psychiatric Aid b. Expansion of the Program at the expense of non-psychotic psychiatric illnesses (for disabled patients) a. Tender-based opening of the

-

special department for the The Ministry of Labor, Health, and Social Care

disabled patients in the existing psychiatric hospital on tender basis a. Preparatory works:

3.

Main directions of the resocialization service of psychiatric patients

Training for professionals Georgian Association for Mental Health

b. Introduction in 1. Rustavi; 2 Kutaisi; 3. Zugdidi; 4. Batumi

4.

Support of the Psycho-social

Georgian Association for Mental Health

a. Maintaining of the volume of

62

Rehabilitation Center in the city of Tbilisi

services available in Tbilisi

-

donors

b. Distribution of the new rehabilitation methods in the city of Tbilisi a. Repairs and equipping the

5.

6.

Organization of intensive treatment of mental patients

Main directions of the development of psychiatric aid of children and adolescents

Scientific Research Institute of Psychiatry

100 000 lari

Within the framework of National Mental Health Program

Within the framework of National Mental Health Program

Within the framework of National Mental Health Program

-

60 000 lari Within the framework of National Mental Health Program

60 000 lari Within the framework of National Mental Health Program

60 000 lari Within the framework of National Mental Health Program

-

15 000 lari

15 000 lari

15 000 lari

-

15 000 lari

15 000 lari

15 000 lari

corresponding department b. Starting the service operating

The Ministry of Labor, Health, and Social Care, The A. Zurabashvili Society of Psychiatrists, JSC “M. Asatiani Scientific Research Institute of Psychiatry”

Starting the service operating

100 000 lari

100 000 lari

a. Preparatory works, getting the

7.

8.

Creation of the Psychiatric Service Monitoring System and Conduct of Epidemiological Research

JSC “M. Asatiani Scientific Research Institute of Psychiatry” A. Zurabashvili Society of Psychiatrists

Creation of a single database of information about psychiatric patients

JSC “M. Asatiani Scientific Research Institute of Psychiatry” A. Zurabashvili Society of Psychiatrists

information delivery system started b. Getting, processing, and analysis of materials a. Creation of the information collection system b. Receiving, processing, and 63

analysis of information a. Creation and equipping of

9.

10.

11.

12.

13.

Program of Urgent Psychiatric Aid

Expanding the crisis prevention services available in the city of Tbilisi, two-channel “Ndobatelephone” Organizing the crisis prevention services room in Rustavi

Getting crisis prevention services started in Kutaisi

Getting crisis prevention services started in Batumi

The Ministry of Labor, Health, and Social Care, Tbilisi “A. Gotsiridze Psycho-neurological dispensary”

Ministry of Labor, Health and Social Care, Department of Public Health,

brigades b. Getting the work of brigades

-

15 000 lari

15 000 lari

15 000 lari

-

to be funded by international donors

to be funded by international donors

to be funded by international donors

-

to be funded by international donors

to be funded by international donors

to be funded by international donors

-

to be funded by international donors

to be funded by international donors

to be funded by international donors

to be funded by international donors

to be funded by international donors

to be funded by international donors

started

a. Preparatory works b. Expansion of service

NGO Ndoba

Ministry of Labor, Health and Social Care, Department of Public Health, NGO Ndoba Ministry of Labor, Health and Social Care, Department of Public Health, NGO Ndoba Ministry of Labor, Health and Social Care, Department of Public Health, NGO Ndoba

a. Preparatory works, logistical base, human resources training b. Getting services started a. Preparatory works, logistical base, human resources training b. Getting services started a. Preparatory works, logistical base, human resources training b. Getting services started

64

14.

15.

Getting crisis prevention services started in Zugdidi

Organizing the expert psychiatrists preparatory courses Total

Ministry of Labor, Health and Social Care, Department of Public Health, NGO Ndoba Medical Academy of Doctors Post-graduate Education JSC Scientific Investigation Institute of Psychiatry

a. Preparatory works, logistical

-

to be funded by international donors

to be funded by international donors

to be funded by international donors

-

Self-financing

Self-financing

Self-financing

0

4 000 000

4 400 000

5 000 000

base, human resources training b. Getting services started

Development of the Program. Getting work started.

65

Annex 7 Georgia’s signature and /or ratification of relevant international instruments The following international documents were ratified by the parliament of Georgia: ƒ UN General Assembly resolution "Convention on the Rights of the Child", April 21, 1994 ƒ The International Covenant on Civil and Political Rights, August 3, 1994 ƒ The International Covenant on Economic, Social and Cultural Rights, January 25, 1994 ƒ The Convention on the Elimination on All forms of Discrimination Against Women, September 22, 1994 ƒ The European Convention on Human Rights, May 12, 1999 ƒ The European Convention "Against Torture and Other Inhuman or Degrading Treatment or Punishment", September 22, 1994 ƒ The European Convention for the Prevention of Torture, May 3, 2000 ƒ The European Convention "On Human Rights and Biomedicine", September 27, 2000 ƒ The European Social Charter, 1 July, 2005

66

Annex 8 LAW OF REPUBLIC OF GEORGIA "ON PSYCHIATRIC CARE"

Adopted by the Parliament of Georgia Tbilisi, 21 March, 1995 ARTICLE 1. GENERAL PROVISIONS 1. The Law ensures medical and social help of persons suffering from mental illness, defends their rights and interests as s well as society from socially dangerous acts of people suffering form mental illness. 2. The Law defines rights and responsibilities of the personnel working at psychiatric facilities and the persons having direct contact with mentally ill. ARTICLE 2. DEFINITION OF CONCEPTS 1. "Patient"- a person, which has been diagnosed as having a mental illness and receives a psychiatric treatment. 2. "Psychiatric Institution"- the therapeutic-preventive institution, which is responsible for providing medical, social and different special help to mentally ill people. 3. "Specialist working in the field of psychiatry"- doctor, psychologist, nurse, social worker or any other person, who has undergone the special training, has a confirmed qualification, and are therefore permitted to provide the special care to mentally ill people. 4. "Decision-making capacity" - person's capacity to realize his\her condition and the main purpose of treatment, and assess its expected positive effects. 5. "Emergency situation"- a state, when a person, due to mental illness or its exacerbation, presents a danger to his/her or surrounding people's life, health and property. ARTICLE 3. MAIN RIGHTS AND SAFETY GUARANTEES OF PATIENT 1. Patient shall enjoy all the rights and freedoms ensured by the Constitution as well as all the other citizens of the Republic of Georgia, if isn't recognized incapable. Restriction of the constitutional rights caused by mental illness is defined by the 4th and 13th Articles of this Law. 2. Patient is guaranteed by: a) Human attitude, which excludes any action that outrages the persons’ dignity; b) Psychiatric care under the least restrictive conditions and with treatment methods, established by the Ministry of Health and Social Welfare of the Republic of Georgia, treatment only in accordance with the medical evidence and as close to his/her relatives' place of residence as possible; c) The information about his/her disease and treatment methods applied. d) The right to refuse the treatment offered in case of having decision-making capacity. In case the person is under 16 or lacks decision-making capacity, a parent or guardian are entitled to have this information and make decision. e) The right to receive a legal aid from a lawyer. Administration of psycho neurological clinic is prescribed to submit to the lawyer all documentation concerning the patient; ensure an appointment of the patient with the lawyer without any witnesses including personnel. Exception is an emergency situation. 67

f) The right to submit an appeal to judicial or other public bodies and have an assistance of psychiatrist when hearing a case in the court; g) The right to participate in elections, independently carry out economic activity, as well as manage his/her property, unless recognized incapable by a court decision; h) The right to get an appropriate medical care in non-psychiatric institutions; i) The right to get all kinds of social protection; j) The right to all sanatorium and resort service. 3. Patient, which has been recognized as disabled, as well as social organizations, public institutions, and educational-industrial institutions serving disabled patients are entitled to tax benefits according to applicable legislation. ARTICLE 4. PARTIAL RESTRICTION OF PATIENTS RIGHTS 1. Patient can be recognized irresponsible or incapable only on the basis of corresponding court decision as prescribed by the appropriate legislation. 2. Patient's professional capacity should be defined by labor-expertise medical commission. 3. Restriction of patient's rights solely on the basis of the psychiatric diagnosis shall be inadmissible. Any kind of restriction should be based on specific psychiatric condition and not on the general assessment of illness. ARTICLE 5. ORGANIZATION OF PSYCHIATRIC CARE 1. Psychiatric care includes: a) Ambulatory care; b) Inpatient treatment; c) Compulsory inpatient treatment. 2. The diagnosis of mental illness should be made in accordance with the International standards. A diagnose of mental illness should be made by psychiatrist, the diagnose should finally be confirmed by the commission of psychiatrists. 3. A conflict within family or at the place of work, person's disagreement with the socially accepted moral, religious, cultural and/or political convictions should not be the basis for making diagnosis of mental illness. 4. The fact that person has in the past been treated at in- or outpatient institutions should not be basis for considering the latter as mentally ill. 5. Psychiatric care to mentally ill should be provided according to his/her request. 6. Persons under 16 or those recognized incapable by the court, should be treated according to the request of the parent or guardian. 7. The doctor conducting the psychiatric examination should introduce him/herself to the person being examined and inform the latter about the purpose of examination, except the emergency cases, if these activities could exacerbate the person’s mental condition. 8. Any kind of treatment should be immediately recorded in medical documentation indicating the voluntary (confirmed by patient’s signature) or involuntary basis of the treatment. 9. Treatment by active biological methods (electro-convulsive) clinical trial or experimental method of treatment should be provided only upon his/her (parent's, guardian’s) consent. If the patient has a lack of decision-making capacity and obtaining a timely consent of the parent (guardian) by impossible by sound reasons, or this method is the only suggested way to improve a patient’s condition, it should be used under permission and supervision of the special independent body, established by the Ministry of Health and Social Welfare. 68

10. In case of chronic mental illness, the issue of patient's capability and guardianship should be decided in accordance with the applicable legislation. ARTICLE 6. PRIMARY PSYCHIATRIC EXAMINATION 1. Primary psychiatric examination refers to the first consultation provided by a psychiatrist to the person, which is not registered at psycho neurological dispensary list or has been removed from the list on the basis of recovery or stable remission. 2. Primary psychiatric examination should be carried out in order to determine whether the person is: a) Mentally ill; b) In need of psychiatric care. 3. The basis of primary psychiatric examination should be the information on person’s behavior arising suspicion for mental deviation. 4. Primary psychiatric examination should be carried out: a) On request of the person to be examined; b) In case the person to be examined needs a medical certificate about his/her health; c) On the basis of the written statement of relatives, co-workers or officials. 5. Primary psychiatric examination is provided at a persons’ consent. Persons under 16 should be examined at a parent’s or guardian’s consent. 6. In the presence of emergency situation criteria, psychiatric examination is provided without consent of the person to be examined. ARTICLE 7. INPATIENT HELP 1. Patient is placed at psychiatric hospital in case he/she can't be treated in ambulatory (outpatient) unit. 2. Hospitalized patient has a right to: a) Receive and send letters and parcels; b) Receive visitors at a special time and place; c) Meet a lawyer or his/her guardian in private. 3. For the security purposes, doctor is entitled to forbid the patient to wear his/her own cloths or use his/her personal belongings, which are enlisted in the patient’s record. 4. The patient should not be kept at the hospital any longer than it's necessary for diagnostics or treatment. ARTICLE 8. VOLUNTARY TREATMENT 1. Voluntary treatment should be provided at the regular psychiatric hospital or any other medical institution. 2. Patient is hospitalized at his/her request or consent (according to the medical reference). Persons under 16 are hospitalized at the consent of parent or guardian. 3. Consent on hospitalization and treatment should be confirmed by the signature of the patient (parent / guardian in case the patient is under 16) made in the patient’s record. 4. Voluntarily hospitalized patient should be examined within 48 hours (except holidays) by a medical commission, which will make a final decision on advisability of inpatient treatment. 5. Voluntarily hospitalized patient should be discharged on the basis of decision of the medical commission according to: a) Request of the patient; b) Request of parent / guardian the patient is under 16. 6. If voluntarily hospitalized patient refuses to continue treatment, but his/her mental illness is exacerbated and falls under the criteria of emergency treatment, the treatment 69

can be continued without patient’s consent in accordance with decision of medical commission. ARTICLE 9. EMERGENCY HOSPITALIZATION 1. Emergency hospitalization shall be provided in case the following criteria of emergency situation are present: a) The patient presents a treat to the life or health of another people; b) Patient's actions may inflict a significant material loss to him/herself or other people. c) Patient’s life or health is imposed to threat due to mental illness. 2. Consent of parent or guardian is not obligatory in case of emergency hospitalization. 3. Decision on emergency hospitalization shall be made by an ambulance or psycho neurological dispensary doctors or doctor on duty at psychiatric hospital. 4. Administrative bodies are obliged to render assistance to the medical staff in case of emergency hospitalization. 5. Within 48 hours (except holidays) after hospitalization, medical commission should examine patient's mental status and make final decision on advisability on hospitalization. 6. If medical commission arrives at the decision that hospitalization is not advisable or necessary, patient shall be immediately discharged. 7. If medical commission finds it advisable to retain the patient at the hospital against his/her will, the public prosecutor at the location of the psychiatric institution and the guardian shall be informed about said decision within 48 hours (except holidays). 8. Upon improving patient's health condition following emergency hospitalization, he/she may be discharged from the hospital in accordance with corresponding decision of medical commission. If patient's condition needs prolonged treatment, the issue shall be discussed and appropriate decision made by medical commission once in every month after admission. If duration of treatment without patient’s consent exceeds 6-month period, the public prosecutor and guardian shall be informed accordingly. Re-examination of the patient by psycho neurological dispensary after he/she is discharged from the hospital shall be carried out at least once in 6 month. ARTICLE 10. COMPULSORY TREATMENT AT PSYCHIATRIC HOSPITAL 1. Decision on compulsory treatment shall be made by court on the basis of conclusion of forensic psychiatric expertise commission. 2. Decision on terminating compulsory treatment or making changes to the course of treatment shall be made by court on the basis of conclusion of corresponding medical commission. 3. Compulsory treatment of persons, who due to diminished responsibility have committed socially dangerous act, shall be provided in hospitals of the Ministry of Health and Social Welfare in accordance with the 58th and 59th Articles of the Criminal Code of Republic of Georgia. 4. Patient subjected to compulsory treatment shall enjoy all the rights and guarantees as any other patient hospitalized against his/her will. 5. Re-examination of patient by medical commission should be carried out not later than in 6 months after hospitalization. Decision of medical commission on terminating compulsory treatment or making changes to the course of treatment shall be discussed by court. ARTICLE 11. RULES OF HOSPITALIZATION AND DISCHARGE OF PATIENT FROM PSYCHIATRIC INSTITUTIONS UNDER THE SYSTEM OF SOCIAL WELFARE 70

1. If patient has no relatives and his/her mental state does not require active psychiatric treatment, as well as if he/she does not impose threat to society and needs only preventive and rehabilitative therapy and care, he/she may be placed in specialized psychiatric institutions of the Ministry of Health and Social Welfare in accordance with decision of medical commission. 2. Patient shall be placed in above-mentioned institutions on the grounds of: a) His\her own application; b) His\her parents' or guardian's request; c) Court decision. 3. Patient shall be discharged from above-mentioned institutions on the grounds of: a) His\her own application, if he/she is able to lead an independent life according to decision of medical commission; b) His\her parent’s or guardian’s request and in accordance with the conclusion of medical commission; c) Court decision. ARTICLE 12. FORENSIC PSYCHIATRIC EXPERTISE 1. Forensic psychiatric expertise shall be provided by authorized, specially licensed medical institutions of the Ministry of Health and Social Welfare of the Republic of Georgia. 2. Carrying out forensic psychiatric expertise by medical institutions under the subordination of administrative bodies shall be inadmissible. 3. Necessary logistics and financing of forensic psychiatry expertise (escort, security, medical assisting staff, expertise commission) to be carried out in the abovementioned institutions (stipulated by Paragraph 1 of the present Article) shall be provided by corresponding administrative bodies and court. ARTICLE 13. PHYSICAL RESTRICTION OF PATIENT 1. Psychiatrist has a right to apply physical restriction of hospitalized patient in certain cases and for a definite period of time, if he/she concludes that there is no other way is to help patient or protect society from his/her dangerous activity. 2. Application of drugs or psychical restriction in order to punish or threaten the patient shall be inadmissible. 3. Physical restriction of patient shall be provided on the basis of decision of the doctor in charge of the case or hospital’s doctor on duty, which should be fixed in the patient's record. 4. Patient subjected to psychical restriction as well as his/her parent, guardian, representatives of official or public organizations may apply court on the issue of appropriateness of psychical restriction provided. ARTICLE 14. PROTECTION OF MEDICAL CONFIDENTIALITY 1. Person, who due to his/her official duties will learn that citizen is mentally ill and use this information carelessly or on purpose in detriment of the patient of someone else, shall be punished in accordance with the applicable legislation. 2. Detailed information on citizen's mental health shall be available only for medical or administrative organizations, on the basis of official inquiry. ARTICLE 15. RESPONSIBILITIES OF SPECIALIST WORKING IN PSYCHIATRY 1. A person, who deliberately hospitalizes a citizen when hospitalization is not needed, detains him/her there for certain period of time, prescribes medication or carries out other activities violating fundamental rights of patient shall be punished in accordance with applicable legislation. 71

2. Specialist working at psychiatric hospital acting in accordance with present Law shall not be responsible for any act of patient, who has been discharged from the hospital according to the requirements of present Law. ARTICLE 16. PROCEDURE FOR MAKING A COMPLAINT IN THE COURT AGAINST SPECIALIST WORKING IN THE FIELD OF PSYCHIATRY 1. Complaint against any specialist working in the field of psychiatry can be submitted in the court. 2. Complaint can be submitted by patient as well as his/her parent or guardian. ARTICLE 17. SOCIAL BENEFITS AND PROTECTION OF LABOUR OF SPECIALIST WORKING IN THE FIELD OF PSYCHIATRY 1. Specialist working at psychiatric institution is recognized to be working under dangerous conditions, therefore is entitled to the following benefits: a. Reduced working week - 30 hours; b. Prolonged holidays - 42 working days; c. Wages increased by 30% as compared to corresponding rank in other medical institution and by 50% for persons working in forensic psychiatry; d. Pension age for woman shall be defined as 50, with 20 years of working experience, including 10 years of working in the field of psychiatry. Pension age for man shall be defined as 55, with 25 years of working experience, including 12,5 years of working in the field of psychiatry. e. Neurosis is recognized as professional disease; f. Persons working in the field of psychiatry pay 50% of communal costs except for electricity. 2. If patient's aggressive action constitutes a threat for psychiatrist's personal security, the latter may refuse to treat the patient, except for the cases if the doctor is the only specialist.

72

Annex 9 Institutions for People with Mental Disabilities Psychiatric hospitals: 1. 2. 3. 4. 5. 6. 7.

Asatiani scientific research institute of psychiatry - 240 beds Zurabashvili (Gldani) Tbilisi psychiatric hospital - 120 beds Naneishvili Kutiri psychiatric hospital - 270 beds Tsalka (Bediani) psychiatric hospital - 100 beds Batumi psychiatric hospital - 90 beds Surami psychiatric hospital - 70 beds Poti psychiatric hospital - 100 beds

Beds at psycho neurological dispensaries: 1. Kutaisi psycho neurological dispensary -15 beds 2. Senaki psycho neurological dispensary -15 beds 3. Lanchxuti psycho neurological dispensary -15 beds Psycho neurological dispensaries (outpatient clinics) and departments: 1. Tbilisi psycho neurological dispensary 2. Rustavi psycho neurological dispensary 3. Signagi psycho neurological dispensary 4. Telavi psycho neurological dispensary 5. Gori psycho neurological dispensary 6. Kutaisi Skhirtladze psycho neurological dispensary 7. Samtredia psycho neurological dispensary 8. Zestaponi psycho neurological dispensary 9. Zugdidi inter-regional psycho neurological dispensary 10. Senaki psycho neurological dispensary 11. Akhaltsikhe psycho neurological dispensary 12. Ozurgeti psycho neurological dispensary 13. Lanchkhuti psycho neurological dispensary 14. Batumi regional psycho neurological dispensary 15. Abkhazia psycho neurological dispensary Outpatient departments: 16. Asatiani scientific research institute of psychiatry outpatient department 17. Zurabashvili (Gldani) Tbilisi psychiatric hospital outpatient department 18. Surami psychiatric hospital outpatient department 19. Naneishvili Kutiri psychiatric hospital outpatient department Shelters funded by Social programs: Special unit at Zurabashvili (Gldani) psychiatric hospital - 70 persons with intellectual disability and persons with mental disorders having restricted ability

73

Dzevri ∗ disabled house - 55 beneficiaries, with severe mental and physical disabilities. Institutions for children with intellectual disabilities

# II.

Name of Institution 1 III.

Age

Diagnosis

Quantity

7 – 18

Intellectual disabilities

55

2

Tbilisi supplementary non-residential school ∗ Tbilisi supplementary boarding school #205

7 – 18

Intellectual disabilities

106

3

Tbilisi supplementary boarding school #200

7 – 18

Intellectual disabilities

151

4

Kutaisi (Gumati) supplementary boarding school # 2 Akhaltsikhe supplementary boarding school # 17 Chokhatauri (Kokhnari) supplementary boarding school # 2

7 – 18

Intellectual disabilities

54

7 – 18

Intellectual disabilities

52

5 6 7

Signagi (Bodbe) supplementary boarding school Chiatura supplementary boarding school #12

8

7 – 18 7 – 18 7 – 18

Intellectual and physical disabilities Intellectual and physical disabilities Intellectual and physical disabilities

57 78 70

Children with severe intellectual and physical disabilities # 1

Name of Institution Kaspi Disabled children’s House

Age 4 - 19

Quantity 55

2

Senaki Disabled children’s House

4 – 19

95

Infants with intellectual and physical disabilities # 1 2

∗ ∗

Name of Institution Tbilisi Infants house Batumi Infants house

Age 0-3 0-3

Quantity 67 66

Imereti region. Only one such institution countrywide.

74

Annex 10

75

76

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