CARTA AOS EDITORES
More for the same?
Mais pelo mesmo?
Dear Editor,
Andreoli et al. reported a significant decrease in the share for Mental Health (MH) in the Brazilian Public Health (SUS) budget.1 They refer to DATASUS as "limited", "unreliable", and unsuitable "for scientific purposes", as it fails to provide accurate information, for instance, on the number of psychiatric beds in general hospitals. Similar complaints were made in a recent audit performed by TCU, our High Court for Finances (www.contas.tcu.gov.br; Process 011.307/2004-9). The critical question is whether more investments should be made in the same model, as proposed by both publications.
Figure 1 shows 2,392 beds in 367 General Hospitals. However, 412 beds are in 224 hospitals with 4 or less beds. In the 90's, there were 2,156 beds in 139 General Hospitals.2 Clearly, Psychiatric Units in General Hospitals were never a priority.
Further information may help understand the budget issue:
1) Legislators and Government were told that community care was cheaper [e.g., "... a de-centralized model, with alternative, more efficient, more humane ... and less expensive..." (Sen. L. Alcântara report, 11/1995);3 or "...resources... channeled to other forms of care, less expensive and certainly revolutionary in their objective of socially including the psychiatric patient" (Sen. S. Rocha, 12/1998)].3
2) Governments often divert money away from MH [e.g., "In many countries which adopted the deinstitutionalization policy, the community care is not reliable and is lacking in both financial and trained human resources ... many Ministries of Finance did not channel the budget of closed mental hospitals into other forms of mental health care services".4
3) According to the TCU audit, our MH system suffers from "severe managerial deficiency".
WHO praises the current CAPS-centric model (1,011 CAPS; only 37 open 24hs; 22,000 jobs; few psychiatrists; R$ 168 million/year; never evaluated). However, it derives from "Il progetto dell'Instituto Mario Negri", the institution which sponsored the "Caracas Conference".5 In 2006, Brazil had 39,567 psychiatric beds (reimbursed at US$ 17/day) or 2.2 beds/10,000 inhabitants ("Saúde Mental em dados 3", CORSAM, December, 2006). From the 120,000 beds supposedly available in the late 70's,3 the reduction of 80,000 beds corresponds to 67% (actually, to 78.6%, given the 65 million population growth), not just the recent 41% change. Moreover, 20,000 beds are currently used for long-term patients; modern medications are not reimbursed for bipolar disorders; and ECT is not recognized as treatment. Clearly, this system does not provide the most efficient care.
Patients are in the streets, jails and prisons, emergency services, or locked at home. TCU recommends modifications in the training of psychiatrists to conform to the "psychiatric reform". Conversely, severe criticism comes, among others, from the President of the Brazilian Psychiatric Association and from the President of the 2006 Brazilian Congress of Psychiatry (see Psiquiatria Hoje, December 2006). After two decades of "dehospitalization", we know that what needs reform is this failed MH model.
Valentim Gentil
Department of Psychiatry,
Universidade de São Paulo (USP) Medical School,
São Paulo (SP), Brazil
References
1. Andreoli SB, Almeida-Filho N, Martin D, Mateus MD, Mari JJ. Is psychiatric reform a strategy for reducing the mental health budget? The case of Brazil. Rev Bras Psiquiatr. 2007;29(1):43-6.
2. Venturini E. Prefácio. In: Amarante P (organizador). Loucos pela Vida. A trajetória da reforma psiquiátrica no Brasil. Rio de Janeiro: Fiocruz; 1995. p.136.
3. Proceedings and "Justification". Paulo Delgado's Project of Law. Diário do Congresso Nacional, June, 27, 1990 (available upon request).
4. Okasha A. Mental patients in prisons: punishment versus treatment? World Psychiatry. 2004;3:1-2.
5. Saraceno B. Il Progetto dell'Istituto Mario Negri: salute mentale in America Latina. Epidemiol Psichiatr Soc. 1994;3:49-58.
Financing: None
Conflict of interests: None
Publication Dates
-
Publication in this collection
06 July 2007 -
Date of issue
June 2007
