Download The Situation of People with Mental Health Problems Georgia_2005

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
23
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
2
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.
3
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