Análise da implantação da política de saúde mental na Bahia: o processo de transição do modelo assistencial entre 2001 e 2021.

Abstract

After twenty years the approval of the Federal Law 10,216, a landmark of the reorientation of the mental health care model in Brazil, it is necessary to evaluate the implementation of the policy of mental health, alcohol and other drugs in Bahia. It is important to know how the implementation of this policy occurred, what were the characteristics of the context, what were the dynamics and what results were achieved. This study aimed to 'analyze the implementation of the mental health policy between 2001 and 2021, considering the transition from the hospital-centered model to the psychosocial care model, having as units of analysis the state context of Bahia'. The reorientation of the care model had as theoretical and practical foundation the 'deinstitutionalization', understood as a set of administrative, operational, managerial, interpersonal actions, which gradually modify the ways of dealing with the insane and with madness. This research is characterized as a case study on the mental health policy of Bahia. With a descriptive-explanatory methodology, we combined quantitative and qualitative data. A triangulation of methods was used. The main sources were: laws and ordinances, official health policy databases, health management instruments, archives of institutions in the mental health field, and consultations with public organs. Based on the logic model of the National Policy of Mental Health, Alcohol and other Drugs (PSMAD), two dimensions were analyzed: the political-managerial dimension and the technical-assistance dimension. The components of the policy and the advocated image-objective were analyzed, comparing the local outcome and the national parameters. It was assumed that, in Bahia, the state health management had low induction capacity to implement a policy with the complexity of the PSMAD. The analysis of the 'political model' allowed us to characterize the support that the agents of implementation (policy operators) offered for the operationalization of this process. The results indicate that Bahia has configured a hybrid model, composite, a combination of heterogeneous paradigms, where community services, born from the Brazilian Psychiatric Reform, coexist with old services such as psychiatric hospitals and Therapeutic Communities. In the technical-assistance dimension, there were advances and shortcomings. Between 2005 and 2021, Bahia reduced 80.11% of the beds in psychiatric hospitals, while it currently has 264 Centers for Psychosocial Attention (CAPS) enabled in 211 municipalities. Thus, in Bahia, the average number of CAPS per 100,000 inhabitants is 1.18, proportionally higher than the average in Brazil, which was 1.04 in the year 2021. However, in Bahia there is significant insufficiency of many of the services of the Psychosocial Care Network (RAPS); there is low coverage of CAPS III, CAPS AD, and CAPS IA. The number of Reception Units, Living Together Centers, mental health solidarity economy enterprises, etc. is also insufficient. It was verified a low articulation among the CAPS, the Primary Care services, and the Urgency and Emergency Network services. Salvador has an average coverage of mental health services below the average of Brazil and Bahia, besides the low integration among the existing services. In the political-managerial dimension, it was verified that the state health management had a low capacity of 'conduction or direction' -government capacity- to overcome the impasses resulting from the reorientation of a care model with the complexity of the psychiatric reform. This confirms the initial hypothesis. Even recognizing the important transformations that took place in this period, it can be concluded that, in Bahia, the reorientation of the mental health care model is currently an unfinished process. The image-objective of this policy was reached in a partial way, with deficits in several aspects: care coverage, intersectoriality, training, diversification of supply, psychosocial reinsertion actions, etc. It is suggested that the management and assistance devices be improved in order to advance in the change of the deinstitutionalization paradigm.