oT pic: The mental health system as a target of transitional justice: Mental Health reform in post-communist Albania THE ALBANIAN TRANSITION Despite continuous propaganda, the economic downturn and isolation that followed the fall of the Communist regime created survival challenges to the Albanian population. Albania was the last European country where communism collapsed. In December of 1990, the communist regime fell after 45 harsh years. The massive protests initiated by students contributed to this process. Their motto was: “We want Albania to be like the rest of Europe!” The first large-scale attempts to change the political system were made since 1989, in Shkodra. Demonstrations in January 1990 peaked on 14 January 1990 with the overthrow of the bust of Stalin. The communist party, under the leadership of the First Secretary, Ramiz Alia tried to prevent potential threats of destabilization and used these demonstrations to pressure the population. Organizers and participants of the demonstration were arrested and some of them were sent for psychiatric treatment. The first democratic elections in 1992 brought to power by a large majority the Democratic Party of Albania and establishment of the rule of law. Albania faced the transition with very low quality and professionalism of public administration. A well-functioning bureaucracy would have influenced probably in limiting the damage caused by the uncertainty of the transition.14 As Havel pointed out in his speech in 1991, ‘successful political transition may depend on the extent of the damage to society wrought by totalitarianism’. The longer-lived and more robust the totalitarian experience, the more arduous the transition. In this respect, the countries of Central Europe which experienced 40 years of communist rule may have an advantage over the nations of the Soviet Union with 70 or more years of authoritarianism. MENTAL HEALTH AND THE MENTAL HEALTH SYSTEM IN LIGHT OF THE ALBANIAN POLITICAL TRANSITION Since the collapse of the Communist regime, government services, including health care, have suffered several setbacks. During the political changes of 1991 and 1992 and the violence that accompanied it, almost a quarter of the health centers and two-thirds of village health posts were destroyed. The World Bank and OPEC Fund contributed to the restoration of the health system, especially the reconstruction of hospitals. Health care spending went through several phases in the 1990s. During the severe recession of 1990–1992, spending on health care nearly halved. From 1993 until 1996, it increased each year, and by 1996 totalled US $85.14 million (10). It then dropped to the US $70 million in 1997, and jumped to the US $108 million in 1999, amounting to about US $33 per capita.15 Privatization of the health system and development of an independent sector in the pharmaceutical industry and dentistry were the main achievements. Doctors were permitted to practice their profession privately, which during the communist regime was strictly forbidden. In 1993, the Ministry of Health produced a new policy for the health care sector in Albania, with the aim of reducing direct state involvement through decentralization. However, the mental health system remained confined to psychiatric hospitals, with no outpatient services at all due to a lack of financial and human resources. As health is a fundamental human right, every citizen should have effective access to healthcare. 14. Gentian Elezi, Establishing the rule of law after communism: a comparative approach, (Polis, 2017). 15. Besim Nuri, Health care systems in transition : Albania, (Regional Office for Europe & European Observatory on Health Care Systems, 2002). 103