Felipe Szabzon

Objective: This study aimed at identifying the perspectives of family carers of persons with severe mental illness (PWSMI) about the challenges they face to support community living in Lisbon Metropolitan Area (LMA). Portugal implemented a National Mental Health Plan (NMHP) in 2008, aiming to change its model of organization and delivery of care. One year after the promulgation of the plan, a severe economic recession gained momentum in the country with potential detrimental impact for caregivers in the communitarian model of care. Early research suggested that the needs of relatives of chronic psychotic outpatients were not fully met by psychiatric services, and that family carers continued to represent a major resource for PWSMI in the country.

Methods:  A sample of 40 caregivers of PWSMI from LMA were assessed by the Caring for Carers (C4C) questionnaire. The C4C is a closed answer questionnaire assessing several domains of burden and positive experiences of caregivers of PWSMI that was developed by the European Federation of Associations of Families of People with Mental illness (EUFAMI). In parallel, participant observation was performed in monthly meetings of three Mutual Support Groups of caregivers of PWSMI over the period of one year.

Results: The results are presented in two sections. The first section presents descriptive statistics of the quantitative results gathered from the C4C Portuguese sample. The second section, discuss these findings in light of the qualitative results gathered at the mutual support groups.
Discussion/Conclusion: The implementation of the NMHP significantly changed the model of mental healthcare provision and posed new challenges for caregivers of PWSMI. The aging of family caregivers that provide a large share of the caring work is an urgent challenge for the future of PWSMI living at the community. Current family carers of PWSMI are the first generation to reach advanced age in the communitarian model of care, and embody an emergent challenge in the near future. Important dimensions associated to independent living and planning for future care are still unaddressed by the current mental health reform and are discussed in this paper.

Responses to COVID-19 have included top-down, command-and-control measures, laissez-faire approaches, and bottom-up, community-driven solidarity and support, reflecting long-standing contradictions around how people and populations are imagined in public health—as a ‘problem’ to be managed, as ‘free agents’ who make their own choices, or as a potential ‘solution’ to be engaged and empowered for comprehensive public health. In this rapid review, we examine community-engaged responses that move beyond risk communication and instead meaningfully integrate communities into decision-making and multi-sectoral action on various dimensions of the response to COVID-19. Based on a rapid, global review of 42 case studies of diverse forms of substantive community engagement in response to COVID-19, this paper identifies promising models of effective community-engaged responses and highlights the factors enabling or disabling these responses. The paper reflects on the ways in which these community-engaged responses contribute to comprehensive approaches and address social determinants and rights, within dynamics of relational power and inequality, and how they are sometimes able to take advantage of the ruptures and uncertainties of a new pandemic to refashion some of these dynamics.

Abstract In Portugal, a mental health reform process is in place aiming to redefine the model of service provision. In 2008, a National Mental Health Plan (NMHP) was approved to provide policy guidance over the transition period. The NMHP intended, among others, to develop community‐based services, with a specific focus on rehabilitation and deinstitutionalization. This study aims to explore the perspectives of service managers of psychosocial rehabilitation services regarding the main challenges to support the community living of persons with severe mental illnesses (PWSMI) in the Lisbon Metropolitan Area (LMA). The paper also contextualises the provision of psy‐ chosocial services within the country's mental health reform process and character‐ ises the profile of service users in socio‐occupational units (SOUs) of the LMA. Semi‐structured interviews were performed with all SOUs’ managers of the LMA (n = 13). Information regarding service user characteristics was collected based on service records (n = 344). Interviews were analysed according to the framework methodology. The results of the interviews were triangulated using document analy‐ sis. Fieldwork took place between June and July 2016. The findings suggest that the development of the mental health reform ensured significant changes to service de‐ livery. Community‐based mental health organisations are an important actor for ser‐ vice provision. However, important asymmetries were identified in the provision of psychosocial care within the LMA. At the same time, family carers are perceived as responsible for ensuring a large part of the social needs of the PWSMI but there is an increasing concern with their own ageing processes. As a conclusion, it is highlighted the current inequality between services and the need to contemplate a life‐course perspective that comprehends the ageing process of caregivers poses an emerging challenge for psychosocial rehabilitation. These findings are also important for other low‐ and middle‐income countries passing through similar reforms.

Paper prepared for the conference “Normale ou ordinaire, accomplie ou autonome? La vie et ses formes pour les personnes souffrant d’un trouble mental chronique dans et après la psychiatrie”

The Portuguese national mental health plan (NMHP), approved in 2008, aimed, among other priorities, at defining best practices in long-term mental healthcare, with a specific focus in rehabilitation and deinstitutionalization. One year after the promulgation of the plan, a severe economic recession gained momentum in the country, resulting in austerity measures with cuts in the health budget and, at the same time, a decrease in families’ revenues. This study aims at understanding how the NMHP was effectively put in practice in such adverse circumstances and the consequences of the implementation path to families and carers of the mentally ill.
We first performed an extensive narrative review of policy documents related to the historical context of the NMHP and its implementation process. Secondly, we interviewed professionals and managers of long-term mental health services created under the NMHP, in order to characterise the provision of psychosocial rehabilitation in Lisbon Metropolitan Area.
On the one hand, the development of community-oriented policies was encouraged mainly to avoid the iatrogenic effects of institutionalization and to promote a “recovery” environment. On the other hand, the transference of caring activities to communitarian milieu should be performed carefully to avoid an excess burden for families, from whom a greater involvement is expected in this new model of care.
The analysis of the NMHP context showed a mix of long-term care providers, mostly private not-for-profit, with very different practices and target population. The lack of instruments to stimulate new solidarity associations, to encourage innovation, support management capacity and to ensure participation brought on obstacles to the emergence of new practices and expected advances. The countries’ path dependency and its fragile economic situation, posed great difficulties in the implementation of the plan accordingly to its own guidelines with potentially detrimental consequences on the well-being of families and patients.

Introdução: O Brasil vem passando por um processo de redirecionamento do modelo de atenção à saúde mental, que tinha o hospital psiquiátrico como principal equipamento assistencial, para um novo modelo pautado pela ampliação dos serviços comunitários, redução no número de leitos em hospitais especializados e na criação de enfermarias psiquiátricas de retaguarda em hospitais gerais. Este processo ganhou força no ano de 2001, quando foi promulgada a Lei Federal 10.216 que tornou a assistência à saúde mental no país parte de uma política nacional compatível com as premissas do Sistema Único de Saúde (SUS). Objetivo: Este trabalho analisa o perfil das internações psiquiátricas hospitalares na cidade de São Paulo no período de 2000 a 2010. Procura evidenciar se o
processo de reestruturação da assistência psiquiátrica em nível hospitalar teve repercussão na utilização destes serviços e quais foram as mudanças decorrentes deste processo no
âmbito municipal e intramunicipal.  Métodos: Trata-se de um estudo exploratório de natureza quantitativa. Os dados desta pesquisa foram obtidos a partir do Sistema de Informações Hospitalares (SIH-SUS), e são referentes à “Autorização para Internação Hospitalar” (AIH). As informações sobre as internações foram organizadas em um banco de dados e processados através do programa SPSS. Foram selecionadas as  informações relativas às internações de especialidade psiquiátrica e de pacientes cujo município de residência fosse São Paulo. A seguir foi realizado o georreferenciamento do CEP de residência do paciente. Resultados: Foram analisadas 153.208 internações psiquiátricas. Os resultados apontam que após uma redução inicial, seguiu-se um aumento no total de
internações. Nesse processo houve a ampliação do percentual de internações realizadas em hospitais gerais e a diminuição do percentual de internações em hospitais especializados. Ressalta que houve uma queda no percentual de internações de longa duração e em hospitais situados em outros municípios do Estado. O georreferenciamento das internações mostra que a criação de leitos em enfermarias psiquiátricas de hospitais gerais ampliou o acesso a estes serviços para a população residente das subprefeituras com os indicadores
socioeconômicos (IDH) mais baixos da cidade.

Over the past 20 years Brazil has made important advances in the
provision of health care services. Great strides were also made in the field of mental health care, and a sectoral reform was set, replacing the psychiatric model, characterized by the long term hospitalization, for an integrated network of primary care services, recognized for its multi-professional care, its integration with local health devices and offering of psychological and social assistance services. The main goal of the reformers was the defense of a public health system with a more equitable provision of services. It was only after the institutionalization of SUS over the 1990’s and especially reinforced by the law Paulo Delgado in 2001 (Federal Law 10.216) that a major reform in mental health care model was held across the country. Since then, a the major trend has being taking place in the city of São Paulo.

Brazil stands out in Latin America for its extensive correspondent network. However, until now we
have known very little from the demand-side about clients’ interactions with banking correspondents
and the extent to which correspondents are used for banking transactions, savings, and credit. This
research set out to investigate whether agents (known as banking correspondents in Brazil) improve
financial inclusion. The findings have implications for agent network development internationally, as
being able to successfully offer a wider range of services than bill pay and cash-in cash-out services
has implications for profitability as well as meaningful financial inclusion. We find that although the
proportion of Brazilians who are using BCs to access financial services is low, those who are using
these services through BCs are poorer, less educated, more likely to be women, and more likely to
live in small towns and rural areas, suggesting that correspondents are improving inclusion by
reaching underserved populations.