Psychiatry in Public Health Services

On April 7, 2009, the Brazilian Association of Psychiatry (ABP) filed a petition with the Office of the Federal Public Prosecutor. The document denounces non-compliance with the pertinent legislation by the Mental Health Division of the Ministry of Health. While the Ministry of Health fails to meet its own deadlines and guidelines, treatment for Brazilian psychiatric patients has become increasingly difficult.

Early 1980s. Brazil was gripped in the final years of a military dictatorship. The world witnessed the rise of neo-liberal policies and the beginning of the end of the Cold War. The Soviet Union was still a major world power. Innovative technologies (for the time) like walkmans and VCRs lured consumers. Now, nearly three decades later, much has changed.

Yet some major problems persist. In the 1980s, the Brazilian Association of Psychiatry tackled such issues as the country’s large (and sometimes poor-quality) psychiatric hospitals, the decreasing number of inpatient beds, and the need to expand the outpatient system and create psychiatric wards in general hospitals. Since then, these issues have become priorities for the association.

Since the 1980s, the scientific debate has spread, encouraged by successive ABP administrations headed by Marcos Ferraz, João Romildo Bueno, Luiz Salvador Miranda Sá Junior, William Dunningham, Othon Bastos, Rogério Aguiar, Miguel Jorge, Marco Antonio Brasil, and Josimar França. Over the years and under various administrations, countless events were held and articles were published.

In the late 1980s, Brazil experienced its historical redemocratization process, culminating in the 1988 Constitution and the creation of the Unified National Health System. Several more years went by, and Federal Law 10.216 was passed on April 6, 2001, emphasizing outpatient, community-based treatment for patients with mental illnesses. For those who had advocated for such changes over the years, the law was a major milestone.

But the reality of public mental health care in Brazil is still daunting. In June 2002, Ministry of Health Ruling 1.101 set the goal of 0.45 psychiatric beds per thousand inhabitants to meet the demand for psychiatric admissions in the country. Nearly six years later, the Ministry of Health has failed to meet its own target. Brazil currently has only 0.23 psychiatric beds per thousand inhabitants.

Collaboration
According to the current president of ABP, during the entire period discussed above, the institution attempted to approach government policymakers to demand the necessary measures. “Our Association’s position has always been to critically monitor this process and collaborate in the development of policies based on the best current scientific knowledge. But in our experience the Ministry’s decisions have been mostly ideological,” commented João Alberto Carvalho.

Thus, one of the most recent initiatives by ABP was the elaboration of “Guidelines for a Comprehensive Mental Health Care Model in Brazil”, in 2006. The document analyzes the current situation and presents suggestions for building an efficient, evidence-based system of psychiatric care. On August 22, 2007, the document was officially submitted to the Minister of Health, José Gomes Temporão.

The president of ABP at the time, Josimar França, emphasized the initiative’s collaborative nature. “This document, prepared by ABP members, represents the official position of Brazilian psychiatrists vis-à-vis the country’s current mental health care policy and proves our willingness to collaborate in the revitalization of medical care in the country,” he stated.

Persistent Disregard
At the end of the meeting, the Minister of Health promised to send the document to his technical team and to hold a new meeting. As of March the following year, ABP had still not been contacted to continue the work, and the Association thus requested a new hearing with the Minister, which took place on the 25th of that same month.

The meeting specified three key action areas for the year 2008: medical residency, primary care in mental health, and psychiatric beds in general hospitals. On the first issue, a year after the meeting the only action proposed by the Ministry was participation by a representative from the field of psychiatry in a meeting of the Sub-Committee for the Study and Evaluation of the Needs of Medical Specialists.

The second item is also at a standstill, having been assigned to the Ministry of Health’s Mental Health Division. The Minister also promised to hold a new meeting with the psychiatrists within 30 days. The meeting was never held. But according to the president of ABP, the situation with the third and last issue is even more serious. “During the hearing with the Minister, the agreement was to create a task force on psychiatric beds and wards in general hospitals. In addition to the delay in making the task force official, the Ministry has failed to meet its own deadlines for producing reports and conclusions,” remarked the ABP president.

On April 18, 2008, ABP held a meeting with mental health policy specialists to define proposals and priorities to orient the work by the task force that was supposed to have been created by the Ministry. This meeting highlighted the need to estimate the presence of psychiatrists working in the Unified National Health System, a calculation ABP performed during its annual congress (where the majority of psychiatrists reported that they preferred to work in the private sector or in teaching institutions).

On September 11, 2008, six months after the meeting, the Ministry of Health issued Ruling 1899, intended to create the Task Force on Mental Health in General Hospitals. The text stipulated a 90-day deadline for the task force to submit the final report with its conclusions. The activities were to be coordinated by the Technical Area on Mental Health under the Department of Strategic Programmatic Actions, in the Ministry of Health. As of current writing, six months have gone by. No report has been produced, and only one meeting was held, on December 9, 2008. According to a Ministry of Health spokesperson, the forecast was for the next meeting to be held in May [2009].

The ABP representative in the task force is Marco Antonio Brasil, member of the Advisory Board. Psychiatrists Rogério Wolf Aguiar and Neury Botega were also invited to participate in the meeting in December, representing the Consultation Liaison Service at the Federal University Hospital in Rio Grande do Sul and the National Strategic Task Force on Suicide Prevention, respectively.

During the task force’s only meeting, the participants were divided into subgroups that assumed the responsibility for producing specific studies. Aguiar commented on the process: “Marco Antonio, Neury, and I studied how to implement this type of service. Initially, a new meeting was supposed to be scheduled for March. Later they postponed it until the end of the month, and now apparently it won’t be held until May. Our report is ready, waiting for the next meeting.”

In nearly three decades, much has changed. But some problems remain the same.

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