The maxim that there is no health without Mental Health emphasizes the importance of the latter. Mental health, previously neglected, has come to be recognized as a critical requirement and has caught the attention of policy makers, professionals and society at large in India and across the globe.. The impact of mental, neurological and substance abuse disorders on the general population in terms of morbidity and mortality is extremely high.
Although mental health diseases are chronic and non-communicable diseases, historically, they have not been treated as a medical illness or have always been treated separate from physical illnesses. Initially the latter kind of differentiation may have been due to the lack of knowledge in the field of mental health. However, this resulted in disparity in the understanding of the existence of these diseases and the allocation of funds thereby impeding the implementation of several schemes of the government which was taking place in the field of several diseases under the category of physical illnesses. According to a report by the World Health Organization, 56 Million i.e., 4.5% of Indians suffer from depression and another 38 Million i.e., 3.5% Indians suffer from Anxiety Disorders .
History of Mental Health Policy In India
In 1974, at Addis Ababa, the WHO expressed concern over the overall lack of mental health care facilities across the world with developing countries as a priority . WHO therein urged all its member states to develop their own National Mental Health Programme (NMHP) to provide compulsory mental health care to its population. In compliance with this recommendation, in India, a final draft report was submitted to the Central Council of Health, the country’s highest health policy making body in August 1982. After thorough discussion, the Council launched the NMHP in 1982, becoming one of the major developing countries to do the same.
The primary aim of the NMHP is as follows:
Ensure the availability and accessibility of minimum mental healthcare for all in the foreseeable future, particularly to the most vulnerable and underprivileged sections of the population.
Encourage the application of mental health knowledge in general healthcare and in social development; and
Promote community participation in the mental health service development and to stimulate efforts towards self-help in the community.
The District Mental Health Program (DMHP) was launched in four districts under the NMHP in the year 1996 in the 9th Five Year Plan, with further expansion to 100 districts in the 10th Five Year Plan. Currently the DMHP is supported by the Govt. of India, in 704 districts of the country. DMHP was based on the Bellary Model, which was a community-based service for mental health services using trained individuals, implemented in the Bellary District in Karnataka with the help of local authorities and NIMHANS.
In 2012, the MoHFW appointed a Mental Health Policy Group to draft recommendations for the DMHP under the 12th Five Year Plan, whose findings of components such as capacity building and awareness generation were included. Post the implementation of NMHP, the Mental Healthcare Act was passed by the Parliament in 2017, which amended the 1987 Act, recognising the rights of persons with mental illnesses and thereby repealing Section 309 of the IPC which criminalised attempt to suicide by persons with mental illnesses. Working of the NMHP and DMHP The NMHP and respective DMHPs operate on three components similar to as stated above. Primarily, it deals with Treatment with specialised psychiatric services at the District level, hospitals with specified wings and teaching departments for mental health problems. A Primary Health Centre (PHC) in smaller towns and villages is also used for the purposes of the implementation of the programme. Second, Rehabilitation, for persons with epilepsy & other neurological-psychological conditions dealt with in centres at the district level and counselling services available. Lastly, Prevention and Promotion of Positive mental health, which would be based on the involvement of health personnel, addressing various ancillary concerns that potentially lead to severe mental health problems.
The mental health care infrastructure is broadly divided into three levels. The first point of contract to the general public is the medical officer at the Primary Health Care Centres while Community Health Care Centres are the first level of Specialist care. Here, PHC staff are trained in providing basic mental health care services by the DMHP team.
Public mental health care in the country is a joint responsibility of the centre and the state governments with the DMHP consisting of the Central Mental Health Authority (CMHA) at the national level and the various State Mental Health Authorities (SMHA) at the state levels. There are several health care providers that primarily deal with mental health. These include psychiatrists, clinical psychologists, psychiatric social workers, and nurses.
In terms of accessibility, considering these are government health services, they are available to all and the extensive implementation of the DMHP project has allowed mental health care access in many parts of the country. As a result, the DMHP envisions expanding mental health care at the community level, eliminating stigma and increasing public awareness. The focus of mental health care services has evolved away from hospital based or institutional care and towards community based mental healthcare.
The Problems and Steps Taken Over the last 25 years, there have been only two Central Government sanctioned, systematic evaluations of the DMHP. Although the intention of the DMHP was de-centralisation for administrative and implementation purposes, it still follows a top-down approach. One of the administrative issues is with regards to the various administrative bodies such as Government Ministries – for example, healthcare comes under the purview of the Ministry of Health and Family Welfare, however, rehabilitation comes under the purview of the Ministry of Social Justice and Empowerment. According to few authors, the programme was focused on pharmacological interventions that it excluded the community and stakeholder participation in the planning and implementation process . Additionally, poor implementation and inadequate attention given to the program has been influenced by the political environment and the commitment of the officers in charge. The lack in leadership and enthusiasm in various levels has further impacted the implementation of DMHP.
Even with the decentralisation due to the DMHP, due to administrative concerns, the approach has failed to accommodate the local differences in different geographical areas. The DMPH is not uniform across the country since in a few states it does not cover quarter of the districts while in some all the districts are covered. Lack of qualified mental health professionals is one of the many challenges that the current program faces in India and this problem may continue to grow. This leads to deployment of several health care workers who are not doctors. Similarly, the inadequate effort to retain staff even when hired has led to a high turnover aggravated due to poor pay, limited resources etc.
Another major concern is the lack of financing that goes to the DMHPs. A delay in funds leading to poor utilisation has been a major cause of concern. The budget for the Financial Year of 2019 reduced the allocation to 40 Crore Rupees from 50 Crore Rupees from the previous year . Although, the overall healthcare budget increased during the pandemic years, the NMHP’s budget remained the same. Similarly, patients and family members of those suffering from mental illnesses must increase their spending on treatment which they are unwilling to do due to a severe lack of knowledge and associated stigma, as well as the fear of losing productive time to contribute to the family as the ill person cannot do so.
There have, however, been several recommendations to bring about changes in the current scheme. Much of the country’s mental health care is provided by private institutions. The aim should be to redesign the public program in such a manner that the results of these private institutions may be replicated. At the same time, Public Private Partnerships, which have been introduced under the NMHP, should be thoroughly implemented. Similarly, the establishment and functioning of Mental Health Review Boards, has set up under the Mental Health Care Act, passed in 2016 for better adjudication of matters pertaining to individuals with mental health illnesses in a variety of situations ranging from treatment to judicial directives. The National Health Policy has also come to introduce several suggestions integrating community-based healing as well as technological advances, which is especially important in the post pandemic period.
Conclusion
India’s National Mental Health Policy has been historically considered one of the most vital steps in addressing the needs of the population. However, the implementation of the same faces several challenges such as stigma, accessibility, administrative and shortage of financial resource continue to persist. There is a requirement to mobilise additional HR, to both prevent and cure mental health issues. Evaluation strategies must be conducted periodically to tackle issues in a systemic manner. To realise the main objectives of the policy and betterment of wellbeing of everyone, it is imperative to implement changes and promote mental health awareness, strengthen services across all districts taking into consideration the diversity and address other systemic issues with the mental health sector. Mental health is essential for the overall well being of citizens as well as the country.
Sahana Ramesh
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