The development of community-based alternatives to hospital care has been a longstanding global policy objective15, including in Brazil. This was the result of a long struggle involving mental health movements18, who represented a range of ideological viewpoints31. These movements had been involved in combating discrimination and inequality experienced by those with mental health problems, including resisting the medicalisation of distress9, increased oppression12 and demanding wider community services29.
The Brazilian Ministry of Health has identified that around 3% of the population suffer from severe or persistent mental disorder, and a further 12% of the population requiring some mental health care, whether continuous or acute24. Furthermore, amongst alcohol and psychoactive substance misusers, more than 6% of the population have serious psychiatric disorders24 14. Brazil’s Mental Health legislation[1] (Law 10.216)[2]8, facilitated the development of a psychosocial care network (RAPS) composed of various mental health services, including Psychosocial Care Centres (CAPS); Therapeutic Residential Services (SRT); Centres of Coexistence and Culture, along with Reception Units (UAS); and beds (in General Hospitals, CAPS III)4. Consequently, many argue that Brazil’s mental health system was heavily influenced by citizens:
We have a national law, won by social Movements, which has been incorporated by society, judiciary branch, public managers. We have put in place a network that, although it still has gaps, extended the rights of users and their families and access to treatment under SUS[3]11.
Indeed, following the implementation of the Psychiatric Reform Law, psychosocial care encapsulated the primary provisions related to mental illness, alcohol and other drugs user care (AOD)3. Key elements of this mental health policy involved: a) reducing poor quality and expensive health care at both financial and social levels; b) rejecting the previous service delivery model by diversifying therapeutic resources and promoting the decentralisation of care14 which was believed to be the result “…of new political and cultural relations”2. The authors believe that the “mental health” issue should be considered locally, at municipal level, but required financing from the three levels, namely: federal, state and municipal (historically a problem that was not solved at the time)14.
Ministerial Ordinance 30886 was instituted as a proposal for the organisational structure of mental health services, which created and regulated the Psychosocial Care Network (RAPS), established guidelines, objectives and components for the network focused on mental health care30. The Mental Health network comprised various care agencies which supported the psychosocial care of services for those with mental disorders based on the population criteria and the demands of the municipalities (Table1).
To understand the complexity of CAPS in Brazil, it is necessary to contextualise the population service requirement. In total there are 5,570 municipalities (including Fernando de Noronha and the Federal District), however the majority of these, around 90% of the municipalities, are small (0 to 50,000 inhabitants) (See Table 2). Municipalities eligible for CAPS are those with a population over 15,000 inhabitants (TCU estimate, 2013), i.e. approximately 2,310 (42%) of Brazilian municipalities. In the CAPS classification for cities eligible for this type of service, small and medium-sized cities are more common, with about 23% and 57% of the population, respectively (See Table 3).
The function of the Centres of Psychosocial Care (CAPS), is to facilitate access to care for the population of a specific geographical area, with services of differentiated sizes and complexity adapted according to their enrolled population11. CAPS linked to the municipal health network are designed to deliver mental health assistance for users with mental disorders, support social and family integration, encourage autonomy and provide medical and psychological care25. Mental health care coverage is defined by the Ministry of Health as the existence of one Psychosocial Care Center per 100,000 inhabitants. The CAPS are of six types (CAPS I, CAPS II, CAPS III, CAPS AD, CAPS AD III, CAPSi) community Psychosocial Care Network (RAPS), with multidisciplinary teams and an interdisciplinary approach providing care only to those suffering from mental ill-health, including those requiring help with alcohol and other drugs, in their geographical area21. The implementation of these services comprise the core of the mental health reform25. As a result of the 201720 mental health reforms, nationally Brazil had 2,341 Caps services, comprising:
- 1,131 Caps I services
- 493 Caps II services
- 94 Caps IIIservices
- 316 Caps AD services
- 90 Caps AD III 24-hour services
- 219 Capsi services
The CAPS20 provide community mental health services which have the following characteristics:
Caps I. Provide services to all age groups who are experiencing intense psychological distress due to severe and persistent mental disorder, including those related to using psychoactive substances, as well as other clinical conditions that make it impossible to maintain social ties or carry out daily living. Minimum staff levels for this service are: one doctor with training in mental health; one nurse; three university-level professionals (psychologist, social worker, occupational therapist, physical educator or other professional that is working therapeutically), four mid-level technical and / or nursing assistant staff members.
Capes II: This service primarily serves people in intense psychological distress as a result of severe and persistent mental disorders, including those related to the use of psychoactive substances, and other clinical situations that which have resulted in relapse. The minimum staffing levels are: one psychiatrist; one nurse with training in mental health; four higher level professionals (psychologist, social worker, occupational therapist, physical educator or other professional needed for the therapeutic project), six mid-level professionals for instance nursing technicians or assistants, administrative technician, educational technician and artisan).
The key difference between CAPs I and II services are the number and type of professionals (as described above) and number of citizens in a city.
Caps III - Primarily serves people in intense psychological distress resulting from severe and persistent mental disorders, including those related to the use of psychoactive substances, and other clinical situations that make it impossible to establish social ties and carry out life projects. This service provides 24-hour year round continuous care services, provide clinical back-up, as well as night time support to other mental health services, including to CAPS AD The minimum staffing levels comprise: two psychiatrists; one nurse with mental health training, five university level professionals for instance psychologist, social worker, occupational therapist, pedagogue, physical educator or other professionals as needed.
CAPS AD assists people of all age groups who present intense psychological distress due to the use of crack, alcohol and other drugs, or who are unable to establish social ties and carry out life ambitions. These services are provided in municipalities or health regions with population over 70,000 inhabitants. Their minimum staffing requirements are: one psychiatrist; one nurse with training in mental health; one clinical physician, responsible for the screening, evaluation and follow-up of clinical complications; four university level professionals (psychologist, social worker, occupational therapist, pedagogue, physical educator or other professional needed for the therapeutic project), six middle level professionals for instance nursing technician and/ or assistant, administrative technician, educational technician and artisan.
CAPS AD III services assist adults, children and adolescents, and in accordance with the Child and Adolescent Statute regulations with service users who are under intense psychological distress and require continuous clinical care. The service has 24-hour observation and monitoring throughout the year with up to 12 beds. Minimum staffing includes 60 hours per week for each medical professional, either psychiatrist and clinicians with training and / or experience in mental health; one nurse with experience and / or training in mental health; five university level professionals (psychologist, social worker, occupational therapist, pedagogue, physical educator or other professional needed for the therapeutic project), four nursing technicians; four mid-level professionals and one mid-level professional to perform administrative activities.
CAPSi services urgent children and adolescents who present with intense psychological distress resulting from severe and persistent mental disorders, including those related to the use of psychoactive substances, along with other clinical situations that make it impossible to maintain social bonds and carry out life tasks. The minimum staff complement comprises: one psychiatrist or neurologist or paediatrician with training in mental health; one nurse, four higher level professionals (psychologist, social worker, occupational therapist, pedagogue, physical educator or other professional required for the therapeutic project), five mid-level professionals (nursing technician and / or assistant, administrative technician, educational technician and Craftsman).
A recurring theme across all service levels, was the prioritization of access, along with the quality improvement of mental health services within the SUS19. In 2014 the Ministry of Health23 identified that the 86% coverage rate had resulted in extra-hospital, territorial and community-based services. In 2016, 103% healthcare coverage was achieved on the basis of the number of CAPS services, although no single institution provided sole care coverage. However, the distribution of the CAPS institutions nationally is not homogeneous and consequently there are gaps in care services. As a result, questions are raised regarding the parameters of coverage and the claims that are made about these.
The National Mental Health Management Plan (2016 to 2019)5 expanded the Psychosocial Care Network (RAPS) and resulted in the total CAPS in Brazil increasing from 1,701 to 2,209, an increase of 29.86%. CAPS AD and CAPS AD 24h, which provide monitoring and treatment of users of alcohol and other drugs, increased 40.5%, from 269 to 3785. Furthermore, objective 2 of the plan, aimed to improve and implement Health Care Networks in health regions, with emphasis on Urgency and Emergency Network, Cegonha Network, Psychosocial Care Network, Disabled Persons Care Network, and the Health Care Network of People with Chronic Diseases.
The Psychosocial Care Network has sought to “ensure health care and the free circulation of people with mental disorders”4, with a key aim being to drastically reduce hospitalisations in psychiatric hospitals through expanded service access i.e. increased coverage of CAPSs, care facilities, residential therapeutic services, mental health beds in general hospitals and solidarity/co-operative enterprises using technical and financial subsidies. In addition, priority was given to expanding the care capacity for alcohol and drug users, with school-based drug prevention interventions being implemented for 6-14-year-olds and family-oriented drug prevention5.
The development and execution of the national mental health plan has been undertaken in a politicalically unstable environment, marked by the impeachment of the Brazilian President Dilma, the new Temer government and latterly the Bolsonaro government (accused as being authoritarian and far right). 2016-2019 has resulted in increased psychiatric hospital beds, reductions in resources for CAPS, an increase in religious led therapeutic communities within the Psychosocial Care Network as well as disputes over public funding14. All of which raised the spectre of the return of asylums. Both the Temer and Bolsonaro government administrations have undertaken a dismantling of the psychiatric reform gains, while promoting a return to the policy of asylums of the past1. Consequently, the Temer and Bolsonaro Governments have resulted in Brazil transitioning away from progressive mental health policies such as the Psychosocial Care Centers.
Footnote:
[1] For World Health Organization (2015) Mental health legislation is a further key component of good governance and concerns the specific legal provisions that are primarily related to mental health. Although, alone 99 countries report having a stand-alone law for mental health, which represents 51% of WHO Member States32.
[2] Act that provides for the protection and rights of persons with mental disorders and redirects the mental healthcare model8.
[3] Electronic message no. 13/2011. On January 24, 2011.28