1 As several countries in Latin America and the Caribbean, Chile was strongly influenced by the Caracas Declaration in 1990 and its call to replace a care system based mainly on mental hospitals by community services [1, 2]. The return to democracy in Chile in the same year, after 17 years of dictatorship by Pinochet, contributed to create a new cultural and political atmosphere favorable to address social problems. Access to care has long been a challenge in the country, which used to have a high level of unmet need for treatment of mental disorders and human rights violations in large psychiatric institutions [3].
2 With the implementation in 1952 of a publicly funded national health care system, Chile developed an extensive network of primary, secondary, and tertiary care facilities. This system is funded by tax revenue and payroll contributions, and covers 78% of the population, mainly blue-collar workers and indigent people, who receive health care services and medication free of charge. This public health system has been used for the integration of new community-based decentralized mental health services [4].
National Mental Health Plans
3As it has been recommended by the World Health Organization (WHO) [5], explicit mental health policies and plans have provided the Chilean Ministry of Health with critical tools to develop a new model of mental health care. The first national mental health plan was launched in 1993, and it was successful in implementing innovative local experiences on a small scale. New facilities were implemented, including day hospitals, group homes and community mental health centres. New programs were developed, such as mental health components in primary care, psychosocial rehabilitation, and inpatient units in general hospitals. All these innovations had a small population coverage because of the limited resources allocated by both national and local authorities. One critical development was the installation of two or three staff members in each of the country's twenty-nine health districts, who were charged with implementing the mental health national plan at local levels, coordinating mental health services networks, managing the budget, planning for additional services, and evaluating the care provided.
4 The lessons learned from the implementation of the first plan and the experience from psychiatric reforms in other countries were an important input to the development of a second national mental health plan in 2000. The core values of this plan were a community approach, promoting the capacities of individuals and groups, an active participation of users and families, a comprehensive view of human beings (biological, psychological and social dimensions), accessibility and quality of care, and comprehensive actions, including promotion, prevention, treatment and rehabilitation. The main strategies utilized to implement the plan were [4]:
- formulating evidence-based national programs focused on seven priority areas: promotion and prevention, attention deficit hyperactivity disorder, domestic violence, depression, schizophrenia, drug and alcohol abuse and dependence, Alzheimer's disease and other dementias;
- implementing a network of mental health facilities in each catchment area. The two key facilities of this network were the primary care centers as the entry point for the treatment for all mental disorders and as the main providers of mental health care, and decentralized secondary care facilities, especially in the form of community mental health centers;
- developing and disseminating clinical guidelines and standards;
- estimating mental health care gaps and resources necessary to overcome them, with the goal of increasing mental health care funds from 1.3% of the global health budget to 5% by 2010 and an increasing allocation of funds for primary care;
- working with other sectors outside health at national and local level;
- participation of persons with mental disorders and their families in the planning and evaluation of mental health services.
Community Mental Health Teams
5A critical aspect for the gradual replacement of the psychiatric hospital functions has been the implementation of community mental health teams in all regions of the country. These teams are composed of psychiatrists, psychologists, occupational therapists, nurses and social workers, and they have the role of providing treatment and rehabilitation for people with severe mental disorders. The majority of users receives both traditional and new generation psychotropic medications, including the entire spectrum that is commonly used in psychiatry: antidepressants, anxiolytics, typical and atypical antipsychotics, and mood stabilizers, which are delivered free of charge. Slightly more than half of the users also receive brief individual psychotherapy by psychologists, who are most frequently trained on psychodynamic approaches. Almost all users receive some other form of individual, family or group psychosocial intervention, delivered by non-psychiatric professionals: psychoeducation, social and work skills training, workshops on managing emotions and relaxation, multi-modal programs for handling substance abuse and dependence, mutual aid groups, and different types interventions delivered at home and in other community places.
6 Another function of community mental health teams is the coordinated work with primary health care teams, and especially with general practitioners and psychologists of these teams. Each specialty mental health center has an assigned territory and there are several primary health care centers in each territory. Each territory defines its protocols for referral and counter-referral between these facilities, but the national standard is that people can only access the specialty centers through a referral from primary care. One or two professionals from a community mental health team visit each primary care center once a month in order to analyze more complex cases and empower primary care teams in their clinical and community management. Thus, about 80% of users with mental disorders are treated by general practitioners, psychologists, social workers and other primary care professionals, although they receive a more limited range of options for psychotropic medications and psychosocial interventions than in the specialty facilities.
7 National policy states that health districts must have one community mental health center with specialized teams for a population of 50,000 to 100,000 people. However, due to limited resources and / or resistance towards the community model from local authorities or professional teams, the community mental health teams work in some districts in an outpatient psychiatric unit at a large medical facility, usually associated with a general hospital, covering a population of approximately 100,000 to 400,000 people. The main differences between community mental health centers and outpatient psychiatric units are that the former have better geographic accessibility, lower mobilization cost for users, lower proportion of psychiatrists in their professional staff, higher frequency of psychosocial interventions and a higher number of users treated in community places.
Macro-level indicators of the mental health reform
8 Although the target of 5% of the national health budget to mental health was not fulfilled, reaching only 2.08%, there was an important increase in resources for mental health care in the public system because the overall health budget increased significantly in the last 25 years. Most of the new funds have been used to strengthening the role of community-based facilities in the delivery of mental health services. Between 1990 and 2012, the expenditure on community services increased from 26 to 79% of the total mental health budget, while the expenditure on mental hospitals decreased from 74 to 21% ( figure 1 ). Most of the national health budget is now allocated to specialist outpatient services (36%) and to the mental health program in primary health care (26%) [6].
Figure 1. Mental hospital and mental health community services expenditures as percentage of all mental health budget: Chile 1990-2012.
Figure 1. Mental hospital and mental health community services expenditures as percentage of all mental health budget: Chile 1990-2012.
9 There has been an augmentation of mental health expertise of primary care teams and all urban primary care centres and many rural centres have developed a mental health program. Almost all of these facilities have incorporated psychologists to their staff and receive consultation from the local outpatient mental health specialist service through monthly visits of psychiatrists, psychologists, or other professionals, primarily aimed at supporting the primary care teams in their management of difficult patients. The primary care mental health strategy with the highest level of development is a comprehensive program for the treatment of depression led by psychologists and general practitioners [7]. With the implementation of these measures, the annual number of visits to primary care medical doctors for a mental health condition in the public sector increased from 13.6 per 1,000 population in 2000 to 57.8 in 2013, while the visits rate to psychiatrists increased only from 30.3 to 36.7 per 1,000 population in the same period (according to information obtained from the Departamento de Estadísticas e Información de Salud, Ministerio de Salud).
10 Parallel to the development of mental health in primary care, the number and capacity of mental health specialized facilities increased significantly, except mental hospitals (table 1). The most notable changes are the increase in community mental health centres, day hospitals and group homes. Mental hospitals play a much smaller role in the Chilean mental health system today. Between 1990 and 2012 nearly half of its acute beds were closed, as well of two thirds of its total beds (table 1).
Table 1. Changes in the number of secondary and tertiary mental health facilities in Chile from 1990 to 2012.
Table 1. Changes in the number of secondary and tertiary mental health facilities in Chile from 1990 to 2012.
Meso-level indicators of the mental health reform
11 Processes of care and human resources indicators in mental health facilities show wide variations among the 29 health districts in which is divided the Chilean territory. For example, a study of the Ministerio de Salud (table 2) [6] demonstrated that the rate of people receiving treatment in outpatient specialist services in 2012 fluctuated from a minimum value of 454 to a maximum of 2,669 per 100,000 population, with a national median of 1,218. The length of time waiting for the first non-urgent visit to a psychiatrist varied between 15 and 129 days in different health districts (national median of 33 days), and the ratio between outpatient/day care contacts and days spent in all the inpatient facilities (mental hospitals, residential facilities and general hospital units) varied between 0.4:1 and 8.9:1 (median of 2.3:1). The number of hours of specialized professionals available per week in outpatient mental health facilities can be as low as 232.5 per 100,000 population in a health district and as high as 941.5 in another (median of 367.8) (2table 2).
Table 2. Mental health specialist outpatient facilities: process and human resource indicators by health district in 2012.
Table 2. Mental health specialist outpatient facilities: process and human resource indicators by health district in 2012.
Micro-level indicators of the mental health reform
12Several studies of the quality of care in mental health facilities in Chile have shown poor compliance with standards in some quality areas and important differences in the level of quality of care among different facilities [8-10]. A study that applied the World Health Organization (WHO) tool “QualityRights” on a representative sample of mental health outpatient facilities showed that none of them complied fully with the quality of care and human rights standards that promotes the WHO and that in some facilities the level of compliance of them was highly insufficient ( figure 2 ) [8]. A low level of achievement was found in most facilities in terms of mental health teams supporting users to cope with community living, access to education or work, participation in community activities, respect for user treatment preferences, and preventive measures to avoid maltreatment and cruelty [8]. Total scores for the set of 18 QualityRights indicators show lower values in interviews with users and families compared with staff, and in three of the four areas studied, significant differences were observed, with users and relatives also perceiving a lower percentage of compliance with standards than did the staff, and the area of rights to inclusion in the community was the one with the greatest difference among the three groups interviewed [11].
Figure 2. Human rights observance in a representative sample of 15 outpatient facilities in 2013-2014 (percentage of achievement in WHO QualityRights standards) [8].
Figure 2. Human rights observance in a representative sample of 15 outpatient facilities in 2013-2014 (percentage of achievement in WHO QualityRights standards) [8].
Discussion
13The reform of mental health services in Chile has been successful in transforming the mental hospital-based model, although it has been implemented at a slow pace over 25 years and still has not been completed fully. In the region of the America, only two other Latin American countries, Brazil and Panama, and one English Caribbean have truly transformed psychiatric institutions into community mental health services at a national level [2]. Chile compares favorably with other countries in the region with a decrease in the number of beds in mental hospitals, the increasing number of community group homes for people with severe mental disability, the increased percentage of public mental health expenditures allocated to general hospitals, outpatient facilities, primary care and community services and their level of implementation. Additionally, the model applied to integrate mental health into primary care has been particularly effective in improving access to care for people with mental disorders, allowing to manage these disorders largely at this level [7, 12, 13]. Key elements in this process have been the role of general practitioners, the incorporation of psychologists as regular members of primary care teams and consulting and support from outpatient specialized teams.
14 The fact of having the second national mental health plan in 2000 with details about the provision of care for priority mental disorders, a clear model for the network of mental health facilities and critical definitions about resource requirements needed for treatment and rehabilitation of priority mental disorders was very important to facilitate the implementation of a community model and to allocate the new funding to community services. In this plan, the same public health language was used as the one used for physical health plans, which helped to convince many national and local health authorities to support its development.
15 The implementation of the plan did not occur flawlessly. One of the main barriers to this process has been the resistance from mental hospitals trade unions to the transformation of these hospitals into a network of community services and they have had enough power to influence government officials and members of parliament to slow down and in some cases to stop the process. The absence of a mental health law that specifies the future of mental hospitals and the need for community mental health services has been a weakness in this respect. In addition, the lack of a mental health law has also been critical for the fact that the rights of persons with disorders and/or mental disabilities have not been in the foreground. For example, several mental health facilities do not fully observe issues like legal capacity of the persons with mental disorders and their rights to live independently in the community [14].
16 Among the factors that have facilitated the process of mental health reform, national and local leadership stands out as one of the most important. In this sense, the establishment of a national team for mental health policies in the Ministry of Health and the investment in capacity building and empowerment of mental health professionals as local leaders in each health district were crucial for the development of community services throughout the country. They developed skills to advocate for more and better services and to carry out the management and coordination of mental health networks. National and local leaders have also been involved in negotiations with many stakeholders in order to have a broad base of support for the implementation of innovative strategies that follow the guidelines of the national plan.
17 Another facilitating factor has been the monitoring and evaluation of different aspects of the national implementation plan: the development of a basic information system was helpful to show both the progress of community mental health services and the gaps that such services presented. The application of the tool “The World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS)” [15], twice, (with a difference of eight years between both studies) has been extremely useful to allow the Ministry of Health and the health districts to better understand the reality of the mental health system and the changes that occurred during that period of time. Several evaluations and research projects about some of the programs and facilities, including a recent study using another WHO instrument “QualityRights Tool Kit” [16], have also provided crucial insights in how to improve services.
18 Despite the significant changes that have occurred in Chile in the last 25 years, with an increased expenditure on mental health services, an allocation of funds for community services and implementation of services closer to where people live, proportionately less people are treated for mental disorders than in countries classified as high income by the World Bank [1]. The prevalence of mental disorders treated in the public health system for the last 12 months has been estimated at approximately 5.3% in Chile [14] (3.9% in primary care and 1.4% in specialist services), while Wang et al. [17] found a treated prevalence by health services of 12.6% (7.3% in general health services and 5.3% in specialist services) in a group of twelve high-income countries. This result, associated with the high prevalence of mental disorders in the Chilean population [18], demonstrates the large treatment gap still present.
19 The main flaw of the reform of mental health services in Chile is that it has not been applied equally in all health districts. As demonstrated in table 2, there are several geographic inequities, such as differences of up to 5 or 6 times in the number of people accessing specialized health services between districts with high and low development of community mental health services. Similarly, there are differences between districts in terms of waiting times for the first non-urgent appointment with a psychiatrist (up to eight times), the ratio between outpatient services and 24 hours-residential care (up to 20 times), and the provision of professional resources in outpatient facilities (up to four times). This means that the level of accessibility, the quality of care and the community orientation of mental health services depend primarily on where a person lives.
20 Also, the level of quality of care and respect for the rights of users of mental health services is still far from what has been described by some authors as the “community perspective” [19]. Not all community mental health services provide real community-based mental health care. To be so, they need to be accessible to all affected people and their families, regardless of their geographic location or socio-economic level, be developed with the active involvement of users, their families and other stakeholders, promote the legal capacity and all human rights of persons with psychosocial disability, and include interventions in the community.
Conclusions
21The Chilean experience with mental health reform has been successful in terms of downsizing mental hospitals and increasing availability, decentralization and accessibility of services, Thus contributing to meeting the mental health needs of the population. International principles and models exist and cooperation is available for countries to implement an effective and efficient community-based network of primary and secondary care facilities, even with a modest budget.
22 Chile could improve the performance of mental health services by increasing the political will and the mental health budget in order to complete the reform process in all health districts; by introducing national policies about quality of care; by reinforcing the community approach of mental health care teams and by implementing community interventions to promote greater social inclusion. There is also a need to protect and promote the human rights of persons with mental disorders. This can be accomplished with a new legislation based on both the “Convention of Rights of Persons with Disabilities” and the standards for mental health services from the World Health Organization, informing users about their rights, understanding their needs and expectations about care and reinforcing the users’ active participation in treatment decisions.
Conflicts of interest
23 none.
Notes
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[1]
As of July 1st, 2013, the World Bank changed the classification of Chile from upper middle-income country to high-income country.
