Introduction

This paper presents the context and history of psychiatric reform in Brazil (PRB). PRB included the reduction of psychiatric hospitals and development of community services in public agenda in the midst of a struggle for redemocratization and support of human and social rights in the 1980’s decade. One of the main decisions made by the authoritarian regime (1964-1985) was to expand psychiatric care in private hospitals. From the 1990’s decade onward and influenced by the Caracas Declaration, PRB public policy has been targeted at changing this care model, while relying on crucial support provided by municipal governments. The fundamental milestone of psychiatric reform in Brazil is Federal Act 10.216/2001, which defines people with mental disorders as a vulnerable part of society and establishes legal conditions for strengthening the mental health community network. The main advances and challenges of PRB are highlighted in this paper.

Brazil’s Healthcare System

Brazil is a Federative Republic consisting of 26 states, a Federal District and 5,564 municipalities. The public healthcare sector, which is called Unified Health System (SUS), provides universal access and was established by the 1988 Federal Constitution. Three levels of government within the Federation share Financial and management responsibility: the Federal, State and Municipal governments. In the 1990’s decade municipal governments were given an extremely prominent role in healthcare through decentralization¹.

Brazil's healthcare system is peculiar in that two subsystems coexist: a public subsystem providing universal access and comprehensive care and a significant private system. In March 2012 there were 47.866.941 private healthcare plan beneficiaries, which totaled 25% of Brazil’s population².

Paradoxically, the Brazilian government has also been favoring the development of the private health insurance  sector through fiscal incentives. Families and companies may deduct medical care expenditures from their taxable income³.

Formation of Psychiatric Reform

Until the late 1950’s decade psychiatric care in Brazil was organized into large, overcrowded public psychiatric asylums, with terrible infrastructure and patients subjected to abuse. In the 1960’s and 1970’s decade the massification of coverage promoted by the authoritarian regime favored beds being contracted in private hospitals by the public sector; therefore the number of such beds quickly increased⁴.

Despite a few reorganization attempts throughout the decade and the development of pioneering deinstitutionalization experiences, the end of the 1980’s decade comes with a standard of care grounded in large-scale psychiatric hospital admissions. There were approximately 85,000 beds in 313 psychiatric hospitals, with an average hospitalization period of over 100 days. This consisted of inadequate and expensive care (representing the third largest spending on hospital admissions in Brazil)⁵. Hospital bed provision totaled 56 for every 100,000 inhabitants⁶.

In 1990, when redemocratization was already established in the country, Brazil adopted a mental health policy based on the Caracas Declaration, produced at the Regional Conference to Restructure Psychiatric Care in Latin America, convened by the Pan American Health Organization (PAHO), which took place in Caracas⁷. Among other guidelines, the Declaration advocates community-based, comprehensive and continuous care, integrated with primary healthcare and that does not resort to psychiatric hospitals.

In the period from 1991-1992 the Federal Government used normative acts to define the conditions for developing a mental health community network throughout the country. The implementation of centers for psychosocial care (CAPS) was actively encouraged by fund transfers from the central government to States and, above all, to municipalities, which manage new PRB facilities directly.

Another crucial factor in psychiatric care model reform was Congressman Paulo Delgado’s bill that proposed, in 1989, progressively extinguishing madhouses in Brazil, as well as providing protection and rights to people with mental disorders. After a long processing time, it was enacted into Federal Act 10.216 in April 2001⁸. This Act regulates psychiatric care in Brazil. It defines preferential treatment in community-based services and psychiatric hospitals as a last resort.

This nationwide act has had remarkable effects on the pattern of Ministry of Health allocation of funds to mental health and on Brazilian municipality adherence to the reform. In 2011 spending on new community services reached 71% of Ministry of Health (MS) expenditures⁹. It is worth noting that this change in priority in terms of allocation occurred within a context of stabilizing MS mental health expenditures, which corresponded on average to 2.5% of the MS budget from 2002 to 2011¹⁰.

The Community Care Network

The core of the mental healthcare deinstitutionalization strategy in Brazil lies in implementing CAPS. The CAPS organization model emerged and became a legitimate alternative in Brazil’s psychiatric reform when the European experienced became widely known, especially that of Italy.

This organization was conceived to replace psychiatric hospital admissions. The target population of CAPS is that with disorders whose severity would justify intensive care. CAPS should operate within an established area, aiming at integration with other health units and admitting users within an intersectoral perspective¹¹.

CAPS are organized into CAPS I, CAPS II and CAPS III, according to the complexity of services and size of the population. CAPS I would have the capacity to provide services in municipalities with over 20,000 people; CAPS II would provide services to municipalities with over 70,000 people. CAPS III and CAPS III AD (alcohol and drugs) would have the capacity to provide services to municipalities with over 200,000 inhabitants. The difference in relation to the others would be the provision of continuous, 24-hour care, including holidays and weekends and also having beds that are integrated with night admission services. In addition to those three categories, there are territorial services of specific clients in the area of alcohol and drugs (CAPS AD) in municipalities with over 70,000 and for children and teenagers (CAPS i) in municipalities with over 150,000 people ¹².

In December 2011 there were 1,742 CAPS, mainly types I and II.This year there were only 63 CAPS III open 24-hours with beds for overnight admissions, 272 for patients who abuse alcohol and other drugs and 149 targeting children and teenagers¹⁰. The role of CAPS is to provide support and supervise the primary healthcare network. However, this integration is relatively recent and still ineffective in large metropolitan regions.

Reduction in Hospital Care

As a result of CAPS’ implementation and of greater effectiveness of regulation over SUS-regulated hospital quality, 85,000 psychiatric hospital beds in the late 1980’s were reduced to 32,284 beds in March 2012.Psychiatric beds in general hospitals accredited by the SUS represented only 11% of all hospitals in that same year(10). The rate of psychiatric beds for every 100 thousand inhabitants was 19/100,000, showing the unequivocal success of the psychiatric care de-hospitalization process in Brazil, and placing it on the same level of systems with consolidated reductions in the number of beds in psychiatric hospitals, such as England (23 for every 100,000 inhabitants)¹³. However, with respect to provision of psychiatric beds in general hospitals, international comparisons do not favor Brazil. Italy, whose care model is a reference for Brazil, fully converted its public psychiatric beds to general hospitals¹³.

Considering the low implementation rate of type-III centers for psychosocial care, which provide beds 24 hours, the support provided by health care networks to crises is still inadequate in 2012, with psychiatric hospitals still predominant.

Among beds currently available in psychiatric hospitals, the Ministry of Health estimates that there are still 11,000 long-term patients who need to be targeted by deinstitutionalization strategies¹⁴. The housing program targeting deinstitutionalization of patients with mental disorders who have been long-term hospital inpatients was implemented in 2000 as an official Ministry of Health policy¹⁵. The instrument was named residential therapy service (RTS) within the SUS. The RTS implementation strategy is strongly bound to another Ministry of Health Program called De Volta para Casa (Back Home), implemented in 2003 and that includes granting a benefit called psychosocial rehabilitation allowance, which is granted to recently discharged patients and totals R$ 320.00(16). In late 2011 625 Residential Treatment Services were operating, providing service to 3,470 inhabitants and 3,961 people were receiving rehabilitation allowances¹⁰.

Such initiatives have limitations in terms of provision expansion. For comparison purposes, in 2007 Italy had 2.9 vacancies in residential facilities for every 10,000 inhabitants¹⁷, while Brazil had 0.18 for every 10,000 inhabitants in 2011¹².

In December 2011, with the aim to expand RTS coverage, the Ministry of Health established a new type of service with financial resources from incentives and defined funding targeting institutionalized people “with a high degree of dependence and that require daily technical and personal support permanently”¹⁸; this allowed for institutional design to provide a team working 24 hours a day. This new organization indicates that at the current stage of the deinstitutionalization process users require residential programs with comprehensive follow-up.

Alcohol Abuse and Other Drugs

Although it used to be restricted to a few regions, use of crack is now widespread in Brazil. The severity of its effects and the social and media repercussions of large user visibility in big cities are politically mobilizing social and security policy sectors supporting involuntary commitment.

Until the early 2000’s decade the Ministry of Health did little more than providing psychiatric hospital admissions and traditional outpatient care. A number of private and philanthropic care facilities emerged independently from the SUS, often funded by public security and social assistance governmental agents; “therapy communities” are the most popular. Such organizations adopt a moral approach to drug use, favor complete abstinence as prerequisite for treatment and emphasize religious support.

The Ministry of Health has supported comprehensive care since 2003 through territorially diverse health actions and services based on the logic of damage control and respect for human rights, coordinating CAPS and primary care and emphasizing more vulnerable populations¹⁹.

However, the implementation of CAPS AD did not receive the same priority as other CAPS types and municipal sector response was not enough and adequate for the complexity of the issue. Within this context, hospital admissions due to psychoactive substances (with the exception of alcohol abuse) increased within the set of admissions caused by mental disorders, jumping from 7.4% n 2005 to 18% in 2011²⁰.Such admissions occur mostly in psychiatric hospitals.

The Ministry of Health has recently presented a set of regulations in an attempt to fill the voids observed in its healthcare network. A new, 24-hour CAPS III AD with up to 12 beds was conceived, operating under specific guidelines that aim to overcome difficulties in terms of access and user compliance with psychosocial care: guaranteeing non-scheduled care seven days a week; admission even under the influence of substances; and overnight stay for up to 14 days a month²¹.

Another new proposed organization is an admission unit, included in the psychosocial care network as a temporary residential care component. Those are facilities that allow voluntary admission for up to six months for people who are socially vulnerable and that require therapy and protective follow-up²². Paradoxically, therapy communities were also bound to the SUS, included in a new category called residential regime care services; this shows conflicting orientations with respect to care for people who abuse alcohol and other drugs.

Private Healthcare Plans

Until 1998 care provided to mental disorders was almost entirely excluded from private healthcare plan company contracts in Brazil. From 1999 onward coverage became mandatory according to Act 9656 of 1998²³.

There is evidence regarding increased provision of services for people with mental disorders by private health insurance companies. With respect to psychiatric admissions, they went from 78,720 in 2005 to 100,650 in 2010 (a 28% increase).In that same period, admissions in the public system fell from 267,256 to 230,629 (minus 16%).When comparing the rate of psychiatric admissions in the private health insurance sector with the SUS rate in 2010, there is significant difference: while private sector rate was 284 for every 100,000 users, in the SUS the rate was 149 for every 100,000 inhabitants(24).

Both subsystems showed opposite trends with respect to admission. While the SUS developed significant de-hospitalization of psychiatric care, the psychiatric hospital component is being strengthened by private health insurance.

Conclusions

Redemocratization has allowed Brazil to successfully implement mental health reforms based on guidelines for reducing the number of psychiatric beds and expanding new community services. Supporting this reform, although it is based on national legislation, has not been a trivial task due to the legacy of prior policies favoring massification of services and resistance from business and professional interest groups.

Social participation in the reform process has been significant. The IV National Conference on Mental Health took place in 2010 and was the first to have intersectoral participation. It was preceded by 359 municipal and 205 regional conferences. An estimated 46,000 people took part in the process, consolidating national conferences as a relevant space for building mental health public policies²⁵.

With respect to users and their relatives, there are few studies or surveys regarding how they are organized in Brazil. Available data suggest that the structure of existing entities (approximately 120 in 2009) was institutionally very fragile and action was too local. They are usually of a mixed nature, gathering users, relatives and technicians; they are not usually organized according to illness and they are created from within a CAPS, strongly depending on it and on its professionals²⁶ .

A few critical relevant points may be highlighted in Brazil’s experience. With respect to crisis support, it is necessary to expand conversion of beds in psychiatric hospitals into beds in general hospitals as well as to expand the number to CAPS with beds. Vacancies in residential facilities remain insufficient. This causes long-term users to inappropriately remain as occupants of psychiatric hospitals.

Incorporation of mental health into primary healthcare is relatively recent and it is still ineffective in large metropolitan areas. Although the so-called mild mental disorders represent a large portion of demand for primary healthcare, the issue still draws little attention in terms of debate and action surrounding Psychiatric Reform.

When compared to the magnitude of private health insurance in the country, the development of a care model focusing strongly on psychiatric admissions in this segment is another normative and political challenge to be addressed. An issue that still needs to be assessed is the extent to which extensive supply of psychiatric admissions by private insurance has contributed to reduce the pressure for hospitalization in the public sector.

And finally, limited provision of specific services for alcohol and other drug users and the inclusion of so-called “therapy communities” in the sectoral arena have both become obstacles to the consolidation of guidelines established from 2003 onward; they have also weakened psychiatric reform stakeholders in terms of control over the agenda addressing the non-anticipated and perhaps underestimated issue of crack. The timely initiative of creating new public facilities for alcohol and other drug users in 2011-2012 still cannot be evaluated satisfactorily.

Notas

Declaración de conflicto de intereses

Los autores han completado el formulario de declaración de conflictos de intereses del ICMJE traducido al castellano por Medwave, y declaran no haber recibido financiamiento para la realización del artículo/investigación; no tener relaciones financieras con organizaciones que podrían tener intereses en el artículo publicado, en los últimos tres años; y no tener otras relaciones o actividades que podrían influir sobre el artículo publicado. El formulario puede ser solicitado contactando al autor responsable.