Cost of a community mental health service: a retrospective study on a psychosocial care center for alcohol and drug users in São Paulo

ABSTRACT BACKGROUND: Psychosocial care centers for alcohol and drug users (CAPS-ad) are reference services for treatment of drug users within the Brazilian National Health System. Knowledge of their total costs within the evidence-based decision-making process for public-resource allocation is essential. The aims here were to estimate the total costs of a CAPS-ad and the costs of packages of care (according to intensity of care); to ascertain the ratio between total CAPS-ad costs and the federal funding allocated; and to describe the methods for estimating unit costs for each CAPS-ad cost component. DESIGN AND SETTING: Retrospective study conducted in a public community mental health service. METHODS: This was a retrospective cost description study on a CAPS-ad located in a city in the state of São Paulo, using a public healthcare provider perspective and a top-down approach, conducted over a 180-day period from March 1 to August 30, 2015. RESULTS: The total mean monthly costs of the CAPS-ad were BRL 64,017.54. Healthcare staff accounted for 56.5% of total costs. The mean costs per capita and per month for intensive and non-intensive care packages were, respectively, BRL 668.34 and BRL 37.12. CONCLUSIONS: The federal budget allocation covered 62.1% of the CAPS-ad costs and the remaining 37.9% end up funded by the municipal government. The cost of the intensive package of care was 18 times greater than the non-intensive package. Developing criteria for using services and different packages of care based on patients’ needs, and optimizing human resources according to specific actions, may improve people’s mental health and avoid wasted resources.


INTRODUCTION
Substance-related disorders have been a priority of the Brazilian public health agenda since the beginning of the last decade, when the federal government established specific policies and programs, 1 such as the Psychosocial Care Network (RAPS). This priority agenda is based on the prevalence of drug and alcohol use in Brazil, and on their consequences for users and society. [2][3][4] The main care strategy for treating substance-related disorders within RAPS comprises community-based mental health services (CMHS), known as psychosocial care centers for alcohol and drug users (CAPS-ad). Knowledge of their costs within the decision-making process for allocation of public resources is essential.
Brazil is a country of huge territorial extent, but 50% of the Brazilian population is concentrated in only 5% of its municipalities. 1 This characteristic has justified regionalization of this country's healthcare management, and the three levels of government (federation, states and municipalities) are expected to agree on the management and costing of healthcare services. The CAPS-ad system is partially funded by the national government, but so far there is no information regarding whether the federal funding entirely covers the costs of CAPS-ad, and what the budget impact on municipalities would be, in relation to implementing and maintaining these services.
The territorial complexities of Brazil, along with the need to expand mental health care coverage for people with substance-related disorders, highlight the need for economic planning through cost studies and economic evaluations. 5 Very few economic studies have examined psychosocial interventions for people with substance-related disorders in low and middle-income countries. 6 This was corroborated by our finding from the literature, while conducting this study, that no cost studies on CAPS-ad have been undertaken. Data on CAPS-ad costs would provide support orcid.org/0000-0003-0503-0893 II for the decision-making process regarding opening new services of this nature, through helping healthcare managers to analyze the feasibility of maintaining such services over time.
The main aim of this study was to estimate the total costs of a CAPS-ad that is located in a city in the state of São Paulo, and the costs of three packages of care (intensive, semi-intensive and non-intensive) delivered by this service for patients with substancerelated disorders, from the public healthcare provider perspective. The additional objectives were to ascertain the ratio between total CAPS costs and the federal funding allocated to this service and to describe the methods for estimating the unit costs for each CAPS cost component.

METHODS
This was a cross-sectional study that was conducted to estimate the total costs of a CAPS-ad located in the city of Rio Claro, state of São Paulo, covering a 180-day period from March 1 to August 30, 2015. Data on costs were extracted from the municipal accounting database and a top-down approach was applied for the cost estimation. The CAPS-ad costs were estimated for a 180-day period in the year 2015 and then the ratio between costs funded by the federal and municipal governments was examined. The 180-day period was chosen because this provided the best data quality in the administrative database that was made available by the municipal government. This study adopted the perspective of the public healthcare provider because there are no national or regional published data on the unit costs and cost components of this kind of service in Brazil. The non-intensive package of care offers support for users who have good social and family ties, those who make moderate or severe use of drugs but who work and can only attend the service at specific times, or those who are in the process of leaving the service because they have presented improvements.

Estimation of cost components
The following CAPS-ad cost component categories were considered: Healthcare staff costs: These were the costs of healthcare professionals working at this center, including two psychiatrists, one general practitioner, one nurse, two nursing technicians, two psychologists, two occupational therapists and one social worker. Firstly, their total costs over a 180-day period were estimated. Secondly, unit costs were determined. Lastly, the costs for each healthcare staff intervention within the care packages were estimated.
Medication costs: These were categorized as the costs of psychotropic and non-psychotropic medications. Firstly, the per capita monthly costs of medication consumption were obtained.
Secondly, the per capita monthly costs were extrapolated to the 180-day period, considering the mean number of patients assisted by the service over this period (810 patients). Then, the unit costs were defined.
Revenue costs: These were the costs of support services (diet service: lunch and snacks), utilities (expenses with electricity, telephone and gas consumption), consumables (medical supplies, catering, stationery and cleaning supplies), non-healthcare human resources (security, which was provided through an outsourced hired service hired; and cleaning services, consisting of one cleaning professional) and overheads (healthcare manager, one assistant and one receptionist). Their costs were estimated considering the number of working hours and salaries.
Capital costs: These consisted of rent, equipment and building repair. Equipment costs were adjusted according to the consumer price index by using the market price for 2015 (presented as Supplementary Table S1). The unit costs were extracted from three online stores in September 2015. Then, these costs were annuitized by estimating the equivalent annual annuity (EAA), with a 5% discount factor (standard in Brazil), and by taking the lifetime use of equipment to be five years, as can be seen in Drummond et al. 7

CAPS-ad funding sources
It is expected that CAPS-ad will be funded from federal, state and municipal public healthcare budgets (Figure 1). The federal healthcare budget is allocated to the state and municipal governments through six funding packages, of which two are oriented towards CAPS-ad: the Medication funding package (arrow 1) and the Medium and High-Complexity healthcare funding package (arrow 2). 8 The Medication funding package is firstly allocated to the state government for drug purchasing.
The Medium and High Complexity healthcare funding is allocated directly to the municipal healthcare budget to fund CAPS-ad and other healthcare services. In 2015, the federal government released Brazilian reais (BRL) 39,780.00 per month to fund each CAPS-ad within the national territory, and the municipal healthcare budget funded the remaining costs, which were not publicly known until the analysis of the present study.
In Figure 1, arrows 3 and 4 respectively represent the federal government budget allocated to municipal government and the municipality's own healthcare budget, which were both used to fund CAPS-ad.

Cost components: packages of care
The   Table 1 shows the unit costs per mental health professional and the total cost per professional category for the 180-day period.

RESULTS
The healthcare staff cost was BRL 216,918.00 over this period, which was equivalent to USD 68,213.20 after conversion using purchasing parity power (PPP) exchange rates relating to 2015. 11 The mental health treatments offered by the CAPS-ad and their respective costs are described in Table 2. results on the total CAPS-ad costs in the best and worst scenarios, compared with the total costs for the service.
In the same year, the federal funding allocated to the munici- Data on the care packages are shown in Table 5. Based on the unit costs for mental health treatment at this CAPS-ad (  The monthly CAPS-ad treatment cost per capita was almost three times lower than the amount paid per month (BRL 1,350.00) by the São Paulo state government to provide inpatient treatment for substance users at private clinics through the "restart program" (Programa Recomeço). 18 It is important to underscore that the decision-making process regarding public resource allocation between different services should be based not only on costs but also on patients' needs and profiles. Moreover, the differences in IPC = intensive package of care; SIPC = semi-intensive package of care; NIPC = non-intensive package of care. costs mentioned above were not compared with differences in outcomes or according to sample characteristics. However, it is also important to establish strict criteria for using more expensive services, in accordance with patients' needs, in order to optimize the public resource allocation.
The unit costs reported here may inform further economic evaluations and modelling studies within similar contexts of services in the state of São Paulo. This is especially important, considering the lack of information on unit costs within healthcare in Brazil. This is unlike the situation in some European countries, where national guidelines for unit costs reference for healthcare services and interventions are available, thus facilitating development of cost studies and economic evaluations. 19,20 There is a lack of cost-effectiveness studies in Brazil, especially in relation to mental health, and the findings from the present study may be useful for further studies in this regard.
The expansion of the CAPS network in Brazil 1 and the way in which public resource allocation for funding a CAPS-ad occurs 8,15 show that only at the federal level is there any specific budget for this purpose. A specific budget for mental health actions has been placed as a priority for mental health policies worldwide, [21][22] and Brazilian states and municipalities need to ensure transparency in the way that they apply resources for mental health services.
According to the current legislation on public health financing in Brazil, 23,24 municipalities and states should, respectively, allocate minimums of 15% and 12% of their budgets to public health.
However, state governments' participation in the cost of CAPS in Brazil remains a challenge and has been the subject of interpellation instigated by municipalities, with the aim of achieving greater participation from state governments, so as to ensure sustainability of these services. 1 It is necessary to ascertain municipal governments' capacity to manage the costs of these services, in order to plan public investment in services that can be sustained over time. After the costs of this type of service have been established, the discussion can shift from focusing on coverage to analysis in greater depth, including in relation to the cost-effectiveness of services and interventions.
The present study has three important limitations:

CONCLUSIONS
The federal government funded two-thirds of the CAPS-ad costs, while one-third was funded by the municipal government.
These findings may enable better planning and management, both for the federal government and for municipal governments that are interested in expanding the CMHS network for people with substance-related disorders. Moreover, these findings also highlight the need for government agencies and the national academic community to focus on mental health policies, not only to expand treatment coverage, but also to attain the best allocation of resources, in terms of costs and outcomes. Careful use of packages of care based on patient needs can improve people's mental health and avoid wasting resources.