Innovation summary

In 1990, Brazil undertook the challenge of reforming the mental health care system. At that time psychiatric hospitals were receiving more than 75% of federal funding for mental health. Low quality institutions with serious human rights violations predominated, and coverage of community-based mental health services was still very low (0.21 /100,000 inhabitants).

The country sought psychiatric reform to decentralize mental health care by promoting community services, primary care integration, and residential and social support programs.

The reform focused on:

  • Changing the federal funding patterns
  • Increasing access to and developing community based care for service users through the existing Psychosocial Services Network
  • Promoting recognition of people with mental disorders as citizens with full rights

Impact summary

  • More than tripled the Psychosocial Healthcare Centres coverage between 2002 and 2015 (from 0.21 to 0.90 per 100,000)
  • 4,349 people benefited by the “Going Back Home” Programme from 2003 to 2015)
  • 58% reduction in psychiatric hospital beds between 2002 and 2014
  • Doubled share of federal funding for mental health dedicated to community-based care between 2002 and 2014 (from 24.8% to 79.4%)

Since I left hospital my life improved a lot. I have my freedom and I am very happy. I make drawings…Here in the Residence we all do our chores.

 

- Resident of Therapeutic Residence, Brazil

Innovation details

The mental health reform of Brazil shifted care from institutions to community services, primary care and residential and social support programmes through the following:

Deinstitutionalization

  • Negotiation with municipalities and states to replace the beds in psychiatric hospitals for community-based mental health services and psychiatric beds in general hospitals
  • Creation of Therapeutic Residential Services for deinstitutionalization of long-stay psychiatric patients

Community services

  • Expansion of federal financial incentives and technical support to implement community mental health services
  • Establishment of initiatives to prevent alcohol and other drugs in schools (campaigns, trainings, guidelines)
  • Implementation of health teams for people living on the streets – Programa Consultório na Rua (Healthcare on the streets Programme)

Integration into primary care

  • Implementation of Mental Health guidelines to Primary Care.
  • Creation of specialized centres to support Family Health teams (NASF) in Mental Health Care and to improve their relationship with other services of the Psychosocial Care Network.
  • e-learning tools for primary care workers [“Caminhos do Cuidado” (Care Pathways) trained more than 216000 professionals] and for mental health professionals (about 10.000 participants), between 2014 and 2015.
  • Sharing of experiences and expertise between different mental health teams [“Percursos Formativos na RAPS” (Formative Pathways in Psychosocial Care Network) had 1600 participants in 2015].

Focus on recovery

  • Creation of transitory residential care units for adults and for children and adolescents, operating 24 hours, 7 days per week to provide continuous care for alcohol and other drug related needs requiring therapeutic assistance and protection
  • Creation of the “Going Back Home” Programme, which aims for the social reintegration of people affected by mental disorders through a monthly payment, paid directly to the beneficiary, for a period of one year or more, if the person has not yet been able to reintegrate into society
  • Establishment of financial support for local initiatives which promotes employment/income generation and empowerment for people with mental disorders

Key drivers

Political context

A political context of democratization with political will to implement the reform and continuity of its programmes over the years was key to the programmes success.

Social movement for psychiatric reform

A strong social movement - involving universities, health professionals, politicians, users and families - promoted the reform.

Local government participation (bottom up approach)

A participatory, democratic and progressive process of psychiatric deinstitutionalization involving the three levels of government was key for the implementation of the programme. The process started from a few municipalities and through a bottom up approach, spread to the nation.

Challenges

Resistance

Prejudice and cultural resistance against the change of paradigm in mental health care, by health professionals, health managers, and representatives of the judiciary

Inequitable and insufficient resources

Inequitable distribution of mental health professionals and services and insufficient financial resources for implementing community based care from all municipalities (costs are shared between federal, about 60%, and municipalities, about 40%)

Continuation

Countries who wish to undertake a similar reform may consider the following recommendations:

1. Adapt legislation to ensure the respect for rights of people with mental disorders and reorient mental health system accordingly

Brazil has had a federal law which sets out the rights of people with mental disorders and reorients the mental health care model in order to serve their needs since 2001. The legal framework, along with social participation, ensured the implementation and sustainability of the Brazilian Mental Health Reform.

2. Plan the gradual replacement of psychiatric beds for community-based and primary healthcare mental health services

The Brazilian Mental Health System Reform includes an assessment to identify the psychiatric hospitals with the worst operating conditions in order to prioritise their closure. In addition, there is a process of negotiation and planning with local authorities and providers to gradually replace psychiatric beds with community-based services. A census of psychiatric inpatients guides their reintegration into their families and communities, with support of residential and mental health services.

3. Promote training, technical and financial support to change mental healthcare paradigm.

Health professionals, managers and family members need to understand the guidelines of the new system, and mental health practices must respect and promote the rights of service users. Mental health teams need to prioritize practices such as recovery, rehabilitation, social inclusion and empowerment of users.

Partners

Funders:

  • Federal government (Brazil)
  • State and municipalities (Brazil)
  • Municipalities which are primarily responsible for the management and delivery of mental health services

Evaluation methods

Assessments conducted:

  • National Assessment Programme of Psychiatric Hospitals (PNASH Psychiatry): biannual, since 2002
  • Psychosocial Care Centres Assessment (CAPS Assessment)
  • Control Agencies Assessments:
    • Court of Audit (TCU)
    • National Audit Department of the NHS (DENASUS)
  • National Health Survey (PNS-2013): access to and use of health services

Note: The Mental Health System Reform in Brazil has not been systematically evaluated.

Cost of implementation

Federal incentives for municipalities for construction of new mental health services:

  • $132,380 USD per transitory residential care unit (municipalities over 100 000 inhabitants)
  • $264,760 USD for each Community Centre for Psychosocial Care (CAPS III and CAPS- Alcohol and Drug (over 150 000 inhabitants)

Federal investments to build new mental health services from 2013 to 2015:

  • US $ 5.3 million

Federal funding for operating mental health services:

  • Approximately $7,494 USD to $27,800 USD monthly, depending on type of Psychosocial Care Centre:

Psychosocial Care Centre

Population criterion

Federal Incentive to implement (US$)

Monthly federal incentive (US$)

CAPS I

15,000

$ 5,295

$ 7,494

CAPS II

70,000

$ 7,943

$ 8,760

CAPS III (24 h)

150,000

$ 13,238

$ 22,275

CAPS IJ (children and youth)

70,000

$ 7,943

$ 8,507

CAPS AD (Alcohol and other drugs

70,000

$ 13,238

$ 10,532

CAPS AD III (Alcohol and other drugs – 24 h)

150,000

$ 19,857 to $ 39,714

$ 27.800
 

All mental health services authorized by the Ministry of Health cost $247 million USD in 2015. In 2015 the total federal spending on mental health (US $ 335 million) represented 1.3% of total federal health spending.

Currency based on exchange rate on 07/03/16 - US$ 1,00 = R$3,78

Impact details

Nowadays, more than 79% of federal funding for mental health is allocated in community-based services and there was a reduction of over 50% of psychiatric beds country-wide (51,393 in 2002 to 25,988 in 2014). On the other hand, coverage of Psychosocial Care Centres increased over 4 times (from 0.21 to 0.90 / 100,000) and Primary Care coverage reached more than 64% of the Brazilian population.

A recent nationwide population-based study shows that most people diagnosed with mental disorders in Brazil are treated in outpatient public health care services (IBGE, 2014), such as primary care units, which meet 33% of common mental health problems.

Assessments of Psychosocial Care Centers (CAPS) indicate that, in general, these services have been fulfilling their role: high user satisfaction (Kantorski et al., 2009; Campos et al., 2009; Surjus et al., 2011), significant reduction in crisis, fewer psychiatric hospitalizations among users in more intensive and longer care and reduction in medication use (Tomasi et al, 2010).

The “Going Back Home” Programme has benefited 4,349 people from 2003 to 2015, through monthly payments, directly to the beneficiaries, for a period of one year or more. Another breakthrough concerns the empowerment of users and families in mental health, with the organization of nearly 100 user associations.

References

  1. Brasil. IBGE (2014). Pesquisa Nacional de Saúde 2013: acesso e utilização dos serviços de saúde, acidentes e violências: Brasil, grandes regiões e unidades da federação / IBGE, Coordenação de Trabalho e Rendimento.
  2. Campos RTO, et al (2009). Avaliação da rede de centros de atenção psicossocial: entre a saúde coletiva e a saúde mental. Rev. Saúde Pública.  43( Suppl 1 ).
  3. Kantorski, LP et al (2009). Satisfação dos usuários dos centros de atenção psicossocial da região Sul do Brasil. Rev. Saúde Pública [online]. 43(1)
  4. Surjus L, Togni S, Onoko R (2011). A avaliação dos usuários sobre os Centros de Atenção Psicossocial (CAPS) de Campinas, SP. Revista Latinoamericana de Psicopatologia fundamental; 14(1).

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