Matej Vinko1, Gabriella Sutton2, Alison Maassen2
1 National Institute of Public Health of the Republic of Slovenia (NIJZ))
2 EuroHealthNet
Public mental health is a relatively well-established sub-field of public health, and its role in the pandemic is well recognised (Campion et al., 2020). The COVID-19 pandemic’s impact on mental health has already been widely documented, but the mid- and long-term consequences remain unknown (Phiri et al., 2021). Similar to the critical review of mental health research practices (Demkowicz et al., 2021), a review of public mental health measures is needed to inform future actions. It is, therefore, necessary to determine the efficacy of interventions to prevent mental disorders and to promote mental wellbeing (Gilbody et al., 2021) as well as to study the processes that lead to the creation of policies and plans aligned with public mental health needs.
This analysis provides a case study from Slovenia on the role of public health agencies, discusses the wider EU perspective, and concludes by setting out the preconditions for addressing mental health in policy and practice.
The Psychological Support Task Force: One of the key initiatives to address mental health during the pandemic in Slovenia
Slovenia, on 4 March 2020, was one of the last countries in Europe to report a COVID-19 case (WHO, 2020); it declared an epidemic a week later (Republic of Slovenia, 2020). Among a series of measures introduced to contain and mitigate the spread of the virus, the government published a decree on 20 March 2020 that halted the provision of all non-urgent and preventive health services (Uradni List, 2020). This decree brought the provision of these services to an abrupt stop, creating inter alia a gap in responding to population mental health needs.
NIJZ is the central Slovenian institution for public health practice, research, and education. It is also the coordinator of the implementation of the Slovenian national mental health programme and has an established team that performs essential public health operations related to mental health. During the first wave of the pandemic in March 2020, NIJZ acted as a coordinator and facilitator of activities addressing the mental health needs of the population (Vinko et al., 2020). Following the first wave, Slovenia adopted a renewed National Protection and Rescue Plan in the Event of an Epidemic (Ministry of Defence, 2020) in which a task force dedicated to coordinating and providing psychosocial support was envisaged.
In October 2020, as the COVID-19 state of emergency was officially declared in Slovenia, NIJZ in collaboration with the Ministry of Health established the Psychological Support Task Force (PSTF), consisting of over 30 stakeholders representing mental health service users, service providers, researchers, and national decision makers. PSTF prepared an action plan focused on reaching four main goals (NIJZ, 2020):
- ensuring that stakeholders of the PSTF work in a coordinated and integrated way;
- recognising and identifying the needs of population groups exposed to higher risk of developing mental disorders due to COVID-19;
- establishing services and activities to address the needs of vulnerable population groups; and
- establishing services and activities to address the whole population.
PSTF was active until the state of emergency officially ended on 15 June 2021.
The PSTF action plan endeavoured to protect the mental health of the population via its coordinated stakeholders
NIJZ acted as the coordinator of the implementation of the PSTF action plan. A small group of stakeholders convened within the PSTF as a coordinating group, representing NIJZ employees, employees of the Slovenian Red Cross, members of the Slovenian Psychologists' Association, and members of the Slovenian Association for Suicide Prevention. These core stakeholders met on a weekly basis to coordinate activities within the action plan, ranging from needs assessment to a psychological support helpline. Defining priorities for public mental health action was a collaborative process with NIJZ acting as the facilitator of the process. Policy briefings and guidance documents on mental health from international organisations provided overarching principles for response activities (McCartan et al., 2021).
The PSTF additionally had a larger implementing group, comprising 15 to 20 stakeholders who were responsible for identifying nationally specific needs and opportunities for action. The majority of stakeholders were NGOs and professional associations, which led the PSTF to have relatively good insight into the emerging needs of vulnerable populations (via NGOs) as well as a sound professional and scientific framework to facilitate action (via NIJZ and professional associations).
The biggest shortcoming of the PSTF was the lack of power or capacity to implement the actions as planned. Actions that relied on resources that were already in place before the pandemic were implemented effectively. That was generally not the case with actions that needed input from outside the PSTF or if additional resources (financial, workforce) were needed to implement the action.
From the process evaluation aspect, the advocacy work could therefore be identified as the least successful part of the public mental health response. In-depth assessment of the work of the PSTF is beyond the scope of this article; however, some probable barriers to success can be identified. The PSTF was an ad hoc structure - it was included in the preparedness plan during the pandemic and had never been established before, therefore there were no existing pathways to communicate or collaborate with other service providers or governmental organisations that were not actively participating in the PSTF. Even though there was a clear sense of urgency, and needed actions were well-developed and presented, influential relationships were not developed and subsequently there was no buy-in from the necessary stakeholders (Moore, 2021).
Developing the EU landscape on mental health promotion and prevention
From an EU perspective, the current health crisis has demonstrated the urgent necessity to provide accessible and equitable mental health promotion and prevention services for the general population, as well as targeted support to those most in need. EuroHealthNet, as well as other actors and stakeholders at EU level, have long argued that the pandemic response requires a more comprehensive approach to mental health policy and practice – focused on the psychosocial aspects of human functioning (EuroHealthNet, 2021). This strongly contrasts with the long-standing approach to mental health from a bio-medical perspective, with treatment and care being the primary focus.
It is worth noting how the pandemic has driven the mental health agenda forward. It has shed light on the necessity and opportunities for starting, continuing or accelerating countries’ efforts to reform their approach to mental health. Preventive and mental health-enhancing interventions across the life-course and from multi-sectoral policy perspectives were underdeveloped and under-utilised. Indeed, mental health and wellbeing should be perceived as an investment and key resource - both to substantially improve health outcomes as well as to overcome the significant economic and social costs that come with mental ill-health, which have been calculated to be up to 4.2% of GDP (OECD, 2021).
This is where EU instruments come into play, including EU processes such as the European Semester; EU funds obtained through, for instance, the Recovery and Resilience Facility, EU4Health Programme, the European Social Fund+, HorizonEurope; and cooperative EU platforms, such as the EU Health Policy Platform, joint actions and the Steering Group on Disease Prevention and Health Promotion.
At the EU level, mental health and wellbeing is being increasingly seen as a key priority, as evidenced in EU Health Commissioner Stella Kyriakides' intervention during the recent International Summit on the impact of the COVID-19 pandemic on mental health, where she urged Member States to invest in mental health to avoid a “mental health pandemic” post COVID-19 (European Commission, 2021). But mental health is not only a remit for the health sector. EU action on occupational health and safety now includes explicit attention to employment-related psychosocial health and wellbeing. Issues related to the digital world of work, child poverty, homelessness, unemployment, and educational performance will now make specific provisions for mental health.
In line with these priorities, high-level discussions on revitalising mental health services through better investments in human and financial resources have also been brought to light as a result of the vulnerabilities brought by the pandemic. In fact, during the same International Summit mentioned above, WHO Regional Director for Europe, Dr Hans Kluge stated that mental health and wellbeing should be seen as fundamental human rights, further noting that “improving public mental health services is a win-win for everyone” (WHO Regional Office for Europe, 2021).
Conclusions
Inclusion of public mental health considerations in preparedness plans is a necessity, especially when an emergency unfolds on a scale similar to that of the COVID-19 pandemic. Moreover, defining accountabilities for a public mental health response is crucial, particularly in sectors where health is not the primary field of action, such as in education, social protection, public administration etc. Increasing awareness of the potential and role of mental health promotion and prevention in such sectors is imperative for a successful public health response.
In addition, capacities to implement public health activities need to be developed for stakeholders to fulfil their potential. We have not yet reached a shared understanding on the importance of mental health and on the ways in which mental health is nurtured and issues in mental health prevented across different sectors. This is a necessary condition to implement a whole-of-society approach in public mental health. In order to reach such a goal, public mental health needs to be mainstreamed within the public health profession as well as in public health institutes.
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