Psychiatric reform in Rio Grande do Sul: an analysis of history, economy and the impact of 1992 legislation

Abstracts

Os autores apresentam uma análise da reforma psiquiátrica do Rio Grande do Sul, utilizando uma perspectiva histórica e uma abordagem por três vertentes: a psiquiatria institucional; os desenvolvimentos na área extra-hospitalar; e as políticas de saúde implementadas ao longo dos anos. A partir do referencial adotado, foi revisada a experiência brasileira e a do Rio Grande do Sul em particular, tendo como fontes: os bancos de dados MEDLINE e Lilacs e documentos oficiais do Ministério da Saúde e da Secretaria Estadual de Saúde do Rio Grande do Sul. Hoje, após 14 anos da promulgação da Lei Estadual nº 9716, que dispõe sobre a reforma psiquiátrica no Rio Grande do Sul e determina a substituição progressiva dos hospitais psiquiátricos por uma rede de atenção integral em saúde mental, nota-se que o número de leitos psiquiátricos foi reduzido em 35%, e a proposta de implantação da rede "alternativa" de assistência ao doente mental não foi implementada da forma preconizada, tampouco de maneira igualitária. Tendo em vista que os atuais desafios, tais como o fenômeno da "porta giratória" e o paciente crônico, refletem a necessidade de extensão dos cuidados primários e secundários, a experiência do Rio Grande do Sul permite pôr em discussão a possibilidade de modificação da estratégia, de tal modo que, ao invés de tentar estruturar um "sistema dentro do sistema", como hoje está colocado, possa-se tirar melhor proveito da integração da saúde mental aos programas-eixo do SUS, como o Programa de Saúde da Família e o Programa de Agentes Comunitários de Saúde.

Psiquiatria, hospital; reforma psiquiátrica; políticas de saúde; avaliação de serviços; economia da saúde

THEORETICAL–CLINICAL COMMUNICATION

Psychiatric reform in Rio Grande do Sul: an analysis of history, economy and the impact of 1992 legislation^*

Fábio Leite Gastal^I; Sérgio Olivé Leite^II; Fabiana Nery Fernandes^III; Andresa Thier de Borba^IV; Cleyson Makoto Kitamura^V; Mario Arthur Rockenbach Binz^VI; Milene Tombini do Amaral^VI

^IPsychiatrist, Associação Brasileira de Psiquiatria (ABP), Rio de Janeiro, RJ, Brazil. PhD in Medicine, Universidad de la República Oriental del Uruguay (UROU), Montevideo, Uruguay. PhD in Medicine/Psychiatry, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil. Guest Professor, Graduate Program in Tropical Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil. Superintendent, Organização Nacional de Acreditação (ONA – Brazilian National Accreditation Organization)

^IIPsychiatrist, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil. Professor, Psychiatry, Universidade Católica de Pelotas (UCPEL), Pelotas, RS, Brazil. Technical Director, Clínica Olivé Leite, Pelotas, RS, Brazil

^IIIPhysician, UCPEL, Pelotas, RS, Brazil. Psychiatrist and former resident of Psychiatry, Universidade Federal da Bahia (UFBA), Salvador, BA, Brazil

^IVPhysician, UCPEL, Pelotas, RS, Brazil

^VPhysician, UCPEL, Pelotas, RS, Brazil. Resident in Ophthalmology, Hospital Banco de Olhos de Porto Alegre, Porto Alegre, RS, Brazil

^VIMedical student, UCPEL, Pelotas, RS, Brazil. Intern, Scientific Initiation Program, research group "Evaluation of services, information systems and health policies," National Counsel of Technological and Scientific Development (CNPq)

^{Correspondence}

ABSTRACT

The authors present an analysis of the psychiatric reform in Rio Grande do Sul, Brazil, using a historical perspective and an approach by three trends: institutional psychiatry; developments in the extra–hospital area; and policies of health implemented along the years. Based on the references adopted, the experience in Brazil and in Rio Grande do Sul was reviewed using the following sources: MEDLINE and Lilacs databases and official documents from the Brazilian Health Ministry and from the Health State Secretary.

Nowadays, 14 years after the promulgation of State Law 9716, which refers to the psychiatric reform in Rio Grande do Sul and determines the progressive replacement of psychiatric hospitals by a network of full mental health care, the number of psychiatric beds was reduced in 35% and the proposal of an "alternative" care network to the mentally ill was not implemented as recommended, neither in an equal form.

Bearing in mind that the present challenges, such as the phenomenon of the "revolving door" and the chronicle patient, show the necessity of extending primary and secondary care. The experience in Rio Grande do Sul brings into debate the possibility of changing the strategy, so that, instead of trying to structure "a system inside the system," as is placed today, more benefits can be drawn from the integration of mental health with the main programs in the Brazilian Unified Health System (SUS), such as Family Health Program (PSF) and Community Health Agents Program (PACS).

Keywords: Psychiatry, hospital, psychiatric reform, health policies, evaluation of services, health economics.

Introduction

Psychiatric reform is inserted in the context of changes that have taken place in the health sector over the past 50 years of the 20th century. These are associated with a set of political changes occurred after the Second World War, which consolidated human rights and democracy as a value to be defended and preserved. In that same setting of social rights, health, service users' and psychiatric patient's rights become a relevant and integrating part of this theme.

Concomitantly to those political and social changes, there has been a technological revolution that directly affects the health sector. In psychiatry, such revolution is represented by huge progresses in therapies, starting with penicillin and antibiotics, which changed the demand profile of classical psychiatric hospitals by eradicating from its care universe brain infections and neurosyphilis. At the same time, modern psychopharmacology begins, with the advent of chlorpromazine in the 1950's and evolving throughout the years, changing the epidemiologic profile and morbidity of traditional mental diseases.

This metamorphosis occurred in all countries in different forms and rhythms. Such diversity could be explained due to different velocities to incorporate therapeutic technologies, ability to finance health systems of each particular society and also due to the priority given by societies to values associated with democracy and human and civil rights.

Anyhow, what can be seen today is that the psychiatric reform is an irreversible process and implies a wide reorganization of health care attention, based on providing prevention, outpatient and emergency care, in hospital psychiatry, both in general and specialized services, as well as strategies in psychosocial rehabilitation. Such reformulation should have integrality of actions, their multidisciplinarity and universality as its foundation, based on epidemiologic references, but obeying the managerial elements that optimize the cost/benefit ratio and quality of organized services provided in the health system.¹

This article aims at analyzing the psychiatric reform in Rio Grande do Sul 14 years after the promulgation of the current legislation, using a historical perspective, official and institutional data corresponding to 2002–3 and an approach by three trends: institutional psychiatry, developments in the extra–hospital area and policies of health implemented along the years.

History in Brazil

The hospital sector in Brazil, until the late 19th century, was characterized by a network of large public hospitals, mainly distributed across the country capitals and remarkably concentrated in the federal capital, Rio de Janeiro. The establishment of the post–republican federative organization gave origin to the process of decentralization and creation of organized services around charity and state public hospitals. In this context, psychiatric hospitals acquire the role of social care and shelter for marginalized individuals, to the detriment of the medical, therapeutic and rehabilitating function.²

Over the first decades of the 20th century, in Pernambuco, Dr. Ulisses Pernambucano, a pupil of Dr. Juliano Moreira, was already discussing the aspects of humanization of care, psychosocial rehabilitation, outpatient approach and cross–cultural research, anticipating the current proposals of psychiatric reform. However, in the 1930's, with the establishment of Vargas' dictatorship, Dr. Pernambuco was arrested and persecuted, due to his social research, thus interrupting a whole debate around those issues.²

In the 1950's, there was a significant change concerning social issue and health sponsorship. Pension funds and retirement and pension institutes were developed, sponsoring medical care for their members. Based on this fact, there is the beginning of democratization of medical care in Brazil, as well as of the development of social security and health system. Health care is no longer dichotomic between private patients and indigents and starts caring also for insured patients, significantly widening its social coverage.

Concomitantly with these social cultural changes, there is an important technological and scientific improvement, especially after the introduction of modern antibiotics (penicillin and others) and phenothiazine neuroleptics, which gave origin to modern psychopharmacology, deeply changing the epidemiologic profile of psychiatric hospitals.

In the 1960's, there was an increase in outpatient care, encouraged by the growing demand of institutes and pension funds, and in 1964 the military coup d'état instituted an authoritative model and unites the institutes, thus creating unified national social security and medical care in that context – Instituto Nacional de Previdência Social [National Institute of Social Security – INPS], Instituto Nacional da Assistência Médica da Previdência Social [National Institute of Medical Care and Social Welfare – INAMPS].

During the 1970's, along with the economic miracle and the expressive growth of the population, there was the establishment and development of welfare medicine. However, by the late 1970's and early 1980's, as a result of general economic crisis (oil crisis, dictatorship and external and social debt) and security and welfare, a new stage of severe financial, administrative, political and ideological difficulties takes place.² The Federal Government then tries to justify the crisis in Social Welfare, blaming medical services and service providers for the problems in the system.

The 1980's are characterized by a deep economic and structural crisis in the Brazilian welfare system, which occurs in association with the progressive deterioration of remunerations paid by the Welfare to service providers. Concomitantly with these issues, the system is globally reformulated, and in this context the movement for the so–called "sanitary reform" is started. At the same moment, international discussions on new care models reflected in Brazil, remarkably in São Paulo, Rio de Janeiro, Minas Gerais and Rio Grande do Sul.³

There are then national debates on the role of psychiatric hospitals, such as in the First National Conference of Mental Health, which took place in 1987 and whose main themes were "reversion of hospital–centered tendency" and "rescue of mental patient's citizenship." Proposals for the psychiatric reform were being discussed and, in 1989, the Act 3657 (Project Paulo Delgado – PT/MG) was issued, basically proposing the implementation of a network of extra–hospital care, progressive extinction of beds of an asylum nature and compulsory communication of voluntary hospitalizations.

Some determinant factors for the implementation of a mental health policy, at a national level, after 1991, were the transference of INAMPS for the Health Ministry and the creation of the Brazilian Unified Health System (SUS) with the approval of the Organic Health Law 8080 and 8142 in 1990, which has as basic principles universalization, integrality and hierarchization of actions, providing access to health for all individuals. Before SUS, all care was linked to welfare contribution, thus excluding a significant part of the population.

Also in 1990 the "Declaration of Caracas" was published, proposing the extinction of the hospital–centered model, humanization of psychiatric hospitals and widening of rights for individuals with mental disorders. This document was a result of the Regional Conference for Restructuring Psychiatric Care in the Continent, called for by the Pan–American Health Organization (PAHO) and World Health Organization (WHO) and sponsored by Institute Mario Negrí, from Milan. Repercussions of this discussion were materialized as Ministry Edicts, such as those by the National Secretary of Health Care: Edict 189/91, which widened and diversified the procedures included in the tables of the System of Hospital Information (SIH–SUS) and of the System of Outpatient Information (SIA–SUS); and Edict 224/92, which established minimum standards for mental health care services in Brazil.

Other important documents were the Basic Operational Norms (NOB) 93 and 96 and the Operational Norm of Health Care (NOAS–SUS), issued in January 2001, which determines that citizens should have access, as close as possible to their place of residence, to a group of actions and services linked to some minimum responsibilities, among which is the "treatment of most frequent mental and psychosocial disorders."

In April 2001, Act 10.216 imposed a new impulse and rhythm for the psychiatric reform in Brazil, dealing with protection and rights of people with mental disorders and redirecting the care model in mental health, thus complementing Decree 24.559, issued in July 1934.

After the creation of the Program "Back Home," the process of deinstitutionalization of patients hospitalized for a long period is accelerated. Such program aimed at social reintegration of people affected by mental disorders, coming from long hospitalization periods, according to criteria defined by Act 10.708, issued on July 31, 2003, which includes the payment of psychosocial rehabilitation support. Act 10.708 regulates this program, in association with Edict 2077/GM, issued on October 31, 2003.

By the end of 2001, the III National Conference on Mental Health is held in Brasília, consolidating the psychiatric reform as a government policy, providing the Center for Psychosocial Care (CAPS) with the strategic value to change the care model.

In 2002, after a series of normalizations of the Brazilian Health Ministry, the process reducing psychiatric hospitals and beds and deinstitutionalization of long–hospitalized people gained a new impulse, with a reduction of 6,227 specialized hospital beds from 2003 to 2005.^3,4

Besides those essential landmarks, there were also other measures, created to regulate and operationalize new services, such as, for example, Edict 824/99 by the Health Ministry (HM), which deals with the regulation of pre–hospital care; Edict 1077/99 HM, which implemented the program for acquiring crucial medications for the mental health area; Edict 106/00 HM, which created new therapeutic services; Edict 44 HM, which instituted the hospital–day care model; and Edict 251/02 HM, which established the guidelines and norms for hospital care in psychiatry, reclassified psychiatric hospitals, defined the structure to be hospitalized in psychiatric institutions for SUS, and provided other measures.

History of psychiatry in Rio Grande do Sul

Psychiatry in Rio Grande do Sul starts with the inauguration of Hospital São Pedro in Porto Alegre in 1884, which, highly influenced by the French school, inaugurated in 1924 the service of mental prophylaxis in this state. This center was the only reference in care for mental patients in the state until 1931, when Sanatório Henrique Roxo (later Clínica Olivé Leite) was built in Pelotas.

Despite the use of the most advanced therapeutic techniques of that time, such as malariotherapy, moral treatment, barbiturates, insulintherapy, convulsive therapy, electric convulsive therapy, as well as labor therapy, hospitalizations were multiplied, and overpopulation and gigantism became a problem of hard solution for Hospital São Pedro.

In the 1950's, what can be called the "first psychiatric reform" was started, with the introduction of antibiotics and psychotropics in therapeutic routine. The drugs used since then have allowed mental patients to leave hospitals to communities and again have social experience with their families.

Changes in the context of psychiatric hospitalizations took place worldwide, and Rio Grande do Sul followed them, under the support of the graduate course in Psychiatric Clinic at Faculdade de Medicina da Universidade Federal do Rio Grande do Sul (UFRGS). In the 1960's, with a total of 5,500 inpatients, Hospital São Pedro started its reform process. Sociotherapy is then organized, labor therapy is widened and multidisciplinary and professional participation in care team is increased. Patients start receiving care by a multidisciplinary team, under a social and family perspective and based on dynamic psychiatry and model of therapeutic community.

During that same period, based on international experiences of new care models for mental patients, mainly focused on replacing the hospital–centered model, there was the movement known as "deinstitutionalization" of inpatients at Hospital São Pedro, directly linked to the historic evolution of the psychiatric reform in Rio Grande do Sul.

Such policy, continued for more than 30 years, has influenced every psychiatric institution in the state and, to a higher or lower level, was implemented in all Rio Grande do Sul.

A clear example of these changes is the data obtained from Clínica Olivé Leite, located in Pelotas. Throughout its history, there is a clear evolution in care, especially characterized by the extinction of asylum–based behavior, as chronically institutionalized patients, which, in the 1930's, reached the percentage of almost 18% of hospitalized patients, but was not more than 0.8% in the 1990's. In addition, there was reduction in mean permanence time from 256 days in the 1930's to 130 days in the 1940's, 92 days in the 1950's, falling to 57 days in the 1960's, reducing to 52 days in the 1970's and reaching 44 days in 1985. Another evidence of this evolution is the change in discharges due to deaths, which fell from 3.5% (1930's) to 0.01% in the 1990's.¹

Those data characterize a deep reformulation and later show the phenomena that will be the great challenges for mental patients' care over the following years: the "new chronic patient" and "revolving door," which represent a group of patients that is responsible for half of hospitalizations/year of services, and to which it is crucial to formulate more adequate care models.

Worldwide, discussions on reformulation and improvement in care to mental patients have multiplied. These ideas had a large influence on our state, such as, for example, the inauguration of the first hospital–day in Rio Grande do Sul in 1961.

In 1965, supported by the Action for Mental Health, launched during Kennedy's government, the "Chronic Plan" is created, with the aim of rehabilitating chronic patients, and the "Extension Plan of Psychiatric Care Services," as an attempt to deinstitutionalize care to mental patients and promote concepts of preventive care.⁵

The 1970's were particularly remarkable. What can be called the landmark of the "second psychiatric reform in Rio Grande do Sul" takes place: division of health care into sectors concomitantly with an internalization plan, promoted by the Department of Health, which was based on hiring beds in private hospitals in the countryside, on the location of relatives by the social service, on programs of social insertion and on capacitation of physicians and professionals in the health area all over the state to receive patients with more technical conditions, thus meeting a greater demand, reducing the number of new hospitalizations and aiming at a progressive deinstitutionalization. After those actions were taken, around 65% of inpatients were discharged until the early 1980's.^5,6

In the 1980's, there is the "anti–asylum movement," or the "third psychiatric reform" in the state, which suggests the extinction of psychiatric hospitals. However, there was a simultaneous lack of resources and gradual deterioration of the community network.

In 1992, through Edict 224 of the Health Ministry, the norms and care services in mental health are regulated.

Until the 1990's, Rio Grande do Sul did not have a specific legislation about mental health care. After the anti–asylum movement, State Law 9716 was issued in 1992, dealing with the psychiatric reform and bringing the following regulations: "construction and reform of psychiatric, public or private hospitals and hiring and sponsoring, by the public sector, of new beds in those hospitals." The law also determines the creation of "varied services of sanitary and social care" and that "compulsory psychiatric hospitalization should be reported by the physician who indicated it, within 24 hours, to the Public Ministry." This law became known as "law of psychiatric reform and protection to individuals with psychic suffering," and according to its article 15, "within five years, after issuance of this Law, the psychiatric reform will be reevaluated as to its directions and implementation rhythm."

Current situation in Rio Rrande do Sul

After Act 9716/92 was regulated, the psychiatric model and care are no longer predominantly hospital–based, with a shift to psychiatric extra–hospital care, only allowing hospitalizations when they are essential and in the shortest time possible.

According to article 2 of Act 9716/92, "the psychiatric reform should consist of the gradual replacement of the hospital–centered system of care to people with psychic suffering by an integrated network of varied care services and social and sanitary attention, such as clinics, psychiatric emergencies in general hospitals, beds or units of psychiatric hospitalization in general hospitals, day hospitals, night hospitals, socialization centers, community centers, psychosocial care centers, residential centers of intensive cares, shelters, community public pensions, workshops of constructive and similar activities."

In 2002, by means of the Mental Health Guide, the State Department of Health in Rio Grande do Sul proposed a network of mental health care, comprised of basic mental health care, which has the health unit (primary health care facility) as reference and develops actions focused on prevention, treatment and rehabilitation performed by clinical physicians, psychologists, nurses, social assistants, nursing assistants and by the Program of Community Health Agents (PACS) and the Family Health Program (PSF). Similarly, specialized mental health care is provided, serving as counter–reference to support, assist or supervise basic care services. To do so, it gathers services as general clinics with mental health team, specialized clinics in mental health, CAPS, day hospital, urgency and emergency in mental health, psychiatric beds and units in general hospitals and finally temporary therapeutic home services.⁷ More specific aspects of each type of service are described in Table 1.

Over the first years of the 21st century, the first deleterious effects of reducing hospital beds and of the insufficient structuring of alternative models start being perceived. There are movements in the civil society demanding a review of 1992 legislation and stressing the need of reopening vacancies and specialized beds.⁸

At the 3rd Regional Health Coordination (CRS) and, more specifically, in the municipality of Pelotas, the city hall developed, throughout the 1980's and 1990's, an integrating effort by the mental health team in the network of primary care and in primary health care facilities. According to the Mental Health Coordination of the 3rd CRS, in 2002 Pelotas had 54 primary care facilities, of which 25 were controlled by the "Mental Health Service," a program of monthly visits, performed by a specialized team, to primary care facilities, for specialized care and supervision of primary care in mental health.

The benefits of incorporating psychiatric care to basic health care can be seen by comparing Pelotas and Rio Grande, both municipalities located in Rio Grande do Sul, in a study that demonstrated a strong impact of structuring mental health care services at the network of primary care on the profile of psychiatric hospitalizations, especially by reducing hospitalizations of schizophrenic patients. It was possible to observe an inversion in the prevalence of admissions of male schizophrenic patients and alcoholics between both municipalities. Rio Grande, which has a limited network, composed of only one psychiatric hospital and a small specialized outpatient clinic, presented hospital prevalence of 36 schizophrenic patients and 25 alcoholics per 1,000 inhabitants. Pelotas, which had at the time of the study a wide care network, equipped with nine teams – each composed of a psychiatrist, a social assistant and a psychologist, acting in 12 primary health care facilities and two specialized outpatient clinics, one group working at an integrated mental health center for students and adolescents and finally another group responsible for providing care to the homeless in night shelters – had 16 schizophrenic patients and 34 alcoholics per 1,000 inhabitants.⁹

These data reveal another aspect to be approached: the problem related to alcoholism in men. These patients have the most prevalent disorder (15%) in psychiatry and can take all the beds previously used by schizophrenic patients. This phenomenon reveals a lack of public health policies concerning alcoholism, even where there already is a community mental health care network.^9–11

According to the information provided by the State Department, care services to mental patients, by mid–2002, were distributed according to Table 2.

Based on the data presented by the Mental Health Coordination of Rio Grande do Sul, it can be observed that there is a concentration of extra–hospital cares at the 1st CRS, which corresponds to Porto Alegre urban area, usually concentrating services in a given municipality. Therefore, approximately 15% of state municipalities do not have any type of mental health care, opposing the Operational Norm of Health Care (NOAS–SUS), which states that access should be as close as possible to patient's residence. Such situation forces most patients to travel long distances to receive psychiatric care.

An important issued to be discussed is the function attributed to CAPS and to day hospitals, which, according to the Mental Health Guide of the Health Department of Rio Grande do Sul, "represent an intermediate resource between hospitalization and outpatient clinic, providing intensive care by a multi–professional team and aiming at the replacement of full hospitalization." However, what can be seen is the extinction of the hospital network, without the implementation of an adequate replacement model to meet the demand of the population, since day hospitals, in case they existed, would not even be related by the Health Department of Rio Grande do Sul, and CAPS are still insufficient and poorly distributed into several regions of the state.

Another observation that draws attention is the fact that urgency and emergency services for psychiatry are only registered as such when they are located in a general hospital, thus excluding, for example, two psychiatric emergency services linked to psychiatric hospitals located in Pelotas, in which around 40% of cares are provided to people coming from other municipalities.

With regard to hospital network, the number of available psychiatric beds in the state has had a marked reduction over the past years, equivalent to a negative variation of 35%.^12–15 This phenomenon was one of the consequences of Act 9716, which "determines the progressive replacement of beds in psychiatric hospitals by a network of full care in mental health."

The distribution of beds destined to psychiatry, by mid–2002, can be seen in Table 3, with information about the total population of each CRS in Rio Grande do Sul, beds distributed in general and specialized hospitals, number of beds recommended by the Health Ministry (around 0.5 beds/1,000 inhabitants) and by WHO (aroudn1 bed/1,000 inhabitants) and also the difference between the total number of available beds and the ideal number according to the Health Ministry.

As well as in extra–hospital services, there is also an unequal distribution of beds between municipalities. There is a high lack of beds at the 1st CRS – around 1,030 – whereas in every other CRS, the resulting value is also negative. The 3rd CRS is the only that has enough beds, according to the Health Ministry; as a consequence, it receives patients from all other CRS. However, in 2003, 199 beds were removed from the network, after another specialized hospital was closed down in the state.

An analysis of what has been exposed shows that Rio Grande do Sul in fact has a reduced number of beds. According to the Health Ministry, Rio Grande do Sul should have, in 2001, 5,155 beds and, according to the World Health Organization, 10,310 beds. However, there were only 1,874, i.e., 0.18 beds per 1,000 inhabitants. Since 1993, there has been a reduction in the number of beds in specialized hospitals, falling from 2,262 in 1993 to 1,471 in 2002. Despite the number of general hospital beds having increased from 366 beds in 1993 to 403 beds in 2002, such increase is still small and does not meet the demands of each coordination.^7,16

Similarly, when analyzed under the perspective of sponsorship in 1999, Rio Grande do Sul used around 3% of the total national amount of SUS expenses in psychiatry, which is approximately the same as Goiás (3.4%), which has half of its population, and less than half of Pernambuco (6.7%), with a similar population.¹⁷

The cost of psychiatric Authorization for Hospitalization (AH) in 1999 was R$ 510.07, representing one of the lowest in the country, below the national average of R$ 538.65.¹⁷

Psychiatry in Rio Grande do Sul has been reducing its percentage participation over the total national expenses on general hospitalizations. In 1999, this percentage was 3.5% over hospital expenses (approximately equal to Distrito Federal – 3.1% – which has 1/5 of its population), whereas the Brazilian average was 9.4% and presented a negative variation of 20% between 1995 and 1999.¹⁷

Expenses per capita in psychiatry per inhabitants/year, in 1999, was R$ 1.36 (Rio de Janeiro was the state with most expenses, R$ 5.59), and Rio Grande do Sul was among the 10 lowest in Brazil. In 2001, it presented expenses per capita of R$ 1.33, below the national average, which was R$ 2.76. From 1997 to 2001, Rio Grande do Sul had a negative variation of 11.9% in expenses per capita in psychiatry.^{11,12,14,16,17}

In addition, concerning day hospital expenses, there is a similar stagnation as to resources used. In 1996, such expenses were R$ 175,000 and, in 1999, they remained at the same level, but there was a negative variation as to percentage destined to this service by SUS, which in 1996 corresponded to 3.2% of the national total and in 1999 was only 1.7%. More updated data, recently published, demonstrate that, in 2000, that amount was reduced to R$ 155,234 (only spending more than Pernambuco – R$ 122,000 – and Mato Grosso do Sul – R$ 96,000), representing, between 1995 and 2000, a reduction of 11.4%, whereas Brazil, over the same period, had an increase of 206.77% in day hospital expenses.^17,18

The percentage of day hospital expenses in Brazil over the total AH was 0.2% in 1999, whereas in Rio Grande do Sul it remained, between 1997 and 1999, corresponding to 0% of the total national AH, behind states such as Piauí (0.9%), which had less than 1/3 of the population of Rio Grande do Sul, and Distrito Federal (1.0%), corresponding to 1/5 of the state population.¹⁷

Per capita day hospital expenses in 1999 were R$ 0.02, whereas the Brazilian average was R$ 0.06. There is a marked deficit compared with other regions in the country, such as Piauí, which presented in 1999 expenses per capita of R$ 0.26, 13 times higher than Rio Grande do Sul, or Distrito Federal, with R$ 0.31.¹⁸

In 2000, the frequency of AH with day hospital was 291, only higher than Pernambuco (191) and Mato Grosso do Sul (154), and between 1995 and 2000, Rio Grande do Sul had a positive variation of 58.9%, whereas Brazil had a positive variation of 202.56%.¹⁸

In Rio Grande do Sul, the number of psychiatric AH in 2000 was 27,977, lower than the volume presented by Goiás (29,218 AH), which has half the population of that state.¹⁸

The number of psychiatric hospitalizations in 2000 was 18,440, with a variation of + 8.5% between 1995 and 2000. However, when psychiatric hospitalizations are calculated per 1,000 inhabitants, Rio Grande do Sul is among the states with fewer hospitalizations, with a rate of approximately 1.8 hospitalizations–year/1,000 inhabitants in 1995 and maintaining the same rate in 2000. When compared with other states, there are remarkable differences, such as, for example, Rio de Janeiro, which had 4.1 hospitalizations–year/1,000 inhabitants in 2000. Annual costs with psychiatric hospitalizations in Rio Grande do Sul in 2000 were R$ 12,797,202.00, with positive variation of 0.7% between 1995 and 2000 (over that same period, the state population grew 4%). Increase in national expenses was 7.2% (the Brazilian population grew 5% over that period).^17,18.

Final considerations

We can conclude, after analyzing the data above, that Rio Grande do Sul spends very little on psychiatry. In addition, it has low–cost services, when compared with other Brazilian states, with low rates of psychiatric hospitalization and progressive reduction in expenses.

Today, more than 10 years after Act 9716, what can be seen is a lack of beds (according to criteria by WHO and Brazilian Health Ministry), both in specialized hospitals and in general hospitals. The proposal of implementing an extra–hospital network to support mental patients was not established in an equal fashion, and a reevaluation of what should have occurred 5 years after the publication of the Law of Psychiatric Reform was not performed.

However, there are positive aspects, such as the communication routine of compulsory hospitalizations to the Public Ministry, which provides more safety for the medical work and for patients, who are more protected by public care services.

Despite failures in the Law of Psychiatric Reform, Rio Grande do Sul nowadays spends less and is more efficient than most Brazilian states. This is mainly due to some peculiarities that existed in the state and that allowed progressive dehospitalization, decentralization and multidisciplinarity in providing care to mental patients. Nowadays, results of a 30–year intervention focused on the community are evident, besides a natural expansion of access to services and distribution of basic medication.

Throughout history, there were no models that could be a panacea or universal solutions, since for a new care proposal, it is necessary to consider social, cultural and economic factors and peculiarities of each region and of each country. Such principles and those proposed by the Caracas Declaration – "restructuring of psychiatric care linked to Primary Health Care and in Local Health Systems provides alternative models centered on the community and on social networks" – develop the proposal of incorporating mental health actions in basic care to a diversified network of services composed by PACS and PSF, followed by an efficient plan of drug distribution.

This brief history shows that the psychiatric reform has already taken place in Rio Grande do Sul in terms of dehospitalization or "dismantling" of the hospital network. The base of this reform, concerning Rio Grande do Sul, was the reduction in the hospital park and in investments, but throughout the decade there was no adequate configuration of spaces and standardized "alternative" resources.

Such delay in implementation, recognizably negative, could become an advantage, since today, after the implementation of SUS and its large–scale programs in the country, it could provide a restructuring of the model and integration of mental health to the practices and general programs of the system (PSF and PACS).

The experience and the example of Southern Rio Grande do Sul raise the debate on the possibility of changing the strategy, so that, instead of trying to structure a "system within a system," as it occurs today through CAPS, for example, more profits and better cost/benefit ratio could be achieved from the integration of mental health to SUS basic programs, such as PSF and PACS.

Nowadays, challenges and problems are similar and due to the need of primary and secondary cares, confronting new challenges, such as the "revolving door" and the chronic patient phenomena in their new manifestations, also faced by Italy, France, USA, Spain and England.

People with mental disorders, despite psychiatrists' claims, exist and should not be ignored. Psychiatric hospitals are efficient and necessary therapeutic alternatives in crisis situations and should be remodeled and modernized, not extinguished. The idea that having a specialized hospital service would avoid advancing to an adequate care model is a mistake, confirmed by the experience in other countries and in Rio Grande do Sul in the 1970's and 1980's, when psychiatry and mental health care were hand in hand with psychiatric institutions.

Acknowledgments

To FIDEPS [Incentive Fund for the Development of Teaching and Research in Health by the Brazilian Health Ministry] for its sponsorship and to Professor Nize Terezinha Martins Antunes for reviewing the original article.

References

Received September 15, 2005.

Accepted September 12, 2006.

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*

This study is linked to the Group of Evaluation in Services, Information Systems and Health Policies, CNPq, and was developed at Clínica Olivé Leite, in Pelotas, RS, Brazil.

Publication Dates

• Publication in this collection
  06 Sept 2007
• Date of issue
  Apr 2007

History

• Accepted
  12 Sept 2006
• Received
  15 Sept 2005