Recollections: The Development and Evolution of Community Mental Health Policies in China from 1998 to 2013

Approximately 16 million individuals in China are living with severe mental illnesses (1), which include six distinct disorders: schizophrenia, bipolar disorder, schizoaffective disorder, delusional disorder (paranoid psychosis), mental retardation, and epileptosis. Without appropriate treatment or management, these severe mental illnesses pose a considerable risk of self-harm and danger to others. The socio-emotional challenges associated with these disorders often emerge from difficulties in self-managing the illness and forming meaningful connections within the social sphere (2). In response, the World Health Organization (WHO) advocates for the incorporation of community-based, ongoing mental health services focusing on managing and treating individuals with severe mental illnesses within their communities. This strategy aims to provide critical support and assistance in the recovery process from these debilitating conditions.

Between the 1950s and the late 1990s, the Chinese government embarked on three significant initiatives to promote community-based mental health services. The earliest effort began in the early 1950s, culminating in the establishment of psychiatric hospitals at the grassroots level and a nationwide distribution of psychiatric beds (3). Several urban and rural areas started exploring community-based approaches to mental health services. The Cultural Revolution, however, disrupted this progress in the late 1960s. The second initiative spanned from the mid-1980s to early 1990s and made considerable strides in aligning community-based mental health services with global developmental trends (4). The momentum of this progress was curtailed by the rise of market-oriented reforms in healthcare services in the early 1990s. The third initiative surfaced in 1991, advocated by the Chinese Disabled Persons’ Federation, asserting “socialized, open, and comprehensive” efforts to prevent and rehabilitate mental disorders in some areas (5). However, owing to inadequate resources for mental health services and insufficient organizational and management structures, this initiative did not manage to formulate a nationwide policy on community mental health. Nevertheless, these three efforts, with the challenges and lessons derived from them, provided a critical foundation for the next phase of China’s community mental health policies, initiated in 1998.

The period from 1998 to 2004 signifies the genesis of China’s community-based mental health service pilot, dubbed Project 686. It was a period of revitalization for community-based mental health services in China. Foundational structures for community mental health policies were established, creating a bedrock within governmental departments, organizations, intellectual communities, and the wider society. These early initiatives laid a foundation of subsequent pilot projects in the field of community-based mental health services.

China, a developing country possessing a vast geographic reach, a large population, a rich historical background, and a diverse cultural framework, is confronted with a distinctive set of challenges in the field of mental health. These challenges not only mirror those faced by other countries globally but also include unique dynamics (6). The 1993 Chinese national epidemiological survey of mental disorders demonstrated an increasing prevalence of severe mental disorders, from 1.269% in 1982 to 1.347% (excluding neurosis) (7). This data underscores the evolving mental health landscape in China. Moreover, the article “Rapid Health Transition in China, 1990–2010: Findings from the Global Burden of Disease Study 2010” highlighted a significant trend. Over a decade, from 1990 to 2010, the proportion of disease burden ascribed to mental and behavioral disorders, as measured in disability-adjusted life years (DALYs), increased from 6.69% to 9.46% of the total disease burden (8). This exemplifies the rising importance of mental health issues within the broader health framework in China during this time period.

China’s transition from a traditional agricultural society to an industrial and now post-industrial society within a mere century, owing to its unique historical trajectory, has expedited the process of modernization. However, this swift transformation imposes two key challenges on mental health. On one hand, the profound societal changes accompanying this transition have triggered a spike in the occurrence of diverse psychological and behavioral issues. On the other hand, China's mental health services and management systems are relatively nascent, dealing with a substantial workload. Equally, the evolution of mental health institutions and the dispersion of human resources vary considerably across the country, which leads to considerable disparities in the number, distribution, and quality of mental health resources (9). Consequently, a significant portion of individuals suffering from mental illnesses struggle to access professional treatment, thereby causing worryingly low identification and treatment rates for these conditions (10). The imbalances and inadequacies apparent within the developmental environment, management system, and service infrastructure of mental health, in addition to service networks, create a substantial void relative to the extensive mental health needs of the population.

The United Nations General Assembly, in the early 1990s, ratified Resolution 46/119, establishing the “Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care.” This resolution initiated a global campaign devoted to enhancing community-based mental health care. Consonant with this international appeal for cooperative action towards community mental health service promotion, the Chinese government introduced substantial measures. In November 1999, China’s Ministry of Health (MOH) hosted the “China/WHO High-Level Seminar on Mental Health.” During this convening, the State Council’s former Vice Premier Li Lanqing, through a letter to the symposium, affirmed the government's commitment, stating, “The Chinese government is deeply committed to partnering with the global community in enduring efforts to improve public health.” Further affirmation was provided by former President Jiang Zemin in March 2001, stating, “The Chinese government has perpetually prioritized mental health advancements and is resolved to engage society in its entirety to cultivate an empowering environment for individuals with mental disorders to reintegrate into society.” This global call to uplift mental health found robust support and endorsement from the highest echelons of the Chinese government.

In October 2001, the MOH, in conjunction with three other governmental bodies, organized the Third National Mental Health Conference. Here, they presented guiding principles which emphasized “prevention as the primary focus, integration of prevention and treatment, targeted intervention, wide coverage, and lawful management.” This symbolized China’s robust dedication towards the considerable enhancement of community-based mental health services. The Chinese government positively responded to the global appeal for community mental health programs by creating a supportive societal atmosphere, further driving China’s renewed efforts in setting up comprehensive community-based mental health services. In 2000, MOH resumed the process of penning mental health legislation (11), indicating the country’s commitment to tackling mental health needs within a legal context.

In April 2002, MOH in collaboration with three additional departments, promulgated the “China Mental Health Work Plan (2002–2010).” Consequently, in September 2004, the State Council released the “Guiding Opinions on Further Strengthening Mental Health Work.” This publication introduced a framework for community mental health policies:

1) The principal objective of the service is to improve the treatment rates for severe mental disorders.

2) The scope of service encompasses the creation of patient records for individuals with severe mental disorders in community settings, implementation of follow-up service, and facilitation of rehabilitation processes.

3) The mental health service provision is organized around a network that includes psychiatric hospitals at its core, supplemented by general hospitals, primary healthcare centers, and community rehabilitation institutions for mental health. These psychiatric hospitals undertake the critical tasks of providing technical training and guidance within this service network.

4) This approach highlights a gradual transition in focus from prevention and treatment of mental disorders to community-based and grassroots-level initiatives.

In 1998, MOH expanded public health’s purview to include mental health (12). From 2000 onwards, the Department of Disease Prevention and Control (DDPC) of MOH organized a national committee comprised of eminent psychiatrists and scholars. These individuals, known for their dedication, accountability, and global perspective provided expert consultations. Following this, in June 2002, MOH sanctioned the creation of the Mental Health Center at Peking University Sixth Hospital, a central part of the China CDC. This center assumed the duties related to the prevention and control of mental disorders.

Institutions and experts held concurrent leadership positions within both the psychiatry sector and professional organizations, bearing the responsibility for societal mobilization and advocacy. By embracing multiple roles and diverse tasks, they were instrumental in driving cooperative ventures encompassing public policy, societal mobilization, and professional training within the mental health domain. From the year 2000 and extending over a decade, the DDPC orchestrated a series of professional training and health education initiatives for mental health institutions nationwide, made possible through the involvement of four prominent mental health facilities ¹. This initiative effectively established a unified consensus regarding community-based mental health services among government officials, academic experts, organization leaders, and practitioners within the field.

From 2004 to 2009, the Community Mental Health Pilot Project (also referred to as the 686 Project), transitioned from its preliminary “pilot first” phase to a more encompassing “from point to surface” policy strategy ². During these years, the 686 Project functioned as a practical platform for the implementation and refinement of policy frameworks. This iterative adjustment significantly contributed to the continual enhancement of organizational structures, service provisions, and operational procedures. As such, the policy initiatives became more practical and accessible, eventually receiving formal acknowledgment.

The implementation of the 686 Project concurrently facilitated the development of mental health professional teams and community personnel. Notably, it further established an expansive societal policy framework, thus providing a solid foundation for the ensuing progression of community mental health policies towards a more legal-oriented direction.

The Community Management and Treatment Project for Severe Psychiatric Disorders, also known as the 686 Project, was underwritten through central government transfer payments directed toward local initiatives. This support was initiated in the wake of the 2003 Severe Acute Respiratory Syndromes outbreak in China when the national government resolved to bolster public health services. In alignment with the community mental health policy framework, the DDPC proposed the aforementioned project (13). Following a successful review in 2004, the project was approved and awarded an inaugural annual budget of 6.86 million Chinese Yuan (CNY) in the first year (12).

The implementation of the 686 Project introduced the formation of integrated hospital and community multi-functional service teams. Launched in 2004, the pilot program was rolled out across 60 districts/counties, scattered among 30 provincial-level administrative divisions — 30 urban and 30 rural — encompassing a population of approximately 42.9152 million (14). By drawing from international practices, each pilot area formed integrated service teams, hospital- and community-based, in 2005 ³. These teams undertook tiered training programs to enhance their capabilities (12). Starting in 2007, support for these training initiatives was provided by international cooperation projects and aid programs (15-16). By 2011, the project had successfully trained an aggregate of 382,000 individuals through nearly 525,000 training sessions. Among the trained individuals were roughly 10,000 psychiatrists, representing about 50% of the country’s registered psychiatrists at the time. Additionally, about 34,000 community doctors received training, with a ratio of mental health staff to other participants estimated at 1∶7.25, effectively increasing the mental health service workforce. This constituted a fundamental step towards the preliminary establishment of community teams purposed for preventing and treating mental disorders (17).

The execution of the 686 Project served as a groundwork for evaluating and refining service delivery and processes. Throughout its development, various components such as patient record handling, community-based management, routine check-ins, rehabilitation guidelines, and application procedures were rigorously tested, defined, and improved. This recurrent process fostered an enhanced operational feasibility of the policy framework. To supplement this, the General Office of MOH dispensed a document in April 2006, which cataloged the project’s content and operating procedures. Concurrently, a “National Steering Group” for the project was instituted, along with the creation of the National Mental Health Project Office.

The implementation of the 686 Project significantly enhanced the unity of the national mental health service system. As the project evolved, leading teams from national mental health industry organizations progressively became engaged ⁴. Through these implementations, there was a robust consensus and alignment on the content and methodologies of community-based mental health services within both psychiatric institutions at the national level and industry associations. The 686 Project facilitated the establishment of collaborative channels amongst different tiers of mental health institutions, thereby promoting cooperation. This initiative provided a forum for provincial mental health institutions to create formal communication platforms, a marked shift from the formerly fragmented and limited communication practices. Consequently, local mental health institutions demonstrated increased enthusiasm towards project participation.

A country’s method of providing mental health services, structuring organizations, and developing service systems is inextricably connected to its social governance system and healthcare framework (18). When the 686 Project was first implemented in 2005, it adopted a three-tier administrative management structure consisting of “national-provincial-pilot/demonstration county.” It was supplemented by a four-tier technical management and service system composed of “national-provincial-pilot county/demonstration county-community.” This model mirrored previous public health initiatives implemented in China. The county functioned as the operational unit, and due to the lack of mental health institutions in numerous counties, the centers of disease prevention and control assumed the role of managing and organizing the community (19).

A national survey carried out by the DDPC in 2007 on mental health service resources revealed a concentration of prestigious mental health institutions at the prefecture/municipal and provincial levels in China (20). The implementation of the 686 Project occurred mainly at the county level, where there was often an absence of specialist mental health institutions for crucial technical support. While mental health institutions at the prefecture/municipal level had the required technical skills, they did not have the authority to supervise the implementation of the 686 Project. This mismatch led to a significant disparity between the project’s conceptual design and its actual execution, both in terms of technical capacities and governing authority.

The structure of service provision underwent a significant revision in March 2008, based on evidence-based research, explicitly implemented by MOH (21). Initial changes saw the primary administrative responsibility for the 686 Project transition from the county level to the municipal level. Further organizational alterations shifted from a three-tier administrative management structure (i.e., national-provincial-pilot county) along with a four-tier technical management and service structure (i.e., national-provincial-pilot county-community), to a more complex four-tier administrative structure (i.e., national-provincial-pilot municipal-project county) and a five-tier technical management and service structure (i.e., national-provincial-pilot municipality-project county-community) (19). Another change was the delegation of authority to pilot municipalities, allowing them to expand the number of project counties and extend the scope of the implementation. Lastly, if the budget for the 686 Project increased, the DDPC had the leeway to augment the number of pilot municipalities.

This realignment and refinement of the service provision’s organizational structure was designed to match the actual distribution of mental health service resources in China. It successfully eliminated obstacles hindering the expansion of project coverage and stimulated active participation from municipal governments and mental health institutions with superior economic and technological capabilities. Mental health institutions organized by local department of civil affairs, and private mental health cohorts became involved in the project. In regions with an absence of mental health institutions, the centers of disease prevention and control assumed the roles of community organization and management (19). This approach enhanced the feasibility and accessibility of the policy scheme and laid a systematic groundwork for the expansion of the pilot program.

In 2006, MOH established the Division of Mental Health in DDPC. Later that year, in November, the State Council approved the establishment of the Inter-Ministerial Joint Conference on Mental Health Work. Initially, this encompassed 17 ministries under the leadership of MOH. By 2007, the number of participating units further increased to 19. The primary responsibilities of the Joint Conference entail providing research-led recommendations for the advancement of mental health initiatives, orchestrating and advancing resolutions for significant issues, determining annual work priorities, and executing and supervising inspections.

In 2007, MOH published “Core Information and Key Knowledge Points for Mental Health Promotion and Education.” Subsequently, from 2008 to 2013, the DDPC conducted training on mental health policy for health managers to enhance their comprehension and command of the national mental health policies (2). This endeavor played a significant role in expediting governmental mobilization and encouraging agreement towards the execution of community-based mental health services.

The advancement and endorsement of community-based mental health services gradually gained recognition within Chinese society, incited through substantial shifts in overall societal policies. Key components of the 686 Project strategy began having a noticeable presence in national work records and plans. In 2006, MOH amongst various departments, introduced the “Management Measures for Urban Community Health Service Institutions (Trial).” This documented the steady involvement of urban community health service centers in mental health initiatives within communities. During the “Eleventh Five-Year Plan” in 2007, the Outline of the Development Plan for Health Services incorporated management and treatment for serious mental disorders for the first time. Following this in 2008, along with 16 other departments, MOH released the “Guidelines for the Development of the National Mental Health Work System (2008–2014).” This defined the crucial need for establishing a national network dedicated to the prevention and treatment of mental illnesses, including a specialized system for managing and treating severe mental disorders.

Following nearly five years of execution, the 686 Project has attained maturity with respect to its content, implementation strategies, and organizational structure. MOH has drawn from, and synthesized, the practical experience gained from the 686 Project, resulting in the formulation of two regulatory documents which were consecutively released in October 2009. These include: the “Norms for the Management and Treatment of Severe Mental Disorders” (“Work Norms”) and the “National Basic Public Health Service Norms — Norms for Management Services of Patients with Severe Mental Disorders” (“Community Service Norms”). The enactment of these departmental norms signifies the legalization of the protocols for community-based mental health services while establishing a system all national health departments must adhere to.

From 2009 to 2013, there was a transition in the regulation of community mental health from a departmental level to a legal framework. Supported by healthcare reform policies and significant financial investments, the 686 Project’s scope rapidly expanded from isolated efforts to wide-ranging implementation. With national investments in the development of mental health institutions and professional training, alongside holistic healthcare reforms, both institutions and personnel were encouraged to actively participate in community-based mental health services. The comprehensive dissemination of departmental regulations for these services was evident across the nation. The necessary groundwork was laid for legislation, which encompassed work systems, service structures, personnel management in institutions, and financial support. The content of community mental health policies was integrated into the relevant sections of the “Mental Health Law of the People’s Republic of China,” thereby achieving a transformation from policy construction to a legal framework.

In March 2009, the “Opinions on Deepening the Reform of the Medical and Health Care System” plan, commonly referred to as the New Medical Reform Policies, was sanctioned by the Chinese government. The enforcement plan for the year 2009 to 2011 had been issued, which was financially supported by the central government, facilitated the provision of basic public health services, including nine key components, to rural and urban communities nationwide. Integral to these services was the management of severe mental disorders at the community level, which encompassed the creation of patient health records, conducting home visits, and providing rehabilitation guidance.

In 2011, performance evaluation methods were enacted for basic public health services by local governments. This involved monthly reports and quarterly evaluations of progress. Moreover, supervisory inspections were conducted by the central government. The “12th Five-Year Plan for the National Basic Public Service System” was later issued by the State Council in July 2012. This policy mandated that management rates for patients with severe mental disorders in community settings should reach a target of 70% by the end of 2015.

In July 2010, MOH capitalized on the opportunities afforded by the New Medical Reform Policies, convening the “National Conference on the Management and Treatment for Severe Mental Disorders.” Their objective was to progressively transition the principles of the 686 Project into community-based management and treatment for severe mental disorders, incorporating it into local government departments’ standard operations. With the assistance and funding from the New Medical Reform Policies and the adaptable structures provided by municipalities for organizing community-based mental health services, the scope of these services widened rapidly. It expanded from the pilot regions of the 686 Project, eventually reaching nationwide coverage.

The 686 Project experienced a modest funding increase of approximately 1.3 times from 2008 to 2013, increasing from 41.49 million CNY to 93.87 million CNY. Concurrently, the project’s adoption significantly expanded across municipalities and counties. In 2008, the project was implemented in 54 municipalities and 61 project counties. By 2013, these numbers had dramatically increased to encompass 275 municipalities and 1,926 project counties (22). Moreover, with assistance from the National Basic Public Health Services Fund, certain regions without direct financial support from the 686 Project were still able to establish community patient management services. According to data provided by the DDPC, as of the end of 2012, over 3 million patients suffering from severe mental disorders had established health records within the community (22).

In September 2010, the central government approved the “Construction and Development Plan for the Mental Health Prevention and Treatment System,” which required a total investment of 15.4 billion CNY over three years, including 9.1 billion CNY from the central government. The primary objective of this initiative was to upgrade and expand 549 mental health facilities. In tandem, the central finance department allocated 149 million CNY in October of the same year to equip 608 mental health institutions with essential equipment. Starting from 2011, an annual allocation of 2.8 million CNY from the central finance was dedicated to the specialized training of mental health professionals (22). Thanks to the support of China’s Disease Prevention and Control Information System, a national information network was established. This network enabled the successful completion and activation of the first phase of the national information system for severe mental disorders by August 2011. This accomplishment allowed for nationwide connectivity and electronic management of community-based mental health services information, thus enhancing operational efficiency.

The implementation of the 686 Project in China culminated in arguably the world’s largest specialized mental health service network. By 2010, the network encompassed an impressive 400,000 various institutions, of which 1,110 were hospitals. Regular follow-up appointments were maintained for approximately two million patients, with close to 100,000 receiving complimentary treatment under the 686 Project. This international endeavor demonstrated the accessibility and equity of public health services (13,17). The inception of nationwide mental health institution building projects, coupled with professional training programs, has stimulated the zeal of mental health institutions and professionals to actively participate in community services. Furthermore, the integration of community mental health initiatives into local government’s yearly work objectives has fortified their execution abilities.

China’s mental health service model has undergone substantial evolution over the years, shifting from a primary reliance on hospital-based services to a comprehensive hospital-community approach. Instead of isolated, sector-based services, the Chinese model now delivers comprehensive and continuous treatment, management, and rehabilitation services (17). This development has led to the establishment of a preliminary, integrated mental health service system that prioritizes the management and treatment of severe mental disorders within a hospital-community framework. The aspiration to transition patients from mental health institutions to community-based treatment and management has been broadly realized. The backbone of the Chinese mental health service system, built around municipal units, has successfully linked the majority of mental health institutions with all primary healthcare institutions in a hierarchical structure (19).

The validity, adjustment, and refinement of community mental health policy schemes occurred during the implementation of the 686 Project, resulting in the formulation of departmental regulations for community-based mental health services. The widespread access to these services was bolstered by support from the New Medical Reform Policies and an influx of increased funding. A comprehensive service system, secondary to the provision of essential work regulations, personnel, and funding, facilitated the maturation of the legislative conditions pertinent to community mental health policy. On October 26, 2012, the “Mental Health Law of the People’s Republic of China” was deliberated and passed by the Standing Committee of the National People’s Congress. It came into effect on May 1, 2013. The 686 Project’s significant contribution, as well as management and treatment efforts focused on severe mental disorders, broadly informed many provisions within the “Mental Health Law.” (23)

The “policy pilot” mechanism (24) has been instrumental in the testing, refining, and validation of policy strategies. A crucial stage in public policy development involves introducing practical and implementable policy solutions. Given a developing nation with over 1.4 billion inhabitants, there is no prior model for developing a nationwide, sustainable, and operative community mental health policy and service framework. The construction of public policies generally follows a five-stage process: agenda setting, policy planning, policy formulation, policy implementation, and policy evaluation. However, during the development of China’s community mental health policy, the unique “policy pilot” mechanism endemic to China significantly contributed to the testing, adjusting, and official endorsement of policy initiatives.

This paper provides an analysis of the evolution of China’s community mental health policies from a public policy development perspective. It clarifies the transformations and shifts observed in these policies, in conjunction with the socioeconomic factors driving them. Specifically, it encompasses the unique “pilot-first, pilot-driven” trajectory of policy formulation, which is distinctly Chinese (24). The role of the 686 Project pilot in shaping policy and elucidating China’s policy construction framework is systematically discussed. This paper reveals that policy development occurs in various stages: initiating the 686 Project, pilot implementation, broadened application, and transitioning from department guidelines to legal statutes. Each phase is informed by the goal of enhancing the feasibility and accessibility of community mental health services, leading to progressive improvements. Contributing factors for each phase are distinct; for instance, international advocacy, governmental mobilization, public awareness campaigns, and professional resource preparation are pivotal during the incubation phase of the 686 Project. The creation of a policy execution framework and service network development is essential during the pilot implementation and expansion phase. As the shift from department guidelines to legal statutes occurs, promoting conditions that support the enforcement of these guidelines and strengthening the execution capabilities of organizational structures and service networks become integral to the successful legal transformation.

Insights garnered from this paper enhance both Chinese mental health policy research and the broader field of public policy research. This consequently enriches the body of knowledge that undergirds social policy theory and its application.

The evolution of mental health services globally is marked by a transition from institutional-based models to community-based methodologies. The “Mental Health Action Plan (2013–2020)” by WHO underscores the importance of government-led improvements in mental health, the development of community-oriented mental health services, and the creation of comprehensive mental health information systems. These principles align with the strategies adopted by the 686 project since its launch.

Historical trajectories, cultures, economic resources, and human capital create differences in mental health service models across countries. However, the principles of tiered mental health services, facilitated collaboration, and integration of mental health into primary healthcare have gained global acceptance as crucial tenets for nations seeking to reform or develop community-based mental health services. Many developing countries, including China, are still establishing pathways to implement these community-based mental health services. This provides China with an opportunity to consolidate, refine methodologies, and share its experiences with other developing nations (23). Despite these efforts, China’s mental health resources remain significantly lower compared to developed countries, as evidenced by the ratio of mental health beds and the density of psychiatrists per 1,000 individuals. It’s also important to note the considerable regional discrepancies in China’s mental health resources, with urban centers and economically developed regions having significantly more mental health professionals and institutions than rural and financially disadvantageous areas (25).

Several key factors have contributed significantly to the success of China’s community mental health policy development. First, Chinese health authorities capitalized astutely on the international momentum toward community mental health development that commenced in 1998. This was followed by procuring policy support from influential government leaders. Subsequently, China’s mental health sector diligently incorporated pertinent international theories and practical experiences into its policy development. Within this transformative process, China effectively mobilized a considerable contingent of non-mental health human resources to partake in community-based mental healthcare delivery. This strategic convergence of mental health and primary healthcare has proved viable despite a somewhat limited pool of mental health professionals, and has been instrumental in the establishment of a functional community-based mental health service system. The fourth key factor involved the active contribution of esteemed domestic medical institutions and academic leaders to the execution, quality control, evaluation, and research initiatives related to the 686 project. This involvement further elevated the prestige and disciplinary dominance of public mental health within clinical psychiatric institutions. Additionally, collaboration with WHO experts and public mental health specialists aided in sharing China’s achievements and experiences globally. Lastly, the project’s sustainability and broader social reach were reinforced by diverse financial means, including funding from central and local government entities, subsidies from medical institutions, corporate sponsorship, and philanthropic contributions.