Authors: Pedro Anderson Ferreira Quirino
Alexandre dos Santos Lima
NMO: IFMSA Brazil
University: Universidade de Pernambuco campus Serra Talhada
Theme: The role of Primary Health Care in achieving Universal Health Coverage
In Brazil, after the implementation of the Unified Health System in 1988, health became the right of all and its guarantee is a duty of the State. In addition, there has been an increasing search for giving importance to this Primary Care Health (PCH), using the dynamics of family health teams for this (1). In 2001, there was the enactment of the Psychiatric Reform Law in Brazil, also known as the Paulo Delgado Law. With it, psychiatric deinstitutionalization began in the country, drastically changing its public mental health policy. However, there are still some challenges to its implementation in Brazil, such as the inclusion of mental health in primary care and in family health teams. (2-4).
According to the World Health Organization (WHO), health is not just the absence of disease, but also a state of complete physical, mental and social well-being. About mental health, it is also necessary to understand that it has a very comprehensive concept, which can be briefly defined as a state of well-being in which the individual is able to use his own skills, recover from routine stress, be productive and contribute to his environment.
Thus, it is perceived that one of the fundamentals for an individual to be healthy is their mental well-being, which is one of the main points to be worked on in the search for universal health coverage. Already knowing that 85% of health problems can be solved at PHC level, and that, according to the Family Medicine Treaty, around 60% of consultations in primary care have mental health as the main reason for seeking care, arises then the need to support this mental health care network (5).
In this case, the PHC is the gateway to the care network within the health system, being responsible for providing support and treatment for the most prevalent diseases in the community. For this, there are a series of preventive, curative, rehabilitation and health promotion measures, with a main focus on disease prevention. It must be one that, acting as a filter, as a regulatory agent of the public health system, manages to prevent small health problems from getting worse, immediately solving most problems that arise, without the need for referral to specialized care, with preservation of individual health.
Therefore, in this context of mental health, PHC has the main objective of making the early detection of mental disorders, starting the treatment of the most prevalent disorders, carrying out the management of intercrisis patients and referring, when necessary, to the other levels of complexity. Furthermore, its focus should be mainly on the prevention and promotion of the community’s mental health, applying the integrality and continuity of care in favor of the population (6).
From a more practical perspective, as participating members of a family health team in Serra Talhada/PE, in the Brazilian backlands of Pernambuco, one as a doctor and the other as a fifth-year medical student, we can report our experience of working with primary care health and its relationship with mental health in favor of universal health coverage.
Initially, the experience of being in a basic health unit makes it possible to monitor the patient more closely, as well as all his social and family dynamics, enabling a broader view of him and the illness process, as well as making it clear the vulnerabilities and stressful situations to which this individual is daily exposed. This makes possible for this health strategy, when applied attentively and individually, to provide a more effective listening in the identification of several disorders that are very prevalent today. Some of those are depressive, anxious, mood disorders, specific phobias, dermatopsychoses, alcohol dependencies and others drugs, among many other pathologies that end up going unnoticed or are not considered as diseases by the general population because they often do not present concrete symptoms, manifesting themselves in a non-specific way.
Therefore, it is important to adopt primary prevention measures that are applied to the context of the territory in which the patient is inserted, following a unique therapeutic project. It must identify the warning signs and risk factors for physical and mental illness. For example, the process of becoming a mother, especially in the first pregnancy, can be quite traumatic, as there are many fears surrounding this new social condition. This causes the pregnant woman to have several concerns in relation to her safety, her marital relationship and with her son, asking herself whether she will be able to educate a human being, worrying about the changes in her body – very linked to self-esteem and femininity -, and the anxiety surrounding the moment of birth. In this context, the prevention strategy to avoid mental illness, reducing mental illnesses in the puerperium, is to offer quality prenatal care, with constant dialogues, clarifying from simple to the most complex doubts, strengthening their family and social bonds, and making pregnancy a moment of personal growth and a pleasant experience for her and her family.
This is just one of several daily situations in which one can act to prevent mental illness, and there are several others, usually linked to changes in social roles, financial instability, violent environments and traumatic situations. It is necessary that the professionals who are on the front line take responsibility for offering the best-individualized strategy to their community.
It is important to emphasize that the Basic Health Units (BHU) are responsible for a restricted territory, with a high flow of patients, with different types of care and demands, serving as a sort of screening for the real needs of patients to move on or not to the specialized care. Since the resources are finite and unfortunately, the patients are much more than the professionals present in the network, often these professionals are overloaded in the care of patients. Therefore, in view of the urgency of treatment, the family health team, in the absence of a sufficient number of specialized professionals, ends up acting as psychologists, occupational therapists, psychiatrists, psychopedagogues, while the patient awaits the long-awaited arrival of his turn at specialized attention.
Thus, it is valid that the BHU professionals are properly trained and safe to offer the initial treatment or to continue the treatment instituted until the patient goes through the difficulties of the system. In other words, the family health team must be prepared to act on three different points in the management of these patients: the plans: diagnostic – further investigate the entire history and biopsychosocial context -, therapeutic – pharmacological and non-pharmacological treatment – and psychoeducational – inform about mental illness for both the patient and their families, promoting health education. For this, there must be constant training for primary care professionals about primary, secondary and tertiary prevention of mental illness. These trainings can use tools already available as a base, just adapting to the local reality, such as the primary care notebooks, available on the Brazilian Ministry of Health’s online platforms. As examples of these protocols we have the notebooks about welcoming spontaneous demand, aging and health of the elderly, health at school, mental health – alcohol and other drugs, depression and anxiety, suicide prevention – signs to know and to act.
This way, with these improvements and the inclusion of mental health in primary care, we can take another step in the promotion of universal health, as already recommended by the WHO in 1990 when it said that no health service was complete without attention to mental health needs. In order to consolidate this new concept of health, a new perspective is essential, from health programs to the training of future professionals in the area. Including students in mental health discussions in the context of Primary Health Care is fundamental to build critical awareness that recognizes the Social Determination of Health as an explanation for the health-disease process (5,6). It is believed to be a way to overcome the strong biomedical view, in which the role of health professionals is only through logical, anatomical and pathophysiological reasoning, based on scientific evidence (2-4).
Therefore, the plans and actions of health managers, professionals and students must be focused on biopsychosocial care. The care practice that aims only at mental disorders and not at the patient as a whole should be ignored, as it has already been demonstrated that this practice makes universal health coverage impossible, fragmenting care in physical/organic well-being and mental well-being, when it is impossible to dissociate them (7).
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