Pan American Journal Special report of

Community , primary health care, and health-promoting universities in Ecuador*

Victoriano Camas Baena1

Suggested citation (original manuscript) Camas Baena V. Salud mental comunitaria, atención primaria de salud y universidades promotoras de salud en Ecuador. Rev Panam Salud Publica. 2018;42:e162. https://doi.org/10.26633/RPSP.2018.162

ABSTRACT The objective of this paper is to describe the current situation of mental health in Ecuador. In Ecuador, although the model of community mental health has been integrated into primary health care services for a decade, its implementation does not seem to have achieved the expected results. It is pertinent to explore the causes of this situation and to propose alterna- tives, taking into account the contributions of social medicine, collective health, and partici- patory action research as emblematic models in Latin America in the field of mental health. For an effective implementation of community mental health in primary care in Ecuador, the role of universities is central, specifically in projects linked to the community and in pre-­ professional practices in health science careers. These projects allow the promotion of commu- nity mental health at the first level of health care from a critical perspective, open to complex- ity and based on the principle that the community is the main active subject of social transformation.

Key words Mental health; primary health care; community participation; universities; Ecuador

The mental in Ecuador conditions. ­Furthermore, it recognizes the promotion, care, and recovery of in- has evolved over the past decade and the role of users, families, and social or- dividual, family, and is hailed as one of the main achieve- ganizations, as well as the central as a human right (2). ments of the country’s integrated fam- role of health professionals, especially Other significant steps forward in ily, collective, and intercultural health those who work in the primary care this process have been the Strategic care model (modelo de atención integral ­services (1). ­National Plan and the Mental Health de salud familiar, colectivo e intercultural – Since 2007, the national government Care Model 2015–2017, which have MAIS-FCI). In this model, mental health has sought to follow the principles sought to replace the curative/hospital- is considered to depend not only on agreed upon by the member states of the focused model with a community ­biological factors but also on living World Health Organization (WHO) at care model. For this purpose, they have Alma-Ata 40 years ago—namely: to pro- promoted the development of PHC * Official English translation from the original tect and promote the health of all the services­ and ­coordination between Spanish manuscript made by the Pan American people of the world, with primary health these centers and the second level of Health Organization. In case of discrepancy, the original version (Spanish) shall prevail. care (PHC) as the guiding principle of an care, ­facilitating the process of deinstitu- 1 Facultad de Psicología, Universidad Laica Eloy integrated health system. This model tionalization (3). Alfaro de Manabí, Manta, Ecuador. Send corre- spondence to Victoriano Camas Baena, vcamas. seeks to replace the medical-biologistic-­ Despite the foregoing achievements, [email protected] curative approach with one focused on the mental health system in Ecuador has

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Rev Panam Salud Publica 42, 2018 1 Special report Camas Baena • Community mental health and health-promoting universities in Ecuador limitations that make it difficult to imple- effective implementation. And there is approach proposed by public agencies— ment this new legislation. They include: still another highly important drawback: comes up short. From the perspective the existing academic and professional being proposed here, CMH is an innova- 1. Insufficient funding in a budget that training programs are unable to prepare tive proposal within the panorama of the gives priority to supporting the sec- the human resources needed to meet the social and health sciences. Unlike the ond and third levels of care. In 2012, legal requirements for offering CMH prevailing traditional models in psychia- the total allocation for health was US$ within PHC. Even though recent years try and clinical psychology, which prefer 1,881,061,107, of which only 0.44% have seen progress in the development to focus on the study and treatment of (US$ 8,308,210) was designated for of higher education in this area, many disease, the integrated CMH proposal mental health, and of this amount, health professionals in Ecuador do not approaches its task from the perspective 98.57% was for psychiatric hospitals. have specific training in mental health at of and protection us- This trend continued in 2014, when the undergraduate or graduate level. To ing an investigative methodology that only 1.46% of the health budget was compound the problem, pre-professional includes community participation (9). set aside for mental health, and al- practices in the health science programs The increase in psychopathologies and most half was for investments in psy- are based on the hospital-focused model psychosocial problems is all the more chiatric hospitals (4). (7). Furthermore, few academic or health reason to seek an integrative approach 2. The primary mental health care ser- institutions offer community-oriented that is not limited to working with vices do not have enough profession- in-service practicums in mental health, ­individuals and their particular set of als or PHC centers to meet the needs nor do university-level teachers have problems/psychopathology, but rather of users. This situation often leads specific competency in health promo- extends attention, evaluation, and pre- them to “self-refer” to institutions at tion. The exception is the graduate pro- vention to the family and community the second and third levels of care (5). gram in family medicine, which includes level. The integrated CMH model en- 3. Most of the professionals who work training in mental health, capacity-­ compasses problems in the community, in the PHC centers lack resources, building to handle mental health prob- including active engagement in social competencies, and expertise in the lems, management of psychotherapeutic participation and the incorporation of area of mental health––much less in agents, and systemic psychotherapy, but mental health in PHC, with priority on community mental health. It is there- the depth of the training varies among the prevention of psychopathologies/ fore quite challenging for them to universities (8). Against this background, psychosocial problems and the promo- meet the needs of users and comply the specific objectives of this manuscript tion of mental health (10). with the terms in the Integrated are to reflect on some ideas for integrat- Bearing in mind the above, we now Family Health Care Model (MAIS). ing CMH into PHC; discuss the complex- turn to the proposals offered by the As a result, they tend to refer users ity of the issue from a critical perspective; Latin American social medicine/collec- to facilities at the second and third and suggest the fundamental role that tive health movement, especially its main levels of care. universities can play in improving health ­authors in Ecuador, as basic theoretical, 4. At the same time, the mental health care in the context of pre‑professional methodological, praxeological, and above system in Ecuador continues to favor practices and outreach to the collectivity. all ethical and political references for re- the biomedical model for evaluation, In addressing social and community thinking and reformulating the country’s diagnosis, and interventions, omit- practices in health from this perspective, current model and the community mental ting the family and community com- we rely on the rich theoretical output of health policies, particularly within the ponent. Because of this limitation, the Latin American social medicine/col- context of primary health care. The Ecua- mental health care tends to focus on lective health movement. dorian authors of this school of social reducing symptoms in the individual medicine emphasize the importance of without considering the family and Community mental health and expanding the country’s current vision of community context. This is one of the primary health care: a critical health. They point to the deterioration of reasons why the numbers of cases overview services provided under the logic of the continues to rise in the health centers, unicausal biomedical paradigm, which along with psychosocial problems in As indicated above, CMH requires a has clearly failed to solve growing health the community. The current public detailed, substantive, and well-inten- problems (11). health scenario is governed by a pa- tioned policy along with legal norms to For these authors from the School of ternalist perspective (product of the regulate it. However, the policy will be Public Health, it is essential to accept a disease-centered biomedical model), empty words unless human and eco- new understanding of health as a process adopted long ago and deeply rooted nomic resources are available to put it that interacts with all the spaces in which in users and professionals, which into practice. Nor can it be effective the individual lives and develops. They continues to stand in the way of exe- ­unless it represents an epistemological construct an alternative proposal, which cuting the mandates of the country’s break with the traditional medical-­ they call social medicine and collective current legislation (6). biologicist-curative model. It must be health. Essentially, it should: (a) break In summary, even though Ecuador’s more than merely a localized outpatient free of the traditional biologicist public current mental health legislation pro- ­remedy that connects the health care health mold, incorporate advances in motes the PHC-integrated community structure with users outside the orbit of ­social , integrate history in mental health (CMH) model, the limita- hospital services. This “domesticated” its real dimensions, recognize heteroge- tions described above are preventing its version of CMH—the paternalist-curative­ neous structural reality as a fundamental

2 Rev Panam Salud Publica 42, 2018 Camas Baena • Community mental health and health-promoting universities in Ecuador Special report determinant, and adopt social dynamics In this sense, PAR is one of the most and theoretical competencies in commu- as the axis of interpretation; and (b) re- important resources for the community nity mental health that the professionals place the empirical-positivist method with mental health model, as it involves all who work in the PHC centers should a dialectic and participatory approach to parties as protagonists in the production possess. Although few universities offer interpreting health problems (12). of appropriate knowledge for transfor- undergraduate or graduate programs in This approach opens up the prospect of mation of their reality. The participation CMH and PHC, there is no lack of initia- changing conventional public health, ex- of all actors is key, especially community tives and projects under way that seek to panding its horizons, and studying the participation. Thus, PAR is both an in- carry out the mandate we have inherited potential to reconstruct public health in a vestigative approach and a methodology from Alma-Ata. field of action that offers an alternative to for social intervention applied to the the biomedical hegemonic model, mov- study of the realities encountered in the Health-promoting universities ing forward in an integrated manner and various contexts of human life. In this in- allowing individuals and collectivities to tervention, the population is also aware These universities offer opportunities generate their health on a daily basis of the objectives and participates actively to carry out projects aimed at greater while building their own proposals for with the investigator in the analysis of connection with the collectivity and supporting and promoting health, pre- the situation and the consideration of pre-professional practices that are not venting diseases, and providing care (13). concrete measures to change it. At the geared toward the biomedical curative/ It also tells us that the events that lead same time, PAR becomes a tool for pro- hospital-focused model. A single school, an individual to get sick affect more than moting active cohesion in the commu- serving society through community-­ one person and can potentially affect an nity as a basis for participation, helping linked activities and pre-professional entire community. It is not that they are its members to discover problems and practices, can start the shift from the cur- generated within an individual space, consider solutions. It is a process that in- rent disease-based health sciences to family, or group and spread outward to cludes the promotion and democratiza- health-based sciences. There are a num- others; rather, they are produced and tion of knowledge for the purpose of ber of examples in Ecuador’s univer- spread within the collectivity as a whole transforming and improving a commu- sities, including many higher education and extend to all of society. Thus, when nity’s situation (9, 15). institutions in the Ecuadorian Network health is approached as a collective prob- Addressing all these elements, along of Universities Promoting Health and lem, it is necessary to propose an inter- with the sociological, clinical, and epi- Well-being (Red Ecuatoriana de Uni- pretation to transcend the linear and demiological implications of mental versidades Promotoras de Salud y Bienestar – reductionist view of health as the effect health problems, means that the culture REUPSB), such as community-linked of isolated causes in order to understand of PHC professionals will have to change. activities and pre-professional practices health in all its complexity (14). Above all, it will be essential to increase in CMH conducted by the Psychology The premise of the social medicine and their sensitivity for working in the psy- Department of the Eloy Alfaro Lay Uni- collective health approach, which applies chological and social dimensions, their versity of Manabí (ULEAM) following to CMH and PHC, is to intervene by competency in health promotion and in the earthquake of 16 April 2016, which ­promoting protective and healthy life- the prevention, diagnosis, and treatment we describe below. styles, coupled with preventive measures of the most prevalent mental health In the context of disasters, it is clear aimed on countering the precipitating problems, and their community involve- that that the most meaningful function risk factors, in the knowledge that these ment and capacity to promote the coordi- of the university—its raison d’être, its measures are effective and that they en- nation of the health and non-health ­social relevance—is to attend to the compass the three dimensions of the per- resources involved in the care process. needs of the collectivity and lend assis- son’s reality: individual, family-group, All this is necessary because the inte- tance in finding solutions. And that is and community. grated practice of CMH within PHC ex- what all of us in the academic commu- The community mental health model tends beyond the specific field of nity at ­ULEAM set out to do just minutes is also closely related to participatory psychopathology. Some studies, such as after the earthquake struck at 6:58 p.m. action research (PAR) in that it departs those by Ciompi, have shown that learn- on 16 April 2016.2 from viewing mental health problems in ing a patient’s history and working with The community-linked project “Com- the context of the biomedical model, un- them on a shared vital endeavor are munity Strengthening in Rural Areas Af- der the control and domination of the more effective than medicines or hospi- fected by the Earthquake in the province institution and “expert” professionals, talization (16). of Manabí” (Fortalecimiento comunitario de and turns the process into participatory The community mental health model las zonas rurales afectadas por el terremoto reflection together with the community applied to primary health care provides en la provincia de Manabí), conducted by in order to construct knowledge and ac- a practical strategy for promoting mental students and faculty form the Psychology­ tions. This approach is based on the rec- health in the case of Ecuador, as well as Department at ULEAM and a team from ognition that mental health is related to an opportunity to reflect on its origin, the well-being of society and the collec- foundation, objectives, and implementa- tive life of the community in a horizon- tion in policies and practices. This leads 2 One of the most devastating events in the history of Ecuador occurred on 16 April 2016, when an tal relationship between professionals us to the important role of the country’s earthquake at 7.8 degrees on the Richter scale re- and mental health users in which both public university system in assuring the sulted in 663 deaths and the disappearance of produce and share wisdom and under- quality and relevance of the education nine other persons. As of mid-May 2017, 7,633 families, or a total of 28,775 individuals, were still standing (10). provided and in developing the practical living in temporary shelters.

Rev Panam Salud Publica 42, 2018 3 Special report Camas Baena • Community mental health and health-promoting universities in Ecuador the International Committee for the communities from a more integrated As we have shown in this article, de- ­Development of People (Comitato Inter- ­social, no longer simply clinical, perspec- spite the challenges and needs that nazionale per lo Sviluppo dei Popoli – CISP), tive, with the goal to empower commu- have been mentioned, a new perspec- was one among the many components nity members to adopt resilient positions, tive on CMH and PHC is possible if the of the macro project “Reconstruction of attitudes, and practices. ­postulates of social medicine, collective Manabí” carried out by ULEAM in coor- Another important byproduct of this medicine, and PAR are taken as theoret- dination with various entities at the experience was the Psychology Depart- ical, methodological, and praxeological ­canton, provincial, national, and interna- ment’s decision to redesign its curricu- referents, as has been demonstrated in tional levels, and, of course, with the lum, incorporating courses in emergency various studies conducted elsewhere people affected by this terrible event. management and disaster response from the Region (17, 18). Through this project, individual, fam- the perspective of clinical psychology, An effective idea for supplementing ily, and community psychological care community psychology, and the social the limited investments in Ecuador’s was provided in a number of rural and sciences. mental health system might be to reor- periurban areas that had not received In addition, a community mental health ganize the current services and human any other aid since the disaster struck. research group was formed, bringing resources available to universities that The project gave people the opportunity ­together teachers, students, and various promote health, especially if they receive to express their emotions and talk about social actors. Based on the participatory support from government agencies or their experiences through active listen- action research (PAR) model, one of its international organizations such as the ing and to receive psychological first aid. main objectives was to identify and char- World Health Organization or the Pan As for CMH and PHC, ULEAM had al- acterize a resilient population profile American Health Organization (19). ready begun to work within the disaster that would encourage healthy organiza- The experience of integrating CMH framework long before the project began. tion, psychoeducation, and approaches into PHC in the project carried out by the However, since the earthquake had pre- to problem-solving, not only in emer- ULEAM Psychology Department shows sented a situation for which the ULEAM gencies. The group also proposed com- that this process is possible in Latin team was unprepared, they could only munity health and mental health American countries, and that it can make try to do their best and learn as they approaches, methodologies, and prac- an important contribution toward im- worked with the affected population, tices, including community-linked proj- proving availability and accessibility in a building a relationship of assistance fo- ects integrated and coordinated with scenario of insufficient resources (20). cused on the emergency response. As a research, teaching, and pre-professional The experience generated some lessons result of this project, we feel that the UL- practices, that can be carried out in PHC for the Region, among them that a na- EAM Psychology Department devel- centers in Ecuador. tional mental and/or plan oped a more organized presence. It also It is important to emphasize that this can play an important facilitating role, showed that it is able to provide care that intervention demonstrated the need to and that it will be necessary to allocate focuses on meeting emergency needs, include CMH in health policies and uni- additional resources to support the pro- which was necessary at the outset. Fur- versity academic programs for the devel- vision of mental health services in PHC thermore, after this initial phase, it also opment of future PHC professionals. and generate mechanisms to encourage managed to position itself as a serious Mutual support and articulation be- its implementation. actor, demonstrating that it operates in tween professionals at the primary and an organized manner and plans ahead, secondary levels of care. Conflicts of interest. None declared. taking into account the needs of the pop- Finally, it appears that Ecuador now has ulation while at the same time using the necessary political will and technical Disclaimer. Authors hold sole respon- ­supervised resources and methods de- strength to implement a model for CMH sibility for the views expressed in the signed specifically for use in the field. integrated into PHC, even though the manuscript, which may not necessarily No longer providing therapy and funds available for this area are ­limited reflect the opinion or policy of the RPSP/ ­encouraging emotional discharge, it and the biomedical curative/hospital-­ PAJPH or the Pan American Health shifted to bringing out the potential of focused model continues to prevail. Organization.

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RESUMEN El objetivo de este trabajo es describir la situación actual de la salud mental en Ecuador. En Ecuador, aunque el modelo de salud mental comunitaria está integrado en los ser- vicios de atención primaria de salud desde hace una década, su implementación no Salud mental comunitaria, parece tener los resultados esperados. Resulta pertinente indagar sobre las causas que atención primaria de salud y determinan esta situación y proponer posibles alternativas, tomando como referencia los aportes de la medicina social, la salud colectiva y la investigación de acción parti- universidades promotoras cipativa como modelos emblemáticos en América Latina en el ámbito de la salud de salud en Ecuador mental. Para la implementación eficaz de la salud mental comunitaria en la atención primaria en Ecuador es trascendental el rol que poseen las universidades, en particu- lar en los proyectos de vinculación con la comunidad y en las prácticas preprofesiona- les de las carreras de ciencias de la salud. Estos permiten incorporar prácticas de pro- moción de salud mental comunitaria en el primer nivel de atención de salud desde una perspectiva crítica, abierta a la complejidad y basada en el principio de que la comunidad es el principal sujeto activo de transformación social.

Palabras clave Salud mental; atención primaria de salud; participación de la comunidad; universidades, Ecuador.

RESUMO O objetivo deste artigo é descrever o estado atual de saúde mental no Equador, um país onde embora o modelo de saúde mental comunitaria está integrado em atenção primária à saúde por uma década, sua implementação parece não ter os resultados Saúde mental comunitária, esperados. É pertinente indagar sobre as causas que determinam essa situação e atenção primária à saúde e propor possíveis alternativas, tomando como referência as contribuições da medicina social, da saúde coletiva e da pesquisa-ação participativa como modelos emblemáticos universidades promotoras na América Latina no campo da saúde mental. Para a implementação efetiva da saúde de saúde no Equador mental comunitária na atenção primária no Equador o papel das universidades é cru- cial, particularmente em projetos ligados à comunidade e nas práticas pré-­profissionais das carreiras das ciências da saúde. Estes permitem incorporar práticas comunitárias de promoção da saúde mental no primeiro nível de atenção à saúde sob uma perspec- tiva crítica, aberta à complexidade e baseada no princípio de que a comunidade é o principal sujeito ativo da transformação social.

Palavras-chave Saúde mental; atenção primária à saúde; participação da comunidade; universidades; Equador.

Rev Panam Salud Publica 42, 2018 5