1 Public Health Reviews, Vol.

34, No 2

Community Mental Health Services in Latin America

for People with Severe Mental Disorders

Alberto Minoletti, MD,1

Sandro Galea, MD, DrPh,2
Ezra Susser, MD, DrPh2,3

ABSTRACT

Mental disorders are highly prevalent in Latin American countries and exact a
serious emotional toll, yet investment in public mental health remains insufficient.
Most countries of the region have developed national and local initiatives to improve
delivery of mental health services over the last 22 years, following the technical
leadership of the Pan American Health Organization/World Health Organization
(PAHO/WHO). It is especially notable that PAHO/WHO facilitated the development
of national policies and plans, as well as local programs, to deliver specialized
community care for persons with severe mental disorders. Nevertheless, at present,
the majority of Latin American countries maintain a model of services for severe
mental disorders based primarily on psychiatric hospitals that consume most of the
national mental health budget. To accelerate the pace of change, this article
emphasizes the need to develop cross-country regional initiatives that promote
mental health service development, focusing on severe mental disorders. As one
specific example, the authors describe work with RedeAmericas, which has brought
together an interdisciplinary group of international investigators to research regional
approaches and train a new generation of leaders in public mental health. More
generally, four regional strategies are proposed to complement the work of PAHO/
WHO in Latin America: 1) to develop multi-country studies on community services,
2) to study new strategies and interventions in countries with more advanced mental
health services, 3) to strengthen advocacy groups by cross-country interchange, and
4) to develop a network of well-trained leaders to catalyze progress across the
region.
Key Words: Community mental health, community psychiatry, public health, Latin
America, psychiatric epidemiology, global mental health

1
School of Public Health, Medical Faculty, University of Chile, Santiago de Chile, Chile.
2
Department of Epidemiology, Columbia University, New York, NY, USA.
3
New York State Psychiatric Institute, New York, NY, USA.
Corresponding Author Contact Information: Dr. Ezra Susser at [email protected];
Department of Epidemiology, Columbia University, 722 West 168th Street, #720E, New York,
NY 10032, USA.
2 Public Health Reviews, Vol. 34, No 2

Suggested Citation: Minoletti A, Galea S, Susser E. Community mental health

services in Latin America for people with severe mental disorders. Public Health
Reviews. 2012;34: epub ahead of print.

INTRODUCTION

The care of people with mental disorders is a growing public health concern
in Latin America. These disorders are highly prevalent and exact a serious
emotional toll on individuals, families, communities and society at large.
Community-based epidemiological studies in this region have estimated
rates of lifetime prevalence of mental disorders among adults ranging from
23.7 percent to 39.1 percent and 12-month prevalence rates ranging from
11.6 percent to 20.1 percent.1 Rodriguez et al estimated that mental and
neurological disorders in Latin America accounted for over 20 percent of
all Disability Adjusted Life Years (DALYs) in 20022; in other words, these
disorders account for over 20 percent of the total “disease burden” in Latin
America. Yet almost all Latin American countries still invest far less in
public mental health than in other public health problems with comparable
disease burden. Moreover, a large part of public mental health resources are
still used to maintain a system of mental hospitals that do not offer
appropriate treatment.
In this paper, we focus on community mental health care for adults with
severe mental disorders in the Latin American region. As in many other
regions, individuals with severe mental disorders comprise a particularly
vulnerable and disadvantaged group whose needs are often overlooked,
whose human rights are often violated, and who do not receive sufficient
services in the communities where they live. We briefly describe the history
of this field, then review its current state, and conclude by offering some
thoughts about future strategies for the development of research, human
capacity, and services. Although other aspects of public mental health in
Latin America are beyond our scope, we believe that they require similar
attention. The countries of the Latin American region, broadly defined, are
many and diverse. Here we focus on countries in which Spanish, Portuguese
or French is the dominant language, and following a common convention,
define them as the 20 countries listed in Appendix 1.
Community Mental Health Services in Latin America 3

HISTORY

As early as the 1950s and 1960s, several researchers conducted epi-

demiological studies that used case ascertainment and random sampling
methods to assess the prevalence of mental disorders among residents of
different countries.3-5 These studies prompted new public health approaches
to addressing the high burden of mental disorders. The hegemonic role of
mental hospitals as the main form of treatment began to be questioned,6-8
and debates arose about alternatives models based on general hospitals and
primary care centers, as well as the need to build day hospitals, group
homes and sheltered workshops to facilitate the social integration of people
with severe mental disorders. In some Latin American countries, there were
early attempts to build mental health services in the community. Innovative
pilot programs were established where psychiatrists, general practitioners
and other health professionals put some of these ideas into practice.6-8
Although the community model was never implemented in full, due to lack
of political support and resources, these early experiences helped to raise
awareness and generate learning about alternatives to mental hospitals.
Most of these innovative programs were subsequently downsized or
shut down by the dictatorships that plagued much of the region during the
1970s and 1980s. Instead, more mental hospitals were built, until their
number surpassed 250, with over 150,000 long stay beds. The majority of
these hospitals were located outside urban centers and lacked sufficient
staff and resources to provide meaningful care. Patients often were cut off
from their environment with no rehabilitation programs, and subjected to
intensive use of physical restraints, pharmacological sedation and other
human rights violations.8,9 In some countries, these mental hospitals became
virtually the only mental health service accessible to the general population.
The return to democracy in many Latin American countries was
accompanied by a new cultural and political atmosphere. Many social
movements and some governments were eager to finally begin addressing
long-ignored social problems. In this context, the community orientation
for delivering mental health services found a receptive audience. The work
of Benedetto Saraceno in Nicaragua9 and Franco Basaglia in Brazil10 were
particularly influential. Notably, Basaglia had previously been a leader in
the Italian movement toward psychiatric reform that flourished in the 1970s
and 1980s. Among their signal contributions was the support their work
generated for two key premises: first, that it is possible to transform the
asylums into a network of community centers, and second, that patients
could become citizens with equal rights to other persons.
4 Public Health Reviews, Vol. 34, No 2

The transformation of ideas about mental health care was soon given
concrete expression in policy recommendations of the Pan American
Health Organization/World Health Organization (PAHO/WHO). Arguably,
the landmark event was the Regional Conference for the Restructuring of
Psychiatric Care in Latin America, convened with the support of multiple
global institutions and held in Caracas, Venezuela in 1990. The conference
brought together key stakeholders and generated an influential position
statement, the Caracas Declaration, which set forth the principles that
served as the conceptual framework for the reform movement that unfolded
in Latin America in the ensuing years.11,12 With respect to the development
of community mental health services in Latin America for people with
severe mental disorders, the Caracas Declaration was especially significant
and influential.
In the Caracas Declaration, the conference attendees endorsed a
commitment to transform antiquated hospital-based mental health delivery
systems into comprehensive community care systems. The Declaration
regarded primary care as the main vehicle for delivering mental health
services, also calling for the adoption of the Local Health Systems Model
and the integration of social and health care networks. In addition, the
Declaration called for legislative action aimed at anchoring the reform
process in a legal framework and protecting the human rights of people
with mental health problems.12
The momentum generated in Caracas was sustained through the PAHO/
WHO Initiative for the Restructuring of Psychiatric Services. This Initiative
was also launched in collaboration with a large number of countries,
international organizations, and experts.13 Its primary goal was to promote
and support mental health reform initiatives in Latin America. Furthermore,
the principles of the Caracas Declaration have been ratified, expanded and
operationalized with numerous other political and technical specifications
over the years through additional documents issued by PAHO/WHO, such
as the CD43.R10 Resolution of the PAHO Directive Council in 2001,14 the
Brasilia Principles on the Development of Mental Health Care in the
Americas,15 and the Strategy and Plan of Action on Mental Health approved
by the 49th Directive Council of PAHO in 2009.16 Also, several cross-
country regional initiatives to promote reform along the lines of the Caracas
Agenda were implemented by PAHO/WHO after 2003, including, among
others, the creation of posts of subregional mental health advisers in Central
America, South America, and the English Caribbean, the creation of
subregional mental health forums, and the development and funding of
projects involving several countries.17,18
Community Mental Health Services in Latin America 5

CURRENT STATE

The Caracas Declaration and further efforts to improve psychiatric services

in the region, as described above, set a clear agenda for mental health
reform in Latin America. We now need to consider the ways in which this
agenda (henceforth termed the “Caracas Agenda”) has and has not been put
into practice. We therefore turn to the present state of community mental
health services in the region.
Political will. The implementation of the Caracas Agenda is not uniform
across the region and depends upon the political will to reform and scale up
mental health services. Thus, it requires that decision makers and political
leaders understand the population’s mental health needs, recognize their
importance, and prioritize actions to address them.19 Governments express
their political will on a particular issue through official documents (national
policy, strategy, plan, or program), legislation and resource allocation,
where they demonstrate their understanding, recognition and priority. The
WHO has collected information on these three indicators of political will
from the majority of countries worldwide through the Project Atlas:
Resources for Mental Health. Although Project Atlas data are currently the
best available source for gauging political will across the region, we note
that it offers only a broad overview; the development of more refined
measures would be an important contribution.
The information collected by Project Atlas for Latin American countries
enables us to review the progress toward the Caracas Agenda in Latin
America over the past decade. As shown in Table 1, for the years 2001,20
200521 and 2011,22 Project Atlas included 18, 20, and 14 of 20 targeted
Latin American countries (listed in Appendix 1) respectively. Between the
years 2001 and 2011, the proportion of countries that had formulated and
officially approved a mental health national policy increased from 40.0
percent to 66.7 percent. During this same time period, the proportion with
a national plan for implementation increased from 47.7 percent to 72.2
percent. The proportion that promulgated mental health legislation
increased from 20.0 percent to 35.3 percent. Finally, the proportion that
spent over 1.4 percent of the total health budget on mental health increased
from 25.0 percent to 40.0 percent. Thus, it is clear that significant progress
has been made in these areas.
But it is also clear that the political will to implement the Caracas
Agenda remains quite incomplete. To underscore this point, we can compare
Latin American countries with countries in other regions classified either as
low and middle income countries (LMIC) or as high-income countries
according to World Bank criteria. These comparisons are exhibited in
6 Public Health Reviews, Vol. 34, No 2

Figure 1. The great majority of Latin American countries are lower-middle

(N=6) or upper-middle (N=13) income (see Appendix 1). It is therefore not
surprising that compared with high-income countries outside of Latin
America,23 Latin American countries overall score lower on all the indicators
of political will described above, especially in regard to legislation and
budget. It is also not surprising that compared with LMIC overall,23 the
Latin American countries score higher for mental health policies and plans
(67 percent versus 54.7 percent and 72.2 percent versus 66.4 percent,
respectively). What may be surprising is that compared to LMIC overall, a
lower percentage of Latin American countries have mental health legislation
(47.1 percent compared with 54.1 percent of world LMIC).

Table 1
Indicators for political will to scale up mental health services
in Latin American Countries
2001 2005 2011
Number of Latin American countries reporting information
18 20 14
to Project Atlas
Countries with a policy sanctioned during the previous 10
40.0 75.0 66.7
years (%)
Countries with a national plan sanctioned during the
47.7 58.3 72.2
previous 10 years (%)
Countries with legislation promulgated during the previous
20.0 45.0 35.3
10 yrs (%)
Countries spending over 1.4% of the total health budget on
25.0 50.0 40.0
mental health
20,21,22
Source: WHO’s Project Atlas: Resources for Mental Health 2001, 2005 and 2011.

The deficiencies in political will are brought into sharper relief when
one considers the financing of mental health services in finer detail. In
Figure 2, countries are divided into low income, lower-middle income,
upper-middle income, and high income. As noted above, most though not
all Latin American countries are classified by the World Bank as lower-
middle or upper-middle income. When Latin American countries are
compared with countries in their same income group, it is evident that they
spend a smaller percentage of their health budget on mental health. The
median percentage in Latin American countries is 1.20 percent in the lower-
middle income group, and 1.52 percent in the upper-middle income group,
compared with 1.90 percent and 2.38 percent respectively for other countries
in these same income groups (see Table 1, Figure 1, and Figure 2).23
Community Mental Health Services in Latin America 7

Fig. 1. Presence of mental health policy, plan and legislation in Latin American
countries and world low-and-middle income (LMIC) and high income countries.
Source: WHO’s Project Atlas: Resources for Mental Health 2011.20,21

Fig. 2. Median percentage of health budget allocated to mental health in Latin

American countries and world countries by World Bank income groups.
Source: WHO’s Project Atlas: Resources for Mental Health 2011.20,21

We can also apply the WHO Assessment Instrument for Mental Health
Systems (WHO-AIMS) mechanism to contribute to our assessment. The
WHO-AIMS data complement those of WHO Project Atlas described
above; similar to Project Atlas, these data offer only a broad overview but
are currently the best available regional data. The application of the WHO-
AIMS confirms the limitations of political will in the region.24 WHO-AIMS
has revealed that unfortunately some of the national policies, plans and
legislation in this region are not sufficiently explicit to support and facilitate
the delivery of community mental health services. Moreover, even when
they are explicit, their implementation is usually inadequate.
8 Public Health Reviews, Vol. 34, No 2

The WHO-AIMS studies have also confirmed the persistence of

historical funding patterns that give low priority to mental health. Perhaps
most troubling is that the mental health budget allocation in most Latin
American countries continues to be far below the level that would reflect
the population’s health needs according to the current epidemiological
evidence.24 Even in Brazil, where progressive mental health policies and
legislation have been quite striking, the health budget allocation for mental
health decreased slightly between 2001 and 2011 (from 2.50 percent to
2.38 percent).20-22,25,26 Fortunately, at least some countries have been
increasing their allocation to mental health. In Chile, for example, the
percentage of the health budget allocated to mental health increased from
1.49 percent to 2.78 percent during that same period.20-22,27
National organization of services. Among the cornerstones of the
Caracas Agenda are promotion of self-care and informal care, inclusion of
mental health into primary care (especially for common mental disorders),
decentralization of specialized outpatient care for severe mental illness,
development of day care programs and psychosocial rehabilitation, and
integration of mental health services in general hospitals (Figure 3).24,28
These features have been increasingly incorporated in national policies,
plans and legislation. By now, most Latin American countries have some
community mental health initiatives. Also, most countries have tried to
downsize and improve the psychiatric hospitals, either nationally or in
some localities (see Figure 3).13,29

Fig. 3. Model for organization of mental health services in Latin America.

Source: Adapted from Funk et al.28
Community Mental Health Services in Latin America 9

The pace of change has, however, been very slow in most countries, as
shown in Figure 4. At the national level, only three Latin American
countries, Brazil, Chile and Panama, have truly transformed the mental
hospital-based model.20-22,30-32 The average reduction of mental hospital
beds in the other countries of the region during the past ten years was only
23.9 percent.33-37 In contrast, in Brazil, Chile and Panama, the number of
hospital beds was reduced (for the three countries combined) by 62.2
percent in the last ten years. Brazil and Chile have also developed an
increasing number of community group homes for people with severe
mental disability and low or no family support; there are now more than
two beds per 100,000 people in Brazil32 and more than eight per 100,000
people in Chile.30 In these three countries, there are also users and family
organizations that frequently participate in the elaboration of policies,
plans and legislation. To achieve this change, all three countries have
increased significantly the percentage of public mental health expenditures
allocated to general hospitals, outpatient facilities and community services
(an increase of 67.7 percent in Brazil, 88.0 percent in Chile, and 56.0
percent in Panama). The rates of psychiatric beds in general hospitals,
outpatient facilities and day facilities (day centers and day hospitals) are
two to seven times higher in Brazil, Chile and Panama than in other Latin
American countries (Figure 4 and Table 2).

Fig. 4. Average rate of psychiatric beds in Latin America 2001-2011 by level of

implementation of comunity-based services and type of hospital (per 100,000
population).18-20,29-44
10 Public Health Reviews, Vol. 34, No 2

Table 2
Average number of psychiatric outpatient and day facilities (by 100,000
population) in Latin American countries and level of utilization20-22,30-37
Other Latin American
Brazil, Chile & Panama
countries
Outpatient facilities 1.41 0.72
Outpatient users in one year 1945.65 1389.05
Day facilities 0.36 0.18
Day facilities users in one year 31.45 4.36

Although we have focused on the 20 countries in Appendix 1, we should

also note an important development in Belize, an English Caribbean country
that is within the Latin American region. Belize has achieved significant
reforms that have had influence on some other countries. This has included
the downsizing of mental hospital beds (a decrease by 55 percent) in a
similar period of time as Brazil, Chile and Panama.38 Confronting the
national reality of a small number of psychiatrists and psychologists, Belize
has opted for a decentralization of mental health care based on the training
of primary care psychiatric nurses in each health district.39
Country-specific initiatives. There are some country-specific programs
that represent significant progress toward the Caracas Agenda. With regard
to specialized ambulatory care for persons with severe mental disorders,
Brazil has developed a system of psychosocial care centers (known by their
Portuguese acronym of CAPS) that has been the cornerstone of the
transformation of the mental hospital-centered approach in Brazil. Modeled
after the community mental health centers in Italy, many of the CAPS have
been effective in the treatment, rehabilitation and follow up in the
community of people with psychosis and other severe mental disorders,
including brief admissions for psychosocial crises.40-43 Cuba has developed
a mixed model of mental health care, where 23 psychiatric hospitals (with
56.7 beds per 100,000 population) coexist with a highly decentralized
community care system. The Cuban centers are closely articulated with
primary care teams and deliver a comprehensive set of interventions,
ranging from promotion and prevention to treatment and rehabilitation,
based on local epidemiological diagnoses, strong community participation,
and inter-sectoral coordination.37,44,45 Also using a mixed model approach,
Uruguay decided to incorporate community mental health teams into
primary care facilities instead of separated specialized centers, developing
a rich experience on interdisciplinary work and social networks.46,47 Initially
Community Mental Health Services in Latin America 11

in Chile, psychiatric outpatient care developed in multispecialty clinics

attached to general hospitals, but in recent years the implementation of
community mental health centers has been prioritized, which has allowed a
greater decentralization, coordination with primary care, and local inter-
sectoral resource utilization.48,49
In order to improve the rehabilitation and social inclusion of people
with disability secondary to mental illness, most countries have developed
interventions to strengthen families and their organizations in order to
encourage people with severe mental disorders to continue living at home,
taking advantage of the strong social support role played by families in
Latin America.50-53 In addition, however, Brazil and Buenos Aires Province
in Argentina have implemented programs that provide monthly financial
support for users with long stays in mental hospitals once they return to
their homes.54,55
Several countries have developed group homes for people with
disabilities who do not have the support of a family. They are known by
different names across countries (e.g., community residences, half-way
homes, sheltered homes) but share similar characteristics, and usually four
to eight people live in these homes with the support of full- or part-time
caregivers. Based on the limited evidence available, it appears that group
homes are feasible to implement in Latin America, cheaper than staying in
mental hospitals, most of the time well accepted by the neighborhood, and
tend to have positive impact on users’ quality of life and social functioning.54-58
Innovations at the local level. In parallel with these national efforts,
many local initiatives have emerged, some of which have been highly
innovative as well as influential. Here we discuss two programs that adopted
the key elements of the Caracas Agenda. These two programs were
established in adjacent provinces in the Patagonia region of Argentina, and
yet were developed independently of one another. In fact, it seems somewhat
remarkable that the two programs were initiated separately within the same
remote region, and that both developed into influential models cited by
international organizations such as WHO and the World Mental Health
Federation.
In the Province of Rio Negro, Hugo Cohen led a bold initiative to
replace institutional care in mental hospitals with community-based mental
health services.59-61 This was one of the earliest attempts to radically
transform public mental health services in Latin America, and helped to
galvanize the process across the region. Backed by community participation
and legislation, the mental health program has developed a comprehensive
network of community services in the public sector, through 27 years of
experience. The main components of this network are primary care teams,
12 Public Health Reviews, Vol. 34, No 2

general hospitals with specialized interdisciplinary mental health teams,

psychosocial rehabilitation with strong inter-sectoral links, group homes,
and social firms to offer employment to people with mental disability.
In the Province of Neuquén, José Lumerman established in the 1990s
what is essentially a non-governmental organization (NGO) to provide
community mental health services.62-64 There were few inpatient beds in
Neuquén (most patients with severe and chronic mental illness were sent to
El Borda Hospital in Buenos Aires), but also virtually no community mental
health services. Initially Lumerman attempted to create such services within
the public system, but his efforts were blocked by government agencies. He
then went outside the public sector to set up a community-based program
that was supported primarily by reimbursements for care from the Seguridad
Social (a form of health insurance accessible to most but not all people).
Since there were very few psychiatrists or other specialized resources, the
program was built with the local resources that were available, using an
approach that would now be called “task shifting”. For example, the
Province did have an excellent public health system and a large number of
general doctors; hence general doctors were recruited and trained to lead
mental health teams. The program also recruited people from outside the
health professions, such as artists and actors, to participate in the
rehabilitation process. This program has sustained its progress, and with
continual expansion and improvement, it now offers high quality care to
virtually all people in the city of Neuquén, and is affiliated in various ways
with the public health system.
To understand why these two excellent programs have proved sustain-
able, one in the public sector and the other outside it, we suggest that it is
related to the enormous and ongoing efforts made by both programs to
sustain relationships with all key stakeholders. These include not only the
government health sector, but also education, justice, and other sectors, the
families and patients themselves, the general doctors of the province, the
local media, the governing party of the Province, and (in Neuquén) the
administrators of the local Seguridad Social. For example, the governing
party of these Provinces changed often, and each time, new relationships
had to be developed and sustained. It was only possible to do so because the
programs had become embedded in the community by the involvement and
support of such a wide range of stakeholders.
Finally, it should be noted that despite the many promising local initiatives
exemplified by these two programs, there are some domains in which only a
few local initiatives have gained experience (the two programs described are
among the few). These domains include supported employment, job
placement and social enterprises. Some programs targeted to these domains
Community Mental Health Services in Latin America 13

have reported promising initial results. Their number is still very limited,
however, and these programs have not yet been adequately evaluated.61,62

LOOKING AHEAD: REGIONAL INITIATIVES

There are many new country-specific programs that aim to improve delivery
of mental health services in Latin America. Several of these have been
described above. Looking ahead, we believe it will be equally important to
develop cross-country regional initiatives that promote reform along the
lines of the Caracas Agenda and that complement the regional work of
PAHO/WHO. A welcome recent development is the emergence of some
promising regional initiatives.
Here we describe one new regional initiative in which the authors have
been engaged by way of providing an example. It is known as RedeAmericas
or simply as “RA”.65 The more formal name is RedeAmericas: Network for
Mental Health Research in the Americas. It is one of five such initiatives
that have recently been funded by the National Institute of Mental Health
(NIMH) in Latin America, Africa, and South Asia. RA brings together an
interdisciplinary group of investigators from urban centers in Argentina
(Buenos Aires, Córdoba, and Neuquén), Brazil (Rio de Janeiro), Chile
(Santiago), Colombia (Medellín) and also from New York City in the
United States. Representatives from all sites have decades of experience in
developing and adapting interventions in a Latin American context. The
overarching objective is to improve the conditions of life for people with
mental disorders. Given limited resources, the primary focus of the RA at
present is on adults with severe mental disorders. Its vision is broader,
however, and offshoots are extending the work to children, to adults with
common mental disorders, and to other arenas such as the impact of
violence and civil conflict on mental Health.
The work of RA is built on four key premises. The first is that a regional
approach is feasible and most likely to lead to wide-scale and sustainable
change. Thus approaches need to be developed and tested that are feasible
in many countries in the region and yet can be adapted to local contexts. We
are presently piloting a regionally led randomized controlled trial of a
psychosocial intervention for people with severe mental disorders, Critical
Time Intervention-Task Shifting (CTI-TS), in three cities (Buenos Aires,
Rio de Janeiro, and Santiago). Although adapted from an intervention
previously tested in high income countries as Critical Time Intervention
(CTI),66,67 CTI-TS has been targeted to the Latin American context68,69 and
has been designed so that the same core principles could be applied, with
local adaptation, across many locales in the region.
14 Public Health Reviews, Vol. 34, No 2

The second premise is that community-based mental health services

should be prioritized, at least for children and adults with severe mental
disorders. Not all community mental health services are community-based
mental health services under the definition of the term used by RA and
implied by the Caracas Agenda. To be so, they need to be close to the
communities that use them, be accessible to all affected people and their
families, include but not be limited to primary care, be developed with the
active involvement of affected individuals, their families, and their
communities (as well as other stakeholders), and include in vivo services
provided in the locations where people live (not only at clinic sites). The
CTI-TS intervention, for example, meets these criteria. It gives especially
high priority to strong ties between primary care and secondary mental
health services, provision of in vivo services, and active involvement of
users and families. RA proposes that this kind of approach is most likely to
foster social integration.70,71
The third premise is that a public mental health discipline and training
program is an essential platform for the future. It should be multidisciplinary
and at a minimum integrate public health and psychiatry. Accordingly,
most of the RA sites are led by an integrated team of investigators from
psychiatry and public health (and when possible, other disciplines). These
teams have launched programs to train and nurture a new generation of
leaders in public mental health across the region. One part of this capacity-
building work entails a training program for Awardees from all sites who,
we hope, will become leaders of public mental health in the next generation.
The fourth premise is that we need to actively combat stigma and
discrimination associated with having a mental disorder.72,73 We believe
that this will help generate the social movements for mental health reform
that are essential to address the lack of political will described above. RA
is doing this in multiple ways, including rigorous studies to document and
understand stigma and discrimination, efforts to identify and remedy
violations of human rights, and the inclusion of persons who have them-
selves had the experience of severe mental illness as paid workers with full
status in the CTI-TS intervention. The latter is somewhat novel in Latin
America. It is based on the proposition that “Peer Support Workers” have
special expertise to contribute to the recovery process, and that it is
important to demonstrate that people who have mental disorders can be
afforded human respect and dignity and participation in civil society.74-77
This brief description of RA is not intended to convey the full scope of
its work. Moreover, we do not wish to single out RA as the only important
new regional initiative. It does, however, offer an example of the kind of
efforts that could promote the acceleration of change in the coming decades.
Community Mental Health Services in Latin America 15

CONCLUSION

We have noted many examples of considerable progress toward the Caracas

Agenda in the countries of Latin America. Nevertheless, 22 years after the
Caracas Declaration, the majority of the countries of the region maintain a
model of services for severe mental disorders based primarily on psychiatric
hospitals that consume most of the national mental health budget. If the pace
of downsizing of mental hospitals and increase of community services
remains the same as in the last ten years, it could take over 50 years to
develop community mental health services in Latin America along the lines
of the Caracas Agenda. Indeed, there are examples of health reforms in some
countries that have arguably set back the agenda for mental health reform.78
This slowness occurs despite Brazil, Chile and Panama having demonstrated
that a transformation from hospital to community mental health services can
be achieved within a 20-year period, and by available indicators, have
thereby improved the quality of life of the affected individuals. At the same
time, substantial knowledge and experience has been generated in numerous
local experiences in different countries of the region.
To accelerate the pace of change, it is important to identify and address
key factors that are impeding progress. We have documented some of these
in our review: a weak political will to implement reforms to which countries
have made commitments, a low allocation to mental health within health
budgets, absence of legislation to protect the human rights of people with
mental disorders, and the persistence of inappropriate but costly systems of
hospital care. There are also other factors not covered in this review.
Probably another important factor is that the shift from a mental hospital-
model to community model requires an initial investment of funds for some
community mental services before starting the process of downsizing
hospitals. Yet another is the insufficiency of human resources, that is,
people who are trained in the delivery, evaluation, and wide-scale
implementation of community mental health services.79
It is, of course, easier to demonstrate the need to accelerate change than
to bring it about. The efforts of PAHO/WHO across the region to address
the factors noted above have been very substantial and yet not sufficient.
Clearly, progress depends upon sustaining these efforts of PAHO/WHO,
but they need to be complemented by other means. We propose that cross-
country regional initiatives have a special role to play in this regard. They
can not only help to catalyze country-specific reforms, but also can create a
synergy among country-specific reforms that may accelerate the overall
process of change.
16 Public Health Reviews, Vol. 34, No 2

We conclude by proposing four strategies that may prove fruitful in

regional initiatives to complement the work of PAHO/WHO in Latin
America: First, we now have the opportunity to develop multi-country
studies that help to better identify factors hindering and favoring the
implementation of community services and the downsizing of mental
hospitals. Second, the countries that have made major advances now have
appropriate conditions in which to study the incorporation of new strategies
and interventions that eventually further improve access, quality and equity
of community-based services. These new strategies can be planned with
their potential for regional application in mind, so that they could be taken
up by other countries in the future. Third, the strengthening of advocacy
groups and their broadening into social movements for mental health
reform could have a major impact on political will and on the reduction of
stigma.80 Both advocacy and social reform movements are strengthened by
cross-country interchange. Fourth, the development of a strong and self-
sustaining regional network of well-trained leaders in public mental health
could catalyze progress across the region.

Appendix 1
Latin American Countries and Classification of Economies
Countries Classification of Economies*
Argentina Upper-middle Income
Bolivia Lower-middle Income
Brazil Upper-middle Income
Chile Upper-middle Income
Colombia Upper-middle Income
Costa Rica Upper-middle Income
Cuba Upper-middle Income
Dominican Republic Upper-middle Income
Ecuador Upper-middle Income
El Salvador Lower-middle Income
Guatemala Lower-middle Income
Haiti Low Income
Honduras Lower-middle Income
Mexico Upper-middle Income
Nicaragua Lower-middle Income
Panama Upper-middle Income
Community Mental Health Services in Latin America 17

Paraguay Lower-middle Income

Peru Upper-middle Income
Uruguay Upper-middle Income
Venezuela Upper-middle Income
*
Upper-middle Income N=13; Lower-middle Income N=6; Low Income N=1
Source: World Bank List of Economies (July 2012). Available from URL: http://muse.jhu.
edu/about/order/wdi2012.pdf (Accessed 16 April 2013).
Acronyms List:
CAPS = psychosocial care centers, Brazil
CTI-TS = Critical Time Intervention-Task Shifting
PAHO/WHO = Pan American Health Organization/World Health Organization
RA = RedeAmericas = Regional Network for Mental Health Research in Latin
America
WHO-AIMS = WHO Assessment Instrument for Mental Health Systems
Acknowledgements: The authors gratefully acknowledge the National Institute of
Mental Health (NIMH 1U19MH095718).
Conflicts of Interest: None declared.
About the Authors: Dr. Minoletti is Assistant Professor of Public Mental Health at
University of Chile (UCH), the largest public university in Chile. He is a psychiatrist
by training with 40 years of experience in program management and research on
community mental health services, especially in low and middle income countries.
Between 1997 and 2010, he was head of the Mental Health Department of the
Ministry of Health, playing a major role designing and implementing national
mental health policies in Chile.
Dr. Galea, a physician and epidemiologist, is the Anna Cheskis Gelman and Murray
Charles Gelman  Professor and Chair of the Department of Epidemiology at the
Columbia University Mailman School of Public Health. His research seeks to
uncover how determinants at multiple levels—from the social environment to
genetics—jointly influence the health of urban populations, with a focus on
worldwide conflict and mass trauma. He chairs the New York City Department of
Health and Mental Hygiene’s Community Services Board and sits on its Health
Board. Dr. Galea is one of the four leaders of the Global Mental Health Program at
Columbia University.
Dr. Susser is one of the four leaders of the Global Mental Health Program at
Columbia University. A relevant project in this area is the RedeAmericas network
for Latin America described in this chapter. In addition, Dr. Susser is Director of the
Imprints Center for Genetic and Environmental Lifecourse Studies and the Dr. Lisa
Oehler Visiting Professor, Dept. Psychiatry, Univ. Göttingen, Germany. A primary
theme in this work has been the relation of early nutritional deficiency to child and
adult neurodevelopmental mental disorders, and the potential for periconceptional
micronutrient supplements to reduce the risk of these disorders. Finally, he is lead
author of a textbook on psychiatric epidemiology and in 2011 won the APHA Rema
LaPousse Award in psychiatric epidemiology.
18 Public Health Reviews, Vol. 34, No 2

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