DESK REVIEWS | 04.07.01. Is there a mechanism to coordinate care across sectors in government for people with dementia?

DESK REVIEW | 04.07.01. Is there a mechanism to coordinate care across sectors in government for people with dementia?

There is no mechanism in government to coordinate care specifically for people living with dementia. However, there is the National Policy for Primary Care (Política Nacional de Atenção Básica) that includes the Family Healthcare Strategy (a multidisciplinary team of health professionals that provides regular care to the community). These groups are the first point of contact between people in the community and the provision of public healthcare (Brazilian Ministry of Health, 2012). Based on a multidimensional assessment, people are referred to more specialized care where they can access diagnoses and treatments when needed. There is also a programme/service called “Matriciamento em Saúde Mental” which is a model of delivering healthcare where two or more professional teams create a proposal of a pedagogical-therapeutic intervention. In Brazil, this model is developed between the Family Health Strategy (reference team) and a supportive mental health team (in the case of dementia). The aim is to make the system less hierarchical by providing a specialized technical support to an interprofessional team so as to broaden their field of action and to qualify their actions (Brazilian Ministry of Health, 2011b).


Brazilian Ministry of Health. (2011b). Guia prático de matriciamento em saúde mental.

Brazilian Ministry of Health. (2012). Política Nacional de Atenção Básica.


PERDOSSI recommends care pathways that enable people with dementia (and their families) to have access to assessments through multidisciplinary teams as well as to psychosocial interventions. It is recommended that each patient suspected to have dementia at primary care level should be referred to the specialistic/secondary level of healthcare (neurology/psychiatry/geriatrics) or a memory clinic. Memory clinics should have multidisciplinary teams including neurologists, psychiatrists, geriatricians, psychologists, nurses, occupational therapists, physiotherapists, and (additional) general practitioners, home care workers, nutritionists, social workers, speech therapists, pharmacists, and local Alzheimer group representatives. The guideline does recommend one care provider to be the key care coordinator (PERDOSSI, 2015).


PERDOSSI. (2015). Panduan Praktik Klinik: Diagnosis dan Penatalaksanaan Demensia. PERDOSSI.

Similar to mental health care, dementia care is not well integrated within health care delivery systems. Mental health care, which also covers dementia care is only provided in 29 of the 284 Level 4 hospitals and above but only few hospitals have a multidisciplinary team (psychiatric nurses, social workers, psychologists and medical doctors). There is also no structured needs assessment on the person with dementia and the caregiver. Often, the first point of entry is the outpatient clinic where a doctor gives a diagnosis and recommends referral to a psychiatric nurse for further psychosocial management after pharmacological and non-pharmacological prescription by the doctor. A care plan is then developed by the nurse or the psychologist rather than with the patient (focus group discussion with health care workers through the STRiDE project). There are no documents illustrating the existence of this process.

As mentioned above, there are no national dementia policies and no care coordination mechanisms are in place.

Support services for persons living with dementia in South Africa are largely provided by the non-governmental organisation (NGO) sector, for example Alzheimer’s South Africa (ASA) and Dementia-SA.