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Mental Health System Reform in Brazil: Innovation and Challenges for Sustainability

  • Cinthia Lociks de AraujoEmail author
Living reference work entry

Abstract

In recent decades, Brazil has made substantial changes in its model of mental health care, through the gradual replacement of psychiatric hospitals with community-based services and new approaches to psychosocial care. These changes have been made possible by a context of political change and social mobilization; however, antagonistic forces have often threatened the progress of this reform. In order to share this experience, besides presenting the design and some results of the Brazilian psychiatric reform, historical, demographic, and political aspects will also be described in this chapter, aiming at a contextualization that favours the understanding of the advances, setbacks, and challenges of this process.

Introduction

Brazilian Mental Health Reform has been recognized for its consistency with international principles and guidelines, such as promoting the rights of people with mental disorders and replacing the asylum-based model by a decentralized network of community-based health services. In the last two decades, Brazil reduced the number of beds in psychiatric hospitals by half, implanted more than 1,000 beds of mental health in general hospitals, and increased the population coverage of Psychosocial Care Centers (CAPS) by 5 times, reaching 1 CAPS/100,000 inhabitant. In addition, Primary Health Care (PHC) is already responsible for more than half of the care for common mental disorders in the public health system (Brazil 2013), and it is possible to observe lower risk of suicide in municipalities with CAPS (Brazil 2018a). Despite these significant advances, many challenges still need to be overcome to achieve the effectiveness of current legislation and sustainability of the Brazilian psychiatric reform. In order to share the Brazilian experience of mental health reorganization, in this work we intend to synthesize some essential aspects to understand the trajectory of the Brazilian reform, as well as the main challenges for its sustainability, based on an integrative review of the literature and official sources.

Before describing the Brazilian model of psychosocial care, it is important to contextualize socioeconomic, political, geographical, and historical aspects that have influenced mental health policy in the country. Every Brazilian citizen has the constitutional right to free and comprehensive health care, through a Unified Health System (Sistema Único de Saúde – SUS). Established in the 1990s, SUS integrates all the public health services of three levels of SUS management: federal, state, and municipal. A recent survey shows that 97% of Brazilians have used SUS in the last 2 years (CFM 2018) and more than 70% of the population has used SUS for the last health care consultation (Brazil 2015a). However, almost a quarter of the Brazilian population (24%) has double coverage: besides the public health system, they have some private health insurance (Brazil 2017b). It is important to emphasize that psychiatric treatments are among the SUS’ ten most used procedures by private insurance beneficiaries. Of the total number of admissions in public psychiatric day hospital, up to 12% are for people covered by supplementary health sector (Brazil 2017b).

The implementation of an universal and comprehensive health system imposes even greater challenges in a country with continental dimensions and large inequities such as Brazil. It is estimated that in 2018 the Brazilian population will surpass 209 million inhabitants, in a territory of more than 8.5 million km2, which places the country in fifth position among the most populous and extensive countries in the world. Insofar as mental disorders are more frequent among the poorest (Patel 2001), it is important to remember that, despite the advances observed in the last decades, Brazil is still among the countries with the worst levels of inequality, presenting a Coefficient of Gini of 0.549 in 2017 (Brazil 2018b). Regarding social development, Brazil ranks 79th among 188 countries, with a Human Development Index (HDI) of 0.754 in 2015 (UN 2016), but with large variations among its states (0.667–0.839).

The complexity and frequent crises of the Brazilian political system have also influenced its mental health policy to a large extent. The Brazilian system of government – coalitional presidentialism – has been associated with serious problems of institutional stability and governance, compromising the sustainability and coherence of public policies. The Brazilian federal system, with three autonomous entities (Union, states, and municipalities) and characterized by uncooperative interfederative relations, greatly hinders the regional articulation of public policies. In addition, more than half of the 5,573 Brazilian municipalities have less than 15,000 inhabitants and low capacity for public funding and policy management.

Another aspect to be considered is the insufficiency of public health financing. In Brazil, although total sector spending is relatively high, close to that of OECD countries and other Latin American countries, public health spending is still low. In 2015, the per capita public health spending (US$ 290) was 26% lower than non-governmental spending (US$ 394), with government health spending accounting for less than 20% of its total expenditure and less of 4% of GDP (Brazil 2017d). Added to the insufficiency of public health financing are the serious challenges to improve efficiency in the use of these resources. Regarding the public financing of mental health, despite the relevance of psychiatric disorders in the burden of disease in Brazil, contributing almost 22% of DALY (disability-adjusted life year), it is estimated that federal expenditures in this area have represented about 2% of the Ministry of Health budget in 2017.

In political terms, the Mental Health Reform has also faced serious challenges. Although international guidelines have been reasonably incorporated into the National Mental Health Policy and by various sectors of society, the Brazilian reform still faces major obstacles to its consolidation and sustainability. Understanding many of these challenges requires a retrospective analysis on how mental suffering has been perceived and treated in Brazil throughout its history, evidencing disputes among various social actors in this trajectory.

Historical Background

Whereas in Europe and the United States of America humanitarian reforms were promoted in hospices back in the eighteenth century, in Brazil, up until the mid-nineteenth century, people with mental disorders were not targeted by any form of assistance. Only around 1830, in response to social pressures, the so-called “alienated” were collected to specific sectors of philanthropic hospitals (Oda and Dalgalarrondo 2004). Nearly two decades later, due to complaints about the terrible conditions of those spaces of confinement, besides the influence of international experiences in mental health care, the first psychiatric hospital was inaugurated in Rio de Janeiro. Inspired by the French model, this luxurious hospital was dubbed “Palace of the Fool.” However, in less than 4 years of operation, it was already overcrowded, sheltering not only people with mental disorders but also the poor and others excluded from society (Oda and Dalgalarrondo 2004).

Other institutions dedicated to the mentally ill were created, but the hospitalized population kept growing, in the absence of any effective treatment and due to the extreme shortage of health professionals. Until 1881 there was no discipline of psychiatry in Brazilian medical schools, and it was only until 1890 that the first nursing school in Brazil was created. Psychiatric hospitals continued to be run by religious organizations until the mid-twentieth century, when a process of secularization of these institutions took place, with doctors taking on their management, aided by the strong involvement of the private sector. However these changes did not abolished human rights violations in these hospitals.

In the early twentieth century, health care for the poor was limited to charities or to the initiative of some companies and some trade unions. In the 1930s, the Brazilian government began to assume health assistance, but it took two decades for psychiatric care to begin to be offered to workers covered by the Institutes of Retirement and Pensions, for example.

Between the 1920s and 1930s, the first initiatives of open mental health services came about in Brazil. Outpatient services gained force in the 1950s, with the arrival of the first anti-psychotic drugs to the Brazilian market. At that time, the National Mental Health Service began an attempt to replace hospitalization with ambulatory care, encouraging the expansion of these services. But this “reform” could not stand long in the face of external and internal challenges, such as the hospital-centered character of Brazilian psychiatry, the privatization logic of the State in the health sector, and strong economic interests of private psychiatric hospitals. In addition to the difficulty of competing with hospitals for public funding, outpatient clinics were also criticized for maintaining patient segregation, with high referral rates for hospitalization (Resende 2000). Thus, there was a gradual regression to the traditional model, with increasing public investments in private psychiatric hospitals and even the return of previously deinstitutionalized patients to these health services (Miranda-Sá 2007).

A characteristic of most Brazilian psychiatric hospitals is worth noting: the geographic isolation. Purportedly, it was due to the need to provide a calm environment for patients, but in practice fulfilled a “sanitary” function of social isolation of persons who would pose a threat to public order. This isolation also makes it difficult to attract health professionals, to assess clients for previous triage, and to supervision (Resende 2000), making patients even more vulnerable.

In the twentieth century, this model of psychiatric care had its rise and decline in Brazil. The progressive privatization of psychiatric hospitals was stimulated by the Brazilian State through the financing of these institutions by productivity and without adequate supervision of their practices. Consequently, in addition to the multiplication of these establishments, some of them accumulated so many residents that they became more populous than many Brazilian municipalities. A study of the situation of these hospitals between the 1950s and 1960s showed the existence of institutions with up to 15,000 beds and hospital mortality of up to 12%, that is, 6 times higher than the average observed in all hospitals (2.2%) at that period (Cerqueira 1984). Besides overcrowding, these hospitals subjected their residents to degrading living conditions and inhumane treatment, such as the indiscriminate use of electroconvulsive therapy (ECT) and over-medication for chemical restraint. In 1968, a survey of the National Directorate of Mental Health identified about 10,000 psychiatric patients in “bed-floor,” that is, in nonexistent beds (Cerqueira 1984). The situation of many of these “hospitals” is often compared to concentration camps and is widely documented in the literature as the so-called “Brazilian holocaust” (Arbex 2013; Silva 2001). It is emblematic Brazil’s first international conviction for human rights violations being the death of a patient in a psychiatric institution (Silva 2001).

In the 1970s, psychiatric care consumed more than 8% of public health expenditure (Cerqueira 1984), and up to 96% of mental health expenses were allocated for the payment of more than 80,000 beds in psychiatric hospitals (Amarante and Nunes 2018). At that time, referral rates for hospitalization were up to 36% of outpatient psychiatric visits (Cerqueira 1984). In 1972, in the context of national economic and political crisis, with increasing reporting of inefficiency, patient mistreatment, and privilege of the so-called “madness industry,” the federal government was urged by the international community to commit to change psychiatric care. It increased control over asylum institutions, reduced their participation in public spending with mental health, and diversified services in this area (Cerqueira 1984).

The Mental Health Reform in Brazil

In the second half of the 1970s, ambitious ideas of Sanitary Reform emerged in Brazil, in the context of political transition, after almost 20 years of military dictatorship. These were rooted the mid-1970s’ social movements and, far beyond sanitary reform, they advocated for real “social reform.” The so-called Sanitary Reform Movement played an important role, both in the political process of re-democratization and in the design of a new health system in Brazil (Paim 2012). Therefore, it can be said that the process of the Brazilian psychiatric reform was influenced not only by the decadence of the asylum-based model, but mainly by the internal and external political context, favorable to these changes.

It is important to emphasize the participatory and ascending character of the Brazilian psychiatric reform, which began in the late 1970s with the pivotal role of the Mental Health Workers’ Movement (Movimento dos Trabalhadores em Saúde Mental – MTSM), bringing together representatives of the Sanitary Reform Movement, associations of users and family members, trade unionists, health workers, associations of health professionals, and other sectors of society. The proposals of the Health Reform movement for the creation of a new health system based on the principles of universality, comprehensiveness, equity, regionalization, and social participation were incorporated by the Organic Law of Health (Law 8.080/90), which established the SUS, in addition to guiding the Brazilian psychiatric reform.

At the end of the 1980s, local experiences of replacing psychiatric hospitals by community psychosocial services emerged in Brazil. The movement called “for a society without asylums” was strengthened through the creation of users and family associations and the holding of Congresses of workers and National Conferences of Mental Health, outlining the guidelines of a Bill for the Mental Health Reform in Brazil (PL 3657/89). Prior to its approval by the National Congress, this project inspired subnational laws that regulated the replacement of psychiatric hospitals by community services in some Brazilian states.

In the 1990s, under the influence of the Caracas Declaration (PAHO 1990) and the resolutions of the II National Conference on Mental Health (1994), the Ministry of Health regulated the implementation of community psychosocial care services and created new norms for the supervision of psychiatric hospitals. However, in spite of this apparently pro-reform political context, the process of its Bill was delayed and troubled by a fierce dispute against an antagonistic project, supported by the Brazilian Association of Psychiatry (Associação Brasileira de Psiquiatria – ABP). This association was opposed to the closure of psychiatric hospitals and the “subordination of medical acts to multiprofessional teams and the public prosecutor’s office,” regarding the reform project as “antiphysician” and “antipsychiatric” (ABP 2006). Resistances to the Brazilian psychiatric reform Bill lead to almost 12 years delay for the completion of the Bill’s process in the National Congress and have determined significant amendments to its original version. Despite the changes from the original version, the approved law (Law No. 10216/2001) represented great advances, establishing the right of people with mental disorders to be treated preferentially in community-based services, considering hospitalization as the last therapeutic option.

In the 10-year period following the enactment of this law, there was a 50% increase in federal spending on mental health and a progressive allocation of these resources in community services (Fig. 1). While nonhospital spending quadrupled, hospital spending was reduced by nearly 40% between 2001 and 2013. The Ministry of Health promoted this change mainly through deinstitutionalization strategies and financial incentives for states and municipalities to implement community mental health services, gradually replacing the psychiatric hospitals.
Fig. 1

Non-hospital and hospital expenditures on mental health. Brazil 2001–2013. (Sources: Adapted from Gonçalves et al. 2012; Brazil 2015)

Eight months after the psychiatric reform Law came into effect, the III National Conference on Mental Health was held, a process that mobilized more than 23,000 participants among services users’ representatives, families, social movements, and health professionals – at three levels of organization: municipal, state, and federal. This social mobilization was essential for the consolidation of the psychiatric reform as a government policy and for the advancements in the process of replacing the previous care model, establishing goals, and deadlines for the deactivation of asylum beds (Brazil 2001b).

In fact, since the III Conference on Mental Health, the process of the deinstitutionalization of residents of psychiatric hospitals was accelerated via different strategies, such as the National Program for Evaluation of the Psychiatry Hospital System (Programa Nacional de Avaliação de Serviços Hospitalares/Psiquiatria, PNASH/Psychiatry), the Annual Program for Restructuring of Psychiatric Hospital Care in the SUS (Programa Annual de Reestruturação da Assistência Psiquiátrica Hospitalar no SUS, PRH), the Going Back Home Program (Programa de Volta para Casa, PVC), the creation of financial incentives for the implementation of Therapeutic Residences (Serviço de Residência Terapeutica, SRT), and Psychosocial Health Centers (Centros de Atenção Psicossocial, CAPS) (Brazil 2005).

The PNASH/Psychiatry was conceived by the Ministry of Health in 2002 as a systematic assessment process of the public and convened psychiatric hospitals, with a view to monitoring their quality and recommending the loss of accreditation of those who did not comply with SUS’ criteria and norms. This program assessed the physical structure of buildings, integration with health care network (PHC, CAPS, etc.), therapeutic processes and resources, patients’ satisfaction, as well as compliance with the general technical standards of SUS (Brazil 2005). The results of this program led to the reorganization of the mental health networks, defining priority regions for the expansion of community services, in order to replace worst psychiatric hospitals, without generating lack of assistance.

In 2003, the “Going Back Home Program” was created, instituting a rehabilitation aid for patients coming from long psychiatric hospitalizations, aiming to their inclusion in municipal social reintegration programs. More than 5,000 beneficiaries of this Program receive monthly financial assistance, around US$ 120 (R$ 412), to support their reintegration to their families and communities, thus promoting their autonomy. The municipalities participating in the PVC are responsible for monitoring their beneficiaries, as well as ensuring their connection to the health services network.

In order to promote the progressive reduction of beds in large psychiatric hospitals (more than 240 beds), the Annual Program for Restructuring of Psychiatric Hospital Assistance in the SUS (PRH) was instituted in 2004, setting up a negotiation and planning process with local health managers, aiming at the gradual replacement of psychiatric beds by community mental health services. To meet this end, the PRH recomposed the financing of psychiatric hospitals, favoring those of smaller size, with a better quality as evaluated by PNASH/Psychiatry, and meeting the goal of reduced number of beds. In addition, deactivation of these beds did not mean loss of financial resources for states and municipalities that manage those services, in that their transfer was allocated to new mental health services (Delgado and Weber 2007). Almost 2,000 beds were deactivated in large psychiatric hospitals in the first year from the onset of this Program.

Another strategy of deinstitutionalization is the Therapeutic Residency Services (SRT), which are alternative housing in urban spaces for people with a history of long psychiatric hospitalizations and who have lost their family ties. These residences should accommodate a maximum of 8 residents, with support of caregivers for re-adaptation to life in society, cohabitation management, support to domestic tasks, circulation in the city, integration in the community, and articulation with health services in the territory. Today there are about 580 SRTs funded by the Ministry of Health, with capacity to accommodate up to 4,000 residents.

CAPSs are considered strategic for the process of Mental Health Reform in Brazil due to its role of coordination of the mental health services network under a new logic of care: multiprofessional and focused on the promotion of rights, autonomy, and recovery of its users. These are community mental health services for the reception and integral daily care of people with severe and persistent mental disorders, in articulation with other health services in the territory: from primary care to hospital. Since 2002, the Ministry of Health has supported the implementation of these services by the municipalities, through financial incentives that vary according to the CAPS modality (Table 1).
Table 1

Minimum Composition of Teams and Federal Funding Conditions According to the CAPS Modality

Psychosocial care centers modalities

Population criterion (inhabitants)

Minimum team composition

Federal incentive to implement (US$)

Monthly federal incentive (US$)

CAPS I

15,000

1 mental health physician; 1 nurse; 3 other graduate health professionals; 4 mid-level health professionals

$ 5,794

$ 8,200

CAPS II

70,000

1 psychiatrist; 1 mental health nurse; 4 graduate health professionals; 6 mid-level health professionals

$ 8,691

$ 9,585

CAPS IJ (for children and youth)

70,000

1 psychiatrist, neurologist or pediatrician with training in mental health; 1 nurse; 4 other graduate health professionals, 5 mid-level health professionals

$ 8,691

$ 9,308

CAPS AD (for alcohol and other drugs)

70,000

1 psychiatrist; 1 mental health nurse; 1 general practitioner; 4 graduate health professionals; 6 mid-level professionals

$ 14,485

$ 11,524

CAPS III (24 h)

150,000

2 psychiatrists; 1 mental health nurses; 5 graduate health professionals; 8 mid-level health professionals

$ 14,484

$ 24,373

CAPS AD III (for alcohol and other drugs – 24 h)

150,000

1 psychiatry; 1 mental health nurse; 5 graduates health professionals; 4 technical nursing; 4 mid-level professionals; 1 mid-level administrative professional

$ 21,727 to $43,453

$ 30,417

CAPS AD IV 24 h

500,000

Day: 1 clinical doctor; 2 psychiatrists; 2 nurses with experience and/or training in the area of mental health; professionals of university level belonging to the professional categories of psychologist, social worker, occupational therapist, and physical educator; 6 nursing technicians; 4 mid-level professionals.

$ 36,211 to $57,937

$ 115,875

PS.: considered exchange rate (23/04/18): US$ 1,00 = R$ 3,452

Psychosocial Care Network (RAPS)

According to SUS guidelines, people with mental disorders should receive health care through an articulated network of services of different levels of complexity in pursuance of the comprehensive care of their different demands: from the simplest to the most complex. In spite of the integration of services into care networks being an organizational guideline of the Brazilian public health system established by the Federal Constitution of 1988 (Brazil 1988: article 198), local and regional articulation of SUS is still one of the major challenges to its consolidation.

After several attempts of regional articulation with limited effects, in 2010 new operational guidelines for the organization of Health Care Networks were regulated in order to overcome the “fragmentation of the care and management of the Health Regions and to improve the political and institutional performance of the SUS” (Brazil 2010). The following year, specific guidelines for the organization of the Psychosocial Care Network (RAPS) were established with the objective of “expanding, diversifying and integrating SUS services targeting people with mental disorders and needs resulting from the abuse of alcohol and other substances, and their families” (Brazil 2012). The original RAPS design was structured in seven components ranging from PHC to hospital services (Table 2).
Table 2

Psychosocial care network: Components, health services, and strategies

Components

Health services and strategies

Primary health care

Family health teams (FHS teams)

Support teams for family health (NASF)

Healthcare teams for homeless people (Consultório na Rua)

Strategic psychosocial care

Psychosocial care centers (CAPS)

Emergency care

Mobile emergency care service (SAMU 192)

Emergency care units (UPA −24 h)

Emergency hospitals

Transitory residential care

Transitory housing for people with alcohol and drug problems

Hospital care

Mental health beds in general hospitals

Deinstitutionalization strategies

Therapeutic residences (SRT)

“Coming Back home” program (PVC)

Psychosocial rehabilitation strategies

Local initiatives for job and income generation

Local initiatives to promote empowerment and advocacy for mental health users and families

Source: Brazil 2012

The emergence of the street drug crack as “social problem” in the Brazilian political and mass media scenarios has led to a significant increase in federal investment for the expansion of RAPS. Despite the low prevalence of regular crack use in Brazilian population (0.8%), the vulnerability and social exclusion of its users led to the argument, in 2011, for the formulation of an intersectoral plan named “Crack, it is possible to win” (Crack, é possível vencer), which provided expansion and qualification of healthcare to problems arising from various types of psychoactive substances (Brazil 2016b). Its implementation strategy involved the three spheres of government and several federal agencies, in three axes of intervention: Authority, Care, and Prevention.

The Ministry of Health participated in this initiative with a significant increase of federal transfers for states and municipalities allocated in mental health, in addition to an average increase of 17% for specific actions in the Crack Program (Fig. 2) such as the construction of new health facilities. This prioritization of mental health allowed the readjustment of federal incentive for CAPS, funding of mental health beds in general hospitals, and the expansion of medical residency vacancies, and other opportunities for continuing mental health education. The implementation of new drug prevention methodologies in schools and community environment was also initiated in partnership with the United Nations Office on Drugs and Crime (UNODC).
Fig. 2

Federal funding transfers to states and municipalities for Mental Health and Crack Program. Brazil 2012 to 2017 (US$ 1,0 million)

With a view to replacing psychiatric hospitals without generating neglect, the Ministry of Health has encouraged, since 2012, the increase of mental health beds in general hospitals. These hospitals are part of the CAPS referral system in case of short-term hospitalizations. Until 2017, the federal government had supported the deployment of 1,355 mental health beds, which, along with 4,600 traditional psychiatric beds in general hospitals, represent almost 3 beds/100,000 inhabitant in nonpsychiatric hospitals.

Within the scope of primary care, the implementation of a Program for street population outreach (Healthcare teams for Homeless People – Consultório na Rua, CnaR), instituted in 2011, represented a major advance in the expansion of the access to a traditionally excluded and particularly vulnerable population, due to the high prevalence of mental disorders and drug abuse problems among homeless people. This strategy is based on multiprofessional teams composed of 4–7 professionals, developing health actions in an itinerant way, oriented by harm reduction guidelines and in partnership with other RAPS’ health services where they operate. In 2017, the Ministry of Health financed 134 street health teams in eligible municipalities with more than 100,000 inhabitants and at least 80 people living in the streets.

Unfortunately, after 2015, this trend towards increased access and financing for mental health has not been maintained as an effect of a sequence of federal managers with a conservative profile and a national policy of general limitation of public spending (Fig. 2). It is important to clarify that the original composition of RAPS was designed as a goal to be reached, still far from reality, based on a proposal of substitutive model that did not include traditional mental health services, like psychiatric hospitals and traditional outpatient services, albeit they still existed in large number and with federal funding. However, its effective implementation as a network still faces many challenges such as difficulty to regional integration among municipalities, the fragility of interinstitutional relations between RAPS services, the low qualification of mental health professionals, and the persistence of a hospital-based culture both among professionals as well as some sectors of the population.

Distribution of Mental Health Services and Health Professionals in Brazil

One of the greatest challenges of the Brazilian psychiatric reform is to improve equity in the access to mental health care. More than half of the Brazilian municipalities do not meet the population criteria, established by the Ministry of Health, to receive federal funding for CAPS, counting solely on PHC and on regional or state referral services for mental health. By 2017 about 60% of Brazilian municipalities with more than 15,000 inhabitants (eligibility criteria) had at least one CAPS funded by the Federal Government.

Despite the advances in the expansion of community mental health services, huge regional inequality persists in CAPS’ population coverage, which ranges from 0.6 to 1.1/100,000 inhabitants. On the other hand, PHC coverage can be considered more equitable taken that regions with the lowest level of socioeconomic development and lower coverage of private health insurance (North and Northeast) present a PHC supply close to, or even better than, the richer regions, less dependent on SUS (Southeast and South), as shown in Table 3.
Table 3

Distribution of PHC teams and CAPS by region. Brazil 2017

Regions

Family health teams

FHS coverage %

PHC (traditional + FHS) %

NASF teams

CAPS team

CAPS coverage per 100,000

Private health insurance coverage %

Midwest

2,989

60.9

71.3

356

123

0.7

21.2

Northeast

15,777

80.4

84.2

2030

746

1.1

12.2

North

3,547

63.0

70.6

389

140

0.6

10.7

Southeast

14,155

53.3

69.3

1,414

720

0.7

35.5

South

6,108

66.0

78.8

697

367

1.0

24.9

BRAZIL

42,576

63.9

75.0

4,886

2,096

1.0

24.4

Source: Datasus/CNES, PHC Department (Brazil 2017f) and Datasus/Suplementary Health Information (Brazil 2017g)

The participation of PHC in mental health also varies considerably, with the two poorest regions of the country showing extreme results. A national survey conducted in 2013 showed that the Northern Region, which had the lowest CAPS coverage (0.49/100,000) at the time, presented the highest use of PHC for depression treatment (38%), whereas in the Northeastern Region, where CAPS coverage was almost double (0.89/100,000), the lowest proportion of PHC visits for depression was observed (20.9%) despite its high PHC coverage (73%) in the year of the survey (Brazil 2013).

Regarding the availability of health professionals, Brazil has a little more than 200 doctors/100,000 inhabitants, being well below the average of other countries with the same profile. The quantity of psychiatrists is even worse: 5/100,000 inhabitants, which represents 3 times lower than the average observed among OECD countries (Scheffer et al. 2018). The insufficient supply of psychiatrists is aggravated by their unequal distribution, with almost 78% of these physicians concentrated in the Southeast and Southern regions, varying from 1 to 12/100,000 inhabitants (Scheffer et al. 2018). The number of psychologists is much higher (89/100,000), but these professionals are also concentrated in the richest regions (Southeast and South: 71%), with even greater variations between states: from 35 to 312/100,000 inhabitants (CFP 2018).

The inequality in the distribution of mental health professionals is reproduced in the public sector so that more than 66% of SUS psychiatrists and psychologists are in the regions with the highest socioeconomic development indicators. On the other hand, the most vulnerable regions have greater number of professionals recruited by the public sector, as shown in Table 4.
Table 4

Proportion of psychiatrists and psychologists in the public health system (SUS) by region. Brazil 2017

Region

Psychiatrist

Psychologists

North

81.6

75.1

Northeast

82.5

69.9

Southeast

64.2

54.1

South

64.9

55.7

Middle-west

65.3

54.9

Brazil

67.7

58.2

Source: Datasus/National Register of Health Services (CNES)

Likewise, the composition of the CAPS is influenced by the insufficient and unequal availability of health professionals; thus, in the regions with a lower supply of psychiatrists and psychologists (North and Northeast), there is a greater participation of other professionals in these mental health teams (Table 5). Although psychologists are the most numerous professionals (31%) in CAPS (Table 5), it is PHC that employs most of these professionals in SUS, followed by other outpatient services (25%) and CAPS (18%). Psychiatrists in the public system are more often allocated to hospitals (38%), with only 28% of them working in CAPS.
Table 5

Composition of CAPS teams by region. Brazil 2017

Region

Psychologists

Nurses

Social workers

Other graduated health professionals

Psychiatrist

Other medical specialties

Total

%

%

%

%

%

%

North

266

22.8

261

22.4

240

20.6

216

18.5

51

4.4

131

11.2

1,165

Northeast

1,341

23.9

1,428

25.4

1,088

19.4

998

17.8

379

6.7

386

6.9

5,620

Southeast

3,014

35.3

1,867

21.9

1,229

14.4

1,274

14.9

593

7.0

555

6.5

8,532

South

1,037

34.0

650

21.3

500

16.4

462

15.1

220

7.2

182

6.0

3,051

Midwest

389

31.1

262

21.0

197

15.8

199

15.9

85

6.8

117

9.4

1,249

TOTAL

6,047

30.8

4,468

22.8

3,254

16.6

3,149

16.1

1,328

6.8

1,371

7.0

19,617

Source: Datasus/SCNES

The difficulty of recruiting psychiatrists can be explained not only by the reduced supply of these professionals, but also by their frequent opposition to the new model of psychosocial care (Andreoli et al. 2007), structured by multidisciplinary teams such as CAPS’. A study carried out in São Paulo, state with the highest concentration of CAPS and pioneer in its implementation, pointed out that only 13% of these facilities had doctors as managers and this position was occupied by psychologists in 51% of cases (Lima 2010). Medical category’s loss of hegemony in CAPS may explain, to some extent, its opposition to the new model and the fierce defense that many of these professionals make of psychiatric hospitals, where hierarchical relationships with other mental health professionals still remains. It seems this opposition against reform from psychiatrists is not unique to Brazil. Saraceno (apud Alves 2011) attributes to a “psychiatry global identity” this resistance to changes in defense of “corporate status quo,” as a common element in the reality of psychiatric care in the world.

The lower the availability of specialized mental health care in a territory, the greater the demand for such assistance in PHC, as well as the need for qualified professionals in this area. However, the national rate of medical specialists in Family and Community Medicine (2.64/100,000) is practically half the rate of psychiatrists and less than a quarter of these GPs are in the poorest and most disadvantaged regions: the availability of family physicians in the Southern Region (6/100,000) is four times higher than in the Northern and Northeast (1.4/100,000). As a result, most PHC teams are comprised of doctors from other specialties, often without the training expected for a generalist and case solving approach to mental health, with only 1/3 of professionals feeling prepared for mental health care, according to assessments of the Family Health Strategy (FHS) teams carried out by the Ministry of Health (Brazil 2015).

To address this gap, the Ministry of Health has stimulated the expansion of medical residency vacancies, particularly in these two specialties – Family and Community Medicine and Psychiatry – with a perspective of changing this scenario in medium to long term. Another important and promising initiative is the requirement that the Residency Programs in Family and Community Medicine contemplate areas considered strategic, such as Mental Health.

Investments in continuing education are another important strategy of the Federal Government to qualify mental health care. Over the past 6 years more than 230,000 professionals have been trained in this area, particularly professionals from the FHS (98%). The dissemination of therapeutic protocols and care guidelines in mental health by the Ministry of Health adds to the efforts to qualify these practices in the PHC. But the challenge of disseminating these materials persists: an average of only 43% of the FHS teams have them (Brazil 2015).

Results of the New Mental Health Care Model

Literature reviews are unanimous in recognizing the insufficiency of comprehensive evaluative studies on mental health care in Brazil. But despite the lack of evaluations on the Brazilian psychiatric reform, there has been a gradual increase in CAPS assessments in recent years. However, these researches are concentrated in the more developed regions, with predominance of qualitative approaches and its scope limited to services, municipalities, or specific regions (Dantas and Oda 2014; Costa et al. 2015; Lima and Schneider 2013).

A CAPS evaluation conducted in the Southern region of the country, involving 1,013 users, indicated a significant reduction in the occurrence of seizures and a lowering in psychiatric hospitalizations among those users in more intensive care and with a longer time of adherence to the treatment in CAPS, besides greater chance of reducing medication needs and increased participation in group activities (Tomasi et al. 2010). Other studies highlight an association of CAPS and/or PHC coverage with the reduction in rates of psychiatric hospitalizations (Barros and Sales 2011; Miliauskas et al. 2017).

In general terms, the best results of the CAPS evaluations refer to user satisfaction, particularly in relation to good communication and relationship with its professionals, access to information, reception of demands, promotion of self-confidence, autonomy, protagonism and co-responsibility (Silva et al. 2012; Kantorski et al. 2009; Silva et al. 2016; Surjus et al. 2011). More recently, an ecological study on factors associated with suicide, carried out by the Ministry of Health based on health data systems, pointed out that the existence of CAPS in municipalities seems to be associated with a 14% reduction in the risk of death due to this cause (Brazil 2018a).

However, the operational profile of CAPS is still heterogeneous, even within the same state. Among the most frequently observed variations in state-wide assessments are those related to work processes organization and composition of teams, insufficiency of staff and difficulty in articulation with other services (Lima 2010; Pitta et al. 2015; Breda et al. 2011). One of the Ministry of Health’s strategies to induce the qualification and homogeneity of mental health practices consists in the normalization of CAPS functioning in terms of the minimum composition of its teams (Brazil 2002) and of the actions to be carried out by them along with its registration in the health data systems (Brazil 2012). However, the fragility of monitoring and evaluation processes has jeopardized the effectiveness of this regulation.

The few evaluations of Therapeutic Residences also point to good results in terms of users’ satisfaction and consolidation of these services, but also recognize several challenges, such as the need to expand coverage, little involvement of health municipal managers, and low social permeability in relation to mental illnesses, which even hinders the implementation of these residences in some communities (Jaegger et al. 2004; Furtado 2006).

The latest National Health Survey (Pesquisa Nacional de Saúde, PNS-2013) is the most comprehensive source of information on the use of health services by people diagnosed with common mental disorders and shows advances and challenges regarding mental health care in the country. This home survey showed that the proportion of SUS users who regularly attended follow-up sessions for depression was similar to that of users of private insurance and direct payers (43%). Among those who did not attend follow-up sessions, the main reason (73%) was having overcome depression, with less than 7% referring reasons associated with barriers such as waiting time or the services operating hours. Regarding the type of treatment, the proportion of people who use medication for depression (56%) is also similar in public and private care, but the same is not true for access to psychotherapy, with more than 10% points lower in the group of SUS users (17%) than among people served by supplementary and private providers (28%). Regarding the place of the last service, 54% of the people diagnosed with depression sought the public system, with a third using PHC, which along with CAPS, accounted for the majority (70%) of the visits for depression performed by SUS (Brazil 2015a).

Mental Health in Primary Health Care

Almost two decades ago, the World Health Organization (WHO) advocated integrating mental health actions into PHC as one of the guidelines for comprehensive care (WHO 2001). This recommendation is confirmed by the WHO 2013–2020 Mental Health Action Plan, based on easier access and timely care, greater potential coverage, evidence of effectiveness and efficiency of primary mental health care, and less exposure to the stigma associated to mental illness.

In Brazil, the commitment to integrate mental health actions in PHC is expressed both in the National Primary Care Policy (Brazil 2017) and in the organizational guidelines of the Psychosocial Care Network (Brazil 2012). In recent years, the Ministry of Health has been having different implementation strategies such as stimulating specialized matrix support actions and continuing education opportunities for PHC teams, practice guidelines, and the adoption of quality standards for mental health care in the context of PHC assessments.

The PHC shows one of SUS major advancements in terms of coverage expansion through the Family Health Strategy (FHS), whose teams are present in more than 98% of Brazilian municipalities, reaching population coverage of almost 64% (Brazil 2018). Family Health teams are comprised of at least one doctor, one nurse, one nurse technician, and 4–6 Community Health Workers (Agente Comunitário de Saúde, ACS) acting on defined areas with approximately 3,450 people under each team’s responsibility. These teams work in specific health units, but also conduct home visits and actions in schools and other community services in their territory. Considering the lack of family physicians and the need to increase the resolution capability and comprehensiveness of the FHS, in 2008 Family Health Support teams (Núcleo de Apoio à Saúde da Família, NASF) were created consisting of multidisciplinary teams responsible for the technical support of up to 9 FHS teams, sharing practices and knowledge through an approach called matrix support. It is important to emphasize that psychologists represent more than 19% of NASF professionals, surpassed only by physiotherapists (26%).

Despite the accumulated evidence on the impact of the FHS on the health of Brazilian population and on the functioning of SUS, many challenges still need to be addressed. There is, for instance, a wide variation of quality among their teams and consequent iniquities of access to comprehensive health care (Macinko et al. 2017). With a view to inducing a process of continuous improvement of PHC, in 2011 the Ministry of Health created the National Program for the Improvement of Access and Quality of Primary Care (Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica, PMAQ-AB), a set of strategies for monitoring, evaluation, and certification of PHC teams. A financial incentive was bound to their performance, which is verified through three evaluative approaches: (1) implementation of self-evaluation process, (2) performance in health indicators, and (3) performance in quality standards verified through external evaluation (Pinto et al. 2014). Available data from the second cycle of PMAQ-AB evaluation included 24,055 health units, 98% of them with Family Health teams.

Most of the teams evaluated by PMAQ-AB (Brazil 2013) serve users with mental disorders (88%); however, only about a quarter of them dispense psychotropic medications and less than 30% offer some kind of mental health group assistance. There are also few FHS teams that provide care for users of alcohol and other substances (41%) or treatment for people on chronic use of benzodiazepines (49%).

The results of the external evaluation of the PMAQ-AB also show inequities in the quality of mental health care, as poorer regions generally present worse results than richer regions (south and southeast) in several dimensions: access to psychotropic drugs, availability of care protocols, and the support of mental health professionals (Brazil 2013; Mendes et al. 2014).

The low availability of psychotropic drugs in the PHC units in Brazil (24.8% of the teams) can be explained by the difficulties of the municipalities to comply with Brazilian legislation in relation to these drugs, regarding protected storage and dispense by a pharmacist. Therefore, most Brazilian municipalities (75%) opt for centralized dispensing of controlled medicines, although this alternative often represents a geographical barrier to population access to these therapeutic resources (Mendes et al. 2014). Among the teams where the dispensing of psychotropic drugs is decentralized, diazepam (89%), haloperidol (85%), fluoxetine hydrochloride (69%), and biperiden hydrochloride (68%) are the most frequently available drugs. The other ten psychotropic medications provided by SUS are available in less than 10% of PHC teams.

Another aspect evaluated by the PMAQ-AB is the support of other professionals with a view to integrating the health care network and improving the resolution capacity of PHC in addressing more complex cases. In regards to mental health, this support can be provided by both NASF and CAPS. Based on the recognition of the potential of this approach to integrate the services of RAPS, one of the goals periodically agreed by SUS managers, under the National Pact for Health, is to expand matrix support practices.

Based on the second PMAQ-AB cycle database (Brazil 2013), most of evaluated PHC teams receive matrix support (89%), varying from 68% (Northern Region) to 93% (Southeast Region). More than half of the FHS teams (54%) receive support from psychologists, which is the professional category most often involved in PHC support practices. Psychiatrists are the least cited regarding CAPS support: less than 19% of the PHC teams, reaching a maximum of 23% in the Southeast region.

The practices that characterize the matrix support in mental health resemble those of the collaborative care and consultation liaison, whose positive results have been widely demonstrated in the international literature, such as reduction of hospitalizations, promotion of patient-centered health systems, improvement of life quality and user satisfaction, better adherence to treatment, and reduced demand for specialized care (Dudley and Garner 2011; Reilly et al. 2013; Goodrich et al. 2013; Gilles et al. 2015). Despite the lack of impact assessments of matrix support practices in Brazil, some municipalities that have implemented good models of integration between PHC and CAPS have recorded promising results, both in terms of reducing hospitalizations and psychiatric emergencies, as well as in the increase of people with mental disorders attended by PHC and greater focus of CAPS in more severe cases (WHO, WONCA 2008).

The academic production focused on the evaluation of mental health in PHC is slightly higher than that dedicated to CAPS. Qualitative approaches also dominate, with insufficient comprehensive studies and lack of those studies that allow generalization of their results (Souza et al. 2012). Literature reviews have pointed out that, despite the high prevalence of mental disorders in PHC demand profile, weaknesses in the supply and quality of mental health care are still more often pointed out than the advances in this area, and a large variation of results is observed, suggesting a lack of uniformity related to practices (Souza et al. 2012; Correia et al. 2011).

Conclusion

As already widely discussed in the previous topics, there are still many challenges to the sustainability of the Brazilian Mental Health Reform, particularly regarding: increasing funding for the sector and the efficiency in the application of resources; addressing inequalities in access and quality of mental health care; integration and qualification of mental health care in PHC; consolidation of the new model of psychosocial care, surpassing practices traditionally linked to the psychiatric model; strategies to change social imaginary about madness and to fight the stigma associated with mental suffering; strengthening psychosocial rehabilitation practices and promoting the rights and protagonism of people with mental disorders; overcoming conflicts and sectarianism among progressive sectors committed to the Reform; the institution of systematic processes of monitoring and evaluation of the services and strategies of deinstitutionalization, among others (Alves 2011; Bezerra 2007; Nicacio 2011, Delgado 2013; Mateus et al. 2008).

The fragility of RAPS evaluative processes and the resistance of many researchers to a broader range of methodologies for the field of mental health assessment have made it difficult to accumulate more robust and uncontested evidence about the results of the new psychosocial care model. Such results beyond promoting advocacy, accountability and sustainability of the Brazilian reform, could provide essential subsidies for the continuous improvement of the organization of mental services and their practices. Saraceno, analyzing the challenges of the Brazilian psychiatric reform, points out the need to overcome hostility against traditional evaluative methods, considered reductionist and conservative by many mental health actors in Brazil. This author also draws attention to a paradoxical convergence between progressives and conservatives in the field of mental health, as both have the complexity of their object as an argument to reject the evaluations of their practices, creating a situation of “immunity” to the evaluation and “impunity” for the misuse of public resources (apud Alves 2011).

Within the Federal Government, the processes of monitoring the implementation of mental health policy have basically been limited to administrative aspects, through structure and process indicators, such as the estimated coverage of CAPS, implementation of other strategic actions and services in the context of RAPS, regularity in data collection by services in health information systems, and completeness of minimum health teams. The few normative evaluation initiatives, such as the “Evaluate CAPS” (2004/2005, 2006 and 2008/2009) and the National Survey of Hospital Services (PNASH-Psychiatry: 2002, 2003/2004, 2005/2006, 2007/2009, 2012/2013), have been carried out in an unsystematic manner and with limited diffusion of their findings.

Although prevention programs implemented by the National Mental Health Coordination are based on approaches widely evaluated in other countries (Unplugged, Strengthening Families and Good Behaviour Game), its implementation in Brazil has been evaluated since the first pilot projects, with a view to improving its cultural adaptation to national circumstances. However, the current administration of the Ministry of Health used some unsatisfactory results observed in the decentralization process of these programs as an argument to determine its interruption.

In order to promote CAPS quality and strengthen the role of RAPS users’ and family associations, in 2015 the Ministry of Health defined as a national goal the adaptation and implementation of a process to improve the quality of mental health services, adapted from tools developed by WHO, based on the Convention on the Rights of Persons with Disabilities (CRPD): QualityRights. However, like the prevention programs, this promising initiative seems to have been aborted.

In sum, in the last 3 years, many essential strategies to the qualification of RAPS and consolidation of the Mental Health Reform have been discontinued or slowed down because of administrative changes in the Ministry of Health. In a scenario of political and economic crisis and rise of conservative sectors, controversial changes in the policies related to mental health were approved. These changes have been repudiated by several entities, such as the National Council of Health (CNS), the National Human Rights Council (CNDH), the Anti-asylum Movement, the Attorney General’s Civil Rights Bureau (PFDC), the Federal Council of Psychology (CFP), Federal Council of Social Assistance, Brazilian Association of Collective Health (Abrasco), and the Brazilian Association of Mental Health (Abrasme). The protests denounce the disfiguring of the mental health policy and the threat of setbacks in the Reform, in that the new regulation not only strengthens the role of psychiatric hospitals, it discourages their replacement by community services, increasing the federal funding for psychiatric beds by up to 60%, jeopardizing the already insufficient funding for RAPS (Brazil 2017). Despite the commitment of the current Mental Health Coordination in the Ministry of Health for the preservation of Reform advancements, some worrying signs of reversals are already evident, such as the reduction of federal transfers in mental health to states and municipalities (Fig. 2), the slowdown in the implementation of new CAPS (Fig. 3), and hundreds of funding requests for mental health services awaiting financial availability at the Ministry of Health.
Fig. 3

Number of CAPS with federal funding. Brazil, 2008 to 2017. (Source: Brazil. SAGE 2018)

It is important to note that in the implementation of public policies, there is often a normally long latency period until its consolidation and the evidence of its impact. Despite the lack of more comprehensive and robust evaluations on the effectiveness of the Brazilian psychiatric reform, it is believed that obtaining evident results still depends, to a great extent, on the overcoming of some challenges such as the expansion of coverage and improvement of articulation and quality of RAPS’ services. Faced with insufficient federal funding for mental health, the recent expansion of the budget for psychiatric hospitals disregards the fact that insufficient and precarious functioning of RAPS – a frequently used argument against the extinction of psychiatric beds – could be addressed more efficiently by the relocation of resources, now being directed to psychiatric institutions, to the expansion and qualification of community mental health services (Kilsztajn et al. 2008).

Based on this account, it is evident that the Brazilian psychiatric reform still faces both external resistance and internal challenges, insofar as the effectiveness of the Anti-Asylum Law depends not only on the replacement of the asylum but also on cultural changes in the management of health system and service practices, so that the new Psychosocial Care Network effectively promotes the rights of its users, showing the expected results.

Höfling (2001), analyzing the evaluation of social policies, emphasizes that public policy decisions are based on issues that are more complex than the available scientific evidence about them, since such analysis depends not only on “technical” rationality and values of the public agents involved in decision making, but also on other political organizations and social actors. For this reason, social policies “take on different features in different societies,” according to prevailing values and other aspects of the sociocultural context. Likewise, benchmarking the “success” or “failure” of social policies involves multiple factors, requiring complex analysis effort.

Practices in the field of mental health are an example of these complex phenomena that “demand the construction of evidences of different orders,” including those related to consensus, social representation, and values of social actors (Campos et al. 2013). In this sense, in addition to the available research evidence, it is necessary to recognize that Brazilian mental health policy is based on a solid legal framework, widely supported by the psychiatric reform movement, international guidelines, and evidences.

In the 1980s, Cerqueira (1984) already compared the trajectory of Brazilian mental health policy to a crab movement: “From a reform to another, while we took a step forward, we often took two steps backwards.” In 2015, members of the Anti-Asylum Movement (MLA) carried out a fourth month occupation of the National Coordination of Mental Health, Alcohol and Other Drugs, in protest against a new coordinator linked to psychiatric hospitals, who was finally exonerated due to pressure from this social movement (Brazil 2015b, 2016a). This fact illustrates the importance of social participation for the sustainability of a public policy. In short, the history of mental health in Brazil is a succession of challenges, advances, and retreats, but the capacity of mobilization, idealism, and resilience of the social movement has been a guarantee of resistance against setbacks and for the consolidation of the Brazilian Mental Health Reform.

Cross-References

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© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Ministry of Health of BrazilBrasiliaBrazil

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