Psychology and social policies: A historical overview of psychological practice in Brazilian Public Health / Psicología y políticas sociales: un repaso histórico sobre la actuación del psicólogo en la Salud Pública brasileña

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Psychology and social policies: A historical overview of psychological practice in Brazilian Public Health / Psicología y políticas sociales: un repaso histórico sobre la actuación del psicólogo en la Salud Pública brasileña

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   U NIV . P SYCHOL . B OGOTÁ , C OLOMBIA   V. 13 No. 5 PP. 1777-1785 EDICIÓN   ESPECIAL  2014 ISSN 1657-9267 1777 Psychology and social policies: A historical overview of psychological practice in Brazilian Public Health* Psicología y políticas sociales: un repaso histórico sobre la actuación del psicólogo en la Salud Pública brasileña Envio 12/12/2013 | Revisión 16/04/2014- 2014-01-20 | Aceptación 21/04/2014  I SABEL  F  ERNANDES   DE  O LIVEIRA  ** O SWALDO  H AJIME  Y AMAMOTO  ***  Universidade Federal do Rio Grande do Norte A  BSTRACT This article examines the evolution of public health policies in Brazil after 1985, when the democratic transition process began at the end of the mi-litary rule, and their impact on the professional practice of psychologists. Brazilian social policies of this period and the construction and development of the Unified Healthcare System – SUS (the Brazilian National Health System) are reviewed, as the context for the discussion of the inclusion of psychologists into public health. Issues such as the suitability of traditional clinic models of practice to public health services, questions concerning the academic training and the limits imposed by social policies for the practice are discussed.  Keywords Health Policy; Political participation; Professional practice R  ESUMEN El presente artículo analiza la evolución de las políticas públicas de salud en Brasil pos-1985 – período en que se inicia la transición democrática en sustitución a la dictadura militar – y su impacto en la práctica profesional de los psicólogos. Las políticas sociales brasileñas del período y la construcción  y el desarrollo del Sistema Único de Salud son revistas en el contexto de la discusión de la inclusión de los psicólogos en salud pública. Tópicos como la adecuación de los modelos clínicos tradicionales para el campo de salud pública, cuestiones relativas a la formación académica y los límites impuestos por las propias políticas sociales para la práctica profesional son discutidos. Palabras-clave Política de Salud; Participación política; Práctica profesionaldoi:10.11144/Javeriana.upsy13-5.psph Para citar este artículo: Fernandes de Oliveira, I., & Yamamoto, O. H. (2014). Psychology and social policies: A historical overview of psycho-logical practice in Brazilian Public Health. Uni-versitas Psychologica, 13 (5), 1777-1785. http://dx.doi.org/10.11144/Javeriana.upsy13-5.psph *  This research was supported by CNPq research grant (#306822/2006-7; #473487/2011-0). **  Departamento de Psicologia, Universidade Federal do Rio Grande do Norte, Caixa Postal 1622, CEP 59090-400, Natal, RN, Brazil. Telephone: +55(84) 3342.2236 ext. 312. E-mail: fernandes.isa@gmail.com. ***  Departamento de Psicologia, Universidade Federal do Rio Grande do Norte, Caixa Postal 1622, CEP 59090-400, Natal, RN, Brazil. Telephone: +55(84) 3342.2236 ext. 312. E-mail: oswaldo.yamamoto@gmail.com.  I SABEL  F ERNANDES   DE  O LIVEIRA , O SWALDO  H AJIME  Y AMAMOTO 1778 U NIVERSITAS  P SYCHOLOGICA  V. 13 No. 5 EDICIÓN   ESPECIAL  2014 The National Health System: background, the New Republic and its aftermath A historical analysis of the evolution of Brazilian health policies reveals that they reflect a govern-ment intervention, common to all other spheres, established as targets of Brazilian social policy (social security, housing, education, employment and income, among others). If the Vargas adminis-tration (1930–1945 and 1951-1954) was marked by the institutionalization of legal framework and ad-ministrative infrastructure for health, the military dictatorship adopted a model of expansion and state control of health services, while favoring foreign participation in the internal market, encouraging the growth of the health insurance and drug indus-tries. Even during this period, the Brazilian health system exhibits characteristics of unequal access, centralization at the federal level, parallel action, separation between curative and preventive action and health promotion, as well as concentration of resources on medical-hospital care. Healthcare policies essentially became a project of exclusion, which did not consider popular movements or requirements of other policies in the sector. Chan-ges made, primarily in regard to the separation of public health and medical care, culminated in a precarious, low-quality, non-universal healthcare service, obliging the middle class to seek care in the private sector in the form of health insurance (Donnângelo, 1975; Luz, 1979). At the end of the 1970s, the healthcare model advocated and encouraged during military regi-me began to show signs of collapse and crisis, as a result of several specific factors: ineffectiveness of the dominant medical practice in changing the morbidity-mortality profile, primarily in relation to preventive measures; overlapping and lack of control and coordination in the face of reduced government efficiency and effectiveness due to high degrees of centralization and fragmentation within both ministries (Health and Social Security and Assistance) responsible for healthcare policy (Teixeira, 1995; Vasconcelos, 1997). During this same period, universities played an important role in studies that exposed healthcare conditions and fostered ideas for reform. Given their essential na-ture of breaking with the existing order, universities became the focal point for contesting the autho-ritarian government. Departments of Medicine were pioneers in implementing alternative social policies to those imposed by the military regime, through Community Medicine programs or by oc-cupying technical and administrative positions in the Ministry of Social Security. During this period, debates point to the need for public investment in primary healthcare infrastructure, which was vir-tually nonexistent in rural Brazilian cities, whose populations suffered primarily as a result of poor living conditions. Malnutrition, diarrhea, malaria, dengue fever, Chagas disease, among others, were the main causes of death.The establishment of the “New Republic” crea-ted the conditions to reform the government’s social policies, preaching the redemption of social debt. The transition period was an interchange in which the country went through a restructuring phase in its political foundations, due to the occupation of elective positions by left-wing politicians, reorga-nization of civil movements and the acknowledge-ment of the failure of military governments. Thus, it is from the beginning of the Geisel administra-tion, marked by the II National Development Plan and the establishment of the Ministry for Welfare and Social Security (MPAS) that public policies acquired characteristics that influenced those transformations seen in the 1980s. Here, we wit-ness the rise of democratic ideals, defended by the first civil-democratic government after 20 years of military dictatorship (Vasconcelos, 1997).All the progressive movement in the health sec-tor after the resumption of the democratic process was called the sanitary reform. It is the milestone that distinguishes the liberal medicine period from the movement towards enhanced public health care. The so-called democratic transition period propelled movements, culminating in healthca-re restructuring and a halt to privatizations that hitherto predominated within the sector. The crisis in the healthcare model surpassed institutional boundaries and social movements, al-  P SYCHOLOGY   AND   SOCIAL   POLICIES : A HISTORICAL   OVERVIEW   OF   PSYCHOLOGICAL   PRACTICE   IN  B RAZILIAN  P UBLIC  H EALTH   U NIVERSITAS  P SYCHOLOGICA  V. 13 No. 5 EDICIÓN   ESPECIAL  2014 1779 ready reorganized by this time, clearly demonstrated their dissatisfaction, through proposals to reverse the course taken by the military. One of the most significant experiments along these lines was the Action Program for Internalization of Health and Sanitation (PIASS) of 1976. It sought to assimilate guidance on primary healthcare, increasing basic outpatient services to populations excluded from access, primarily in the Northeast of the country.The creation of the Brazilian Collective Health Association – ABRASCO, in 1979 strengthened the role of research centers and provided a plat-form for the organization of academic research, criticizing the healthcare model and proposing its reorganization (Barros, 1997; Rêgo, 2002). Such initiatives were strongly influenced by international events, particularly the 1 st  International Conference on Primary Healthcare, sponsored by the World Health Organization (WHO) and held in Alma Ata, Russia in 1979. This conference established the goal of “Health for everyone by 2000”, assigning the responsibility of comprehensive healthcare to governments (Dâmaso, 1995).During the 1980s, the financial crisis in welfare reached alarming proportions, leading to the crea-tion of a National Program for Basic Healthcare Services (PREV-SAÚDE) and the National Cou-ncil of Welfare Administration (CONASP), whose goal was the expansion of basic healthcare by esta-blishing a National Network of Basic Healthcare Services. Based on these plans, the policy of Inte-grated Healthcare Actions (AIS) was implemented, seeking levels of institutional coordination that would enable more efficient and effective actions (Noronha & Levcovitz, 1994).Integrated Healthcare Actions established the infrastructure for the network of basic healthca-re services, broadening the extent of outpatient capacity. This network was fundamental to the development of universalization and decentraliza-tion policies. Despite its importance, it was unable to dismantle the parallelism of actions, managerial multiplicity and centralization of decisions. In spite of difficulties, in 1986 the VIII National Health Conference (VIII CNS), centerpiece of the sanitary reform movement, was held. Its final report propo-sed the progressive nationalization of the system and implementation of the National Health System (Sistema Único de Saúde - SUS) for all Brazilians (Vasconcelos, 1997).Several points were highlighted at the Con-ference; however, the creation of SUS under Go-vernment responsibility for provision, finance and management, guided by a healthcare con-cept based on the material living conditions of people, was undoubtedly one of the major ad-vances resulting from reformist efforts. The final Conference report also contained the core ideo-logical concept, translating expectations regar-ding the Government’s role in relation to health and adjacent policies that should guarantee the-se conditions. Thus, at the VIII CNS, the defi-nition of healthcare in contrast with dominant clinical-biological knowledge is based on social determination of the health-disease process and relies on Government for its provision. The right to health signifies a State guarantee to dignified living conditions and universal and equal access to services that promote, protect and recover health, on all levels and across the country, allowing individuals to fully develop their individuality. (Mi-nistério da Saúde [MS], 1987, p. 382) Health, according to the new concept proposed and in the broadest sense, “is the result of nutrition, housing, income, environment, work, transport, employment, freedom, access to and ownership of land and access to healthcare services” (MS, 1987, p. 382).Following the VIII CNS the emphasis on de-centralization gains strength and, thanks to the political direction taken by the centralization/de-centralization debate, on June 20, 1987 President  José Sarney, through decree 94.657, established the Unified and Decentralized Healthcare Systems – SUDS (MS, 1987).Parallel to the development of SUDS in the Executive setting, within the Legislature another movement attempted to include the principles of sanitary reform from the final report of VIII CNS in the new Brazilian Constitution. The  I SABEL  F ERNANDES   DE  O LIVEIRA , O SWALDO  H AJIME  Y AMAMOTO 1780 U NIVERSITAS  P SYCHOLOGICA  V. 13 No. 5 EDICIÓN   ESPECIAL  2014 political coalition surrounding the proposed sa-nitary movement encompassed, in addition to its representatives, an alliance between progressive left or center-left parliamentarians, the trade union movement and some sectors of the popular movement.This intense mobilization served as a form of political pressure that led to a change in federal law. The primary result was the inclusion of a spe-cific chapter in the 1988 Constitution dedicated to health, where it appears as (…) an universal right, and responsibility of the Government, guaranteed by social and economic policies aimed at reducing the risk of disease and other infirmities with universal and equal access to actions and services for its promotion, protection and recovery. (Constituição da República Federativa do Brasil, 1988, art. 196 and 197). The National Health System The SUS model, considered one of the most demo-cratic in the world, has its roots in the restructuring of Cuban healthcare policies after the 1959 revolu-tion. Regulated on September 19, 1990, the intro-ductory provision defining the SUS considers it as a set of healthcare services and actions provided by public federal, state and municipal institutions and organizations, direct and indirect adminis-tration and foundations maintained by Govern-ment Authority. The role of private initiatives is in complementary participation (Lei nº 8.080 de 19 de setembro de 1990, 1990).Following rational logic, the SUS should attend to user needs, prioritizing segments of the popula-tion or a healthcare agenda defined by the Fed-eral Government, respecting regional differences. Broad objectives guiding SUS actions refer to the identification and dissemination of conditioning and determinant factors in health, the creation of healthcare policies designed to promote the afore-mentioned goals on social and economic levels, offering care through health promotion, prevention and recovery (Cordeiro, 1997).After 21 years of existence, SUS was undoubted-ly an advance in the construction of policies aimed at social justice and is established in government organizations, seeking the integration of a wide-ranging healthcare network. Despite this effort, the historical context of its implementation and development was substantially unfavorable (Cam-pos, 2007). Notwithstanding its innovative and democratic goals, relevant aspects of the model are either not implemented or disparaged. Electing the candidate supporting neoliberal proposals allayed the implantation of SUS, initiating a phase of stag-nation in reformist proposals, crisis in healthcare and Government incentives for reform according to principles of the neoliberal agenda. This dis-mantling of the government framework generates a crisis in healthcare models, transforming proposals for the sector so as to encourage participation by private initiatives through tax incentives, subsidies and contracts, compromising the already inefficient operations of the SUS. This scenario appears to invert with the resignation of Fernando Collor de Mello and the inauguration of Itamar Franco as president. From then onwards, basic healthcare expands considerably, both in resources and infra-structure (Lei nº 8.142 de 28 de dezembro de 1990, 1990). Nevertheless, SUS was not accessible to all citizens, primarily for those most in need.Those still unable to access SUS belonged to the so-called risk category (populations bordering on poverty and extreme poverty). Thus, although idealized as a single Brazilian healthcare system, accessible to everyone, whether rich or poor, the SUS never achieved its goal. In an attempt to reach this population group, The Family Health Program (Programa de Saúde da Família - PSF) was created in 1994.Considered a strategy for reorganizing basic healthcare, the PSF became a gateway into SUS, focusing on the so-called areas of risk: extremely poor and rural communities (Oliveira, 2005). In 1994 and 1995, more than 1,000 family health teams (ESF) were created. However, as is customary in Brazil, constitutional reform adjusted reformist projects to neoliberal thinking and the reorgani-zation strategy for basic healthcare competes for  P SYCHOLOGY   AND   SOCIAL   POLICIES : A HISTORICAL   OVERVIEW   OF   PSYCHOLOGICAL   PRACTICE   IN  B RAZILIAN  P UBLIC  H EALTH   U NIVERSITAS  P SYCHOLOGICA  V. 13 No. 5 EDICIÓN   ESPECIAL  2014 1781 funding with human resource training and manage-ment, substantial investments in high complexity areas, and with poor administration of municipal services. Between 1998 and 2002, ESF expanded the offer of basic healthcare, but faced difficulties in guaranteeing universality and comprehensive-ness. In 2007, the PSF covered 56.8% of Brazilians, which promoted its transformation into a strategy for organizing and strengthening basic care as the first level of healthcare in SUS. In 2010, the fam-ily health strategy had 31,974 ESFs covering more than 100 million Brazilians in 5,285 municipalities. Infant mortality fell by 60% when compared with 1990; SUS became a leader in public funding for organ transplants and excellent in immunization programs; SUS cared for 184 thousand HIV-posi-tive individuals and began distributing free blood pressure and diabetes medication in 2011. Never-theless, challenges remain in the form of struggles for democratic policies versus Government unac-countability for its provision.In an attempt to increase the scope of primary care activities, Support Centers for Family Health-care (NASF) were created in 2008, widening the scope and resolution of SUS, sustaining the family health strategy in the service network, and the te-rritorialization and regionalization process within primary healthcare (MS, 2008). The NASF should act in conjunction with ESF, sharing healthcare practices and providing support in their geographi-cal jurisdiction. For the first time, mental health actions emerged as a priority within primary care in non-specialized units. Alternative healthcare prac-tices were also offered more systematically in the NASF, revealing a further attempt at health actions less centered on medical specialties. Since this sce-nario is recent, the Ministry of Health is still deve-loping guidelines for the operation of NASF teams and work procedures are still in the design phase. As such, an accurate evaluation of the impact of this new device on the set of Brazilian institutions and healthcare policies is currently not available. In a general assessment of the evolution of SUS, particularly during its implementation, Campos (1997) highlights three forms of provi-ding healthcare services in Brazil: a neoliberal bloc, hegemonic in concrete structural relation-ships, but with a degree of dissonance regarding sanitary law; a healthcare project subordinate to SUS, with a legal basis, but not effective in terms of social practice; and a third, rationalizing pro-ject, which applies the underlying concepts and terminologies of SUS, but in practice remains a neoliberal supporter.Despite the growth in neoliberal production of healthcare services in the country, the effects of social movements from the 1980s are still being felt. These proposed a health model in line with demo-cratic principles strongly advocated by progressive and left wing sectors during the New Republic. However, pressure to downsize the Government was evident in public health. Campos (2007) states that there are still problems and dilemmas, since its implementation has occurred heterogeneously, with inequality in meeting the needs and use of servi-ces. Not to mention difficulties regarding funding, administration of the system and employment in healthcare. As such, one cannot currently state that the SUS represents Brazilian government policy.It is against this backdrop that psychologists, in a broad move to reorganize democratic forces, align themselves with professional groups acting in segments within trade unions and professional and political areas of the social struggle and, subse-quently, join the health workers movement (Bock, 1999; Vasco ncelos, 1999). Psychology in public health policy: a new configuration for the “psychological subject”? Forty-nine years of regulation portray psychology as a profession still in pursuit of greater social inclusion and political representation. It established itself as a conservative science and practice, belatedly focu-sing on the construction and/or execution of social transformation. In the history of the profession in Brazil, it seems psychological knowledge was often used for control, segmentation and differentiation, thereby contributing to maintaining and increasing the profit needed for reproduction of capital. A combination of vectors, including action by pro-fessional entities, enables significant change in the
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