Abstracts
Introduction: Analysis of the results of the ongoing expansion of the Brazilian public mental health care network has used the indicator of coverage offered by Psychosocial Care Centers (Centros de Atenção Psicossocial, CAPS), which considers the rate of one CAPS per 100,000 inhabitants to be adequate, as its outcome measure. The state of Rio Grande do Sul ranks third in nationwide CAPS coverage standings, with 0.7 centers per 100,000 inhabitants. The present study sought to assess the variability of coverage in different regions in order to verify the representativeness of the overall coverage rate. Method: We used data collected from the National Database of Health Facilities (Cadastro Nacional de Estabelecimentos de Saúde, CNES) and 2009 population data made available at the website of the Ministry of Health Department of Information Technology. We calculated 19 coverage indicators, one for each health region, and computed a coverage rate based on the ratio between the actual indicator and the expected indicator according to the population of each region. Results: Analysis of the variability of coverage for each region showed that seven regions had inadequate coverage, with 49% of the state population receiving inadequate coverage. Conclusion: This study showed that the use of an overall rate for mental health care coverage can be considered a fallacy, as it fails to represent regional realities; roughly half of the regions with excessive coverage masked the regions with poor coverage. This finding suggests that analysis of care coverage must be broken down into geographic areas, in order to identify regional needs and provide support for equal expansion of the community mental health care network for users living in different geographic areas.
Mental health services; state health care coverage; health services evaluation
Introdução: A análise dos resultados da expansão da rede de atenção à saúde mental para a população brasileira tem utilizado como medida de desfecho o indicador de cobertura dos Centros de Atenção Psicossocial (CAPS), que considera adequada a existência de um CAPS para cada 100 mil habitantes. O Rio Grande do Sul encontra-se classificado em terceiro lugar no ranking nacional, com índice de 0,7 CAPS/100.000 habitantes. Este estudo objetivou testar a variabilidade de cobertura de cada região para verificar se esse índice global representava as realidades regionais. Método: Foram utilizados dados do Cadastro Nacional de Estabelecimentos de Saúde (CNES) e dados populacionais do ano de 2009 disponibilizados pelo site do Departamento de Informática do Sistema Único de Saúde do Ministério da Saúde. Foram calculados os indicadores de cobertura para as 19 regionais de saúde, sendo gerado índice de cobertura resultante da razão entre o indicador observado e o esperado de acordo com a população de cada região geográfica analisada. Resultados: Analisada a variabilidade de cobertura de cada região, foi evidenciada a ocorrência de sete regiões com cobertura insuficiente, representando 49% da população do estado com cobertura inadequada. Conclusão: O estudo demonstrou que o uso do índice global é falacioso, pois não representa as realidades regionais, sendo que cerca de metade das regiões com excesso de cobertura mascaram as regiões deficientes. Isso sugere que as análises de cobertura devem ser realizadas por áreas geográficas para identificar carências regionais e fornecer subsídios para a extensão da rede de forma igualitária para usuários de diferentes regiões do estado.
Serviços de saúde mental; cobertura de serviços públicos de saúde; avaliação de serviços de saúde
ORIGINAL ARTICLE
The fallacy of adequate coverage offered by Psychosocial Care Centers in the state of Rio Grande do Sul
Veralice Maria GonçalvesI; Rafael Henriques CandiagoII; Sérgio da Silva SaraivaIII; Maria Inês Rodrigues LobatoIV; Paulo Silva Belmonte-de-AbreuV
IMBA, Gestão em Saúde. Servidora pública federal, Ministério da Saúde/Departamento de Informática do Sistema Único de Saúde (MS/DATASUS).
IIMestre, Psiquiatria, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil. Médico psiquiatra.
IIIMédico psiquiatra, UFRGS.
IVDoutora, Medicina, Ciências Médicas. Médica psiquiatra, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil.
VPós-Doutor, Biologia Molecular. Coordenador, Programa de Pós-Graduação em Psiquiatria, UFRGS.
Correspondence
ABSTRACT
Introduction: Analysis of the results of the ongoing expansion of the Brazilian public mental health care network has used the indicator of coverage offered by Psychosocial Care Centers (Centros de Atenção Psicossocial, CAPS), which considers the rate of one CAPS per 100,000 inhabitants to be adequate, as its outcome measure. The state of Rio Grande do Sul ranks third in nationwide CAPS coverage standings, with 0.7 centers per 100,000 inhabitants. The present study sought to assess the variability of coverage in different regions in order to verify the representativeness of the overall coverage rate.
Method: We used data collected from the National Database of Health Facilities (Cadastro Nacional de Estabelecimentos de Saúde, CNES) and 2009 population data made available at the website of the Ministry of Health Department of Information Technology. We calculated 19 coverage indicators, one for each health region, and computed a coverage rate based on the ratio between the actual indicator and the expected indicator according to the population of each region.
Results: Analysis of the variability of coverage for each region showed that seven regions had inadequate coverage, with 49% of the state population receiving inadequate coverage.
Conclusion: This study showed that the use of an overall rate for mental health care coverage can be considered a fallacy, as it fails to represent regional realities; roughly half of the regions with excessive coverage masked the regions with poor coverage. This finding suggests that analysis of care coverage must be broken down into geographic areas, in order to identify regional needs and provide support for equal expansion of the community mental health care network for users living in different geographic areas.
Keywords: Mental health services, state health care coverage, health services evaluation.
INTRODUCTION
The model for mental health care expansion implemented in the Brazilian Unified Health System (Sistema Único de Saúde, SUS) from 2002 onwards establishes a reform of psychiatric care in the country, based on normative documents issued by the Brazilian Ministry of Health and made into law by ordinances and by the Ministry's Department of Health Care (Secretaria de Atenção à Saúde, SAS). These ordinances, most of which are drafted by the Office of the National Coordinator for Mental Health (Coordenação Nacional de Saúde Mental), provide political, legal, and theoretical/conceptual backing1 as well as objective instruments for assessment of the quality of coverage and services, for use by Health Ministry administrators, State and Municipal Departments of Health, and the Brazilian Court of Audit (Tribunal de Contas da União, TCU). The overarching goal is to foster greater rationality and efficiency in public administration and increase visibility of the benefits reaped by society.2
Official data on coverage indicators and their evolution over time show a trend toward elimination of psychiatric beds3 and expansion of the network of Psychosocial Care Centers (Centros de Atenção Psicossocial, CAPS) throughout the decade.4 As of 2009, the state of Rio Grande do Sul (RS) had 110 accredited facilities for a population of 10,914,042.5 The state's overall coverage rate is therefore considered good, and Rio Grande do Sul ranks third in the national standings, with a weighted índex of 0.7 CAPS per 100,000 inhabitants according to 2006 data.4
Comparative data on the various states of Brazil show that the model of care is undergoing changes; however, there are significant regional differences in this model, and data also show a lack of local mental health care structures in different states.
The state of Rio Grande do Sul is devided into 19 regional health authorities, or health regions-technical and administrative health organizations with authority over specific geographic areas and differences in terms of number of municipalities, population, and socioeconomic scenario.
The present study sought to assess the variability of CAPS coverage between regions in order to ascertain whether the state's overall coverage rate is representative of distinct regional realities.
METHODS
To test the hypothesis that CAPS coverage is good in the various regions of Rio Grande do Sul state, we calculated indicators for each of the state's 19 health regions and generated coverage rates, computed as the ratio of each actual indicator value to its expected value according to the population of the region. Indicators were calculated from National Database of Health Facilities (Cadastro Nacional de Estabelecimentos de Saúde, CNES) data and March 2009 population data made available by the Ministry of Health at the Unified Health System Department of Information Technology (Departamento de Informática do SUS, DATASUS) website. The number of CAPS expected for each region is calculated with the formula (number of CAPS)/100,000 inhabitants, and the coverage rate (CR) was calculated as the ratio of the actual number of CAPS in each region to the number of CAPS expected for its population.
RESULTS
The data obtained show that 43.55% of the population of Rio Grande do Sul state lives in municipalities where CAPS coverage rates are 30% below expected levels (Table 1).
On the other hand, coverage exceeded desired levels by at least 30% in nine regions (37.28% of the state population); in one region, coverage exceeded expected levels by 100%. When access to treatment is analyzed according to state health region, the official data paint a revealing picture of coverage inequality. Of the 19 health regions in the state of Rio Grande do Sul, only 12 had adequate coverage rates, showing that CAPS coverage meets expected standards for only 51% of the population.
The data therefore reveal a dearth of CAPS coverage, even though overall figures suggest an adequate number of Centers in the state (110 CAPS in operation versus 109 expected). This is due to a profound inequality in offer across different populations, which affects not only large urban areas that offer coverage rates more than twofold higher than expected, but also regions with roughly 50% insufficient coverage, including the Porto Alegre metropolitan area and other major urban centers (Figure 1).
CONCLUSIONS
The data presented herein show the fallacy of using overall indicators that rank the state of Rio Grande do Sul as having good CAPS coverage. Furthermore, studies aimed at determining population needs that should be met in each region reveal a need for more adequate analyses to support changes in the care model and allow the equal extension of community health networks into patients' home regions.
REFERENCES
- 1. Borges CF, Baptista TW. O modelo assistencial em saúde mental no Brasil: a trajetória da construção política de 1990 a 2004. Cad Saude Publica. 2008;24(2):456-68.
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2Tribunal de Contas da União. Avaliação das ações de saúde mental. Programa atenção à saúde de populações estratégicas e em situações especiais de agravos. Brasília; 2005.
- 3. Candiago RH, Abreu PB. Use of Datasus to evaluate psychiatric inpatient care patterns in Southern Brazil. Rev Saude Publica. 2007;41(5):821-9.
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4Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde/DAPE. Saúde Mental no SUS: acesso ao tratamento e mudança do modelo de atenção. Relatório de Gestão 2003-2006. Brasília: Ministério da Saúde; janeiro de 2007.
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5Ministério da Saúde/Departamento de Informática do Sistema Único de Saúde. População residente. Sistemas de Informações de Saúde, demográficas e socioeconômicas. Censo 2009. Disponível em www.datasus.gov.br Acessado em 17/03/2008.
Correspondência
Publication Dates
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Publication in this collection
28 July 2010 -
Date of issue
2010
History
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Received
13 May 2009 -
Accepted
30 July 2009
