|Year : 2018 | Volume
| Issue : 4 | Page : 285-288
Prioritizing rural and community mental health in India
Roy Abraham Kallivayalil1, Arun Enara2
1 Department of Psychiatry, Pushpagiri Institute of Medical Sciences, Tiruvalla, Kerala, India
2 Senior Resident, NIMHANS, Bengaluru, Karnataka, India
|Date of Web Publication||19-Nov-2018|
Dr. Roy Abraham Kallivayalil
Department of Psychiatry, Pushpagiri Institute of Medical Sciences, Tiruvalla - 689 101, Kerala
Source of Support: None, Conflict of Interest: None
With a huge population of 1.3 billion and deficient mental health personnel and infrastructure, India needs newer strategies for rural and community mental health care. There is a huge and unmet gap in mental health services, which needs our immediate attention. The National Mental Health Program and District Mental Health Program have made very welcome beginnings, but they are a long way off from even remotely reaching an optimal coverage. Nongovernmental organizations have been playing their important part as well. However, an important impetus can potentially come from the new mental health policies and legislation, which are in keeping with the United Nations Convention on Rights of Persons with Disabilities. Still, there is a lot to be done. The rural mental health services are often neglected and need immediate attention considering the burden of disease and treatment gap. Identifying the economic, social, and political barriers to the utilization of existing services would strengthen the delivery and utilization of these services. The mental health professional should be at the helm of leading and heralding the changes needed. This provides us with the challenge, as well as an opportunity.
Keywords: Community, legislation, mental health care, programs, rural
|How to cite this article:|
Kallivayalil RA, Enara A. Prioritizing rural and community mental health in India. Indian J Soc Psychiatry 2018;34:285-8
“Almost half of the population of the world lives in rural regions and mostly in a state of poverty. Such inequalities in human development have been one of the primary reasons for unrest and in some parts of the world, even violence.”
– A.P.J. Abdul Kalam
| Background|| |
With a huge population of 1.3 billion and deficient mental health personnel and infrastructure, India needs newer strategies for rural and community mental health care. There is a huge and unmet gap in mental health services, which needs our immediate attention. Utilizing the existing workforce in our community becomes essential. Incorporating informal resources to supplement the specialist services is an option, which needs consideration.
The estimates from the National Mental Health Survey suggest that 15 crore (150 million, 12.5%) people are in need of active interventions for mental illness in India. Of these, nearly 1.2 crore (12 million) are living with serious mental disorders. This survey, carried out across 12 states in India, found that the overall prevalence for the current mental health morbidity is 10.6%. Failure to receive any treatment for mental illness varies between 70% and 92% across various states in India. There are just 0.3 psychiatrists, 0.07 psychologists, and 0.07 social workers per 100,000 people in India. The ratio of psychiatrists in developed countries is 6.6/100,000. There is a 40–60 fold deficit in the number of clinical psychologists, social workers, and nurses. An estimated 36–45 lakh (or 3.6–4.5 million) people in India require hospitalization for mental illnesses; however, only 6.4–8 dedicated psychiatric beds are available for every 1000 patients in need of hospitalization. Despite cost-effective and feasible packages of care, very few mentally ill people receive mental health care in India., The mental health workforce and facilities largely revolve around the major cities and in the private sector. In India, the community mental health programs face numerous challenges. According to the World Health Survey, the prevalence of psychosis in India is between 0.7% and 3.6%, while the treatment rates range between 36% and 85%. The National Mental Health Survey data concur with these figures.
There are also significant limitations in the availability and integration of mental health services in the public health sector. There is an increasing need to develop local solutions to build and strengthen the community mental health system in India, which would in turn increase the accessibility to appropriate care for people with mental illness.
| The Evolution of Mental Health Policies in India|| |
The adoption of National Mental Health Programme (NMHP) by the Government of India in August 1982 was in many ways a landmark event in the history of psychiatry in India. Growing awareness regarding the magnitude of mental health problems in the country, a flurry of health activities in the late 1970s which included Alma Ata Declaration, the commitment to provide health to all by 2000, and the realization that mental health care was possible through the existing primary health-care system led to the launch of NMHP by the Government of India in 1982. The NMHP envisioned to ensure availability and accessibility to minimum mental health care for all, particularly to the most vulnerable sections of the population and to promote community participation in service development and stimulate self-help in the community. The aim of the NMHP also included promotion of the community mental health care through an intersectoral approach and also through integration with primary care by training the primary health workers to diagnose and treat mental disorders. On the understanding that the mental health models were too resource intensive for a small catchment area, a district-level initiative was launched in the Bellary district of Karnataka. The Bellary model, one of the few operationalized and favorable programs, was taken up by the government as a national model and has remained the model for primary mental care delivery ever since. This also paved way for the development of the District Mental Health Programme (DMPH).
The DMPH was a community-based mental health-care plan at district level and was initiated in four districts in 1996. It was extended to 27 districts across 22 states/union territories in the ninth 5-year plan. The NMHP was modified during the tenth 5-year plan to incorporate the expansion of DMHP to 100 districts all over the country; with special focus on modernization of state-run mental hospitals; upgradation of psychiatry wings in the government medical colleges/general hospitals; implementation of information, education and communication (IEC) activities; and incorporation of research and training in mental health for improving service delivery. By the end of the tenth 5-year plan, DMHP was extended to 110 Districts and upgradation of psychiatric wings of 71 medical colleges/general hospitals and modernization of 23 mental hospitals were funded.
The rise of the nongovernmental organization (NGO) movement to fill the gap of the NMHP also requires a special mention. DMHP in its initial days focused on early diagnosis and treatment, training of primary health center staff, and IEC activities with the core clinical team. The impetus was also on health promotional activities such as life skills' education and counseling in schools, counseling services in colleges, workplace stress management, suicide prevention services, as well as a managerial team for implementing various DMHP activities. The major achievements of the program have been the development of community mental health services in the most underserved areas. This was in turn an attempt to decentralize the existing NMHP using the existing public health resources. Apart from the national and district mental health programs, the National Rural Health Mission became the vehicle for delivering mental health as a part of integrated primary care. This paved the way for partnership with the existing private and alternative care providers in the delivery of mental health services.
The implementation of NMHP and DMHP resulted in significant improvement in human resource development. The community-based mental health care delivery resulted in significant improvement in the public awareness. The Indian Council of Medical Research Severe Mental Morbidity demonstration project showed that about 20% of people with mental disorders could be brought into care with this approach. However, the population covered was very small in comparison to the national need.
The British government in 1858 introduced the first mental health legislation in India. This was followed by the adoption of three acts namely the Lunacy (supreme courts) Act, the Lunacy (district courts) Act, and the Indian Lunatic Asylum Act in India. The focus of these acts was on asylum-based care, until the Indian Psychiatric Society submitted a revised mental health-care bill in 1950. This was enacted as the Mental Health Act in 1987. The important changes introduced in the Mental Health Act 1987 included refined terminologies, the creation of state and central mental health authorities, and streamlined admission and discharge processes. With the advent of United Nations-Convention on Rights of Persons with Disability (UN-CRPD) published in 2006, the existing Mental Health Act (1987) was not found to be in line with the provisions recommended by the UN-CRPD. On August 8, 2016, the Rajya Sabha passed The Mental Healthcare Bill, 2016. The aim of the bill was “to provide for mental healthcare and services for persons with mental illness and to protect, promote and fulfil the rights of such persons during delivery of mental healthcare and services and for matters connected therewith or incidental thereto.” The Mental Health Care Act (MHCA) received the assent of the President on April 7, 2017, and is currently in being. The new MHCA aims to protect the rights of the patients with mental illness, which will prevent their exploitation and abuse. This has particular relevance in the Indian context considering the poor socioeconomic status of the people and limited awareness regarding mental illness in the community.
After India signed and ratified the UN-CRPD in 2007, the process of enacting a new legislation in place of the Persons with Disabilities Act, 1995 (PWD Act, 1995), began in 2010 to make it compliant with the UN-CRPD. The Rights of PWD Act, 2016, was passed by both the houses of the Parliament and was notified on December 28, 2016, after receiving the presidential assent. The Act focuses on nondiscrimination, full and effective participation and inclusion in society, respect for difference and acceptance of disabilities as part of human diversity and humanity, equality of opportunity, accessibility, equality between men and women, respect for the evolving capacities of children with disabilities, and respect for the right of children with disabilities to preserve their identities. The principle reflects a paradigm shift in thinking about disability from a social welfare concern to a human rights' issue.
There is also a potentially effective opportunity to increase policy attention and interventions in the ongoing discourse on advancing universal health coverage (UHC), both at global level and in India. The UHC aims that “all people have access to needed promotive, preventive, curative, and rehabilitative health services, of sufficient quality to be effective, while also ensuring that people do not suffer financial hardship while paying for these services.” The National Health Policy, 2017, lists UHC as one of its key objectives.
| Prioritizing Rural and Community Mental Health in India – The Road Ahead|| |
The community care takes into account the family and community structure, as well as the cultural and religious values. This approach is very practical in the Indian scenario when it comes to delivery of mental health care. It also works well considering the economic and demographic conditions. This mode of care is inclusive and ensures accessible and affordable services to the remote rural populations.
Psychiatric services in India are available in a wide variety of settings including general hospital psychiatric units (GHPUs), psychiatric hospitals, psychiatric nursing homes, polyclinics, and office-based practices. A GHPU is the psychiatric wing in a general hospital or medical school which embodies the idea of integration of mental and physical health care, a concept included as one of the objectives of the NMHP of India. GHPUs have come a long way and firmly established as the main resource for mental health care, training, and research in the country. The strengthening of the GHPUs will be one of the ways forward to ensure the delivery of quality, affordable care to the rural India. In the recent past, there has been an increase in the mental health budget in the 5-year plans of the Government of India (especially since the 10th plan onward), with a focus also on upgrading the psychiatric wings of government medical colleges. Under the re-strategized NMHP of 2003, the psychiatry wings of government medical colleges and general hospitals in 88 medical colleges have been upgraded. These upgrades were primarily of infrastructure and equipment, with an aim to strengthen the training facilities for undergraduate and postgraduate students, thereby catering to the large unmet workforce requirement in the delivery of mental health care.
GHPUs have helped bringing psychiatry out of the closet and into the mainstream and have been firmly established as the main setting for clinical care and teaching and research in mental health in the country. However, this important sector of the mental health services needs more focus and resources from the health planners so as to utilize its full potential.
The way forward for the large rural population to be involved in its own mental health is through enhancing mental health awareness. The rising awareness will ensure early recognition and access to treatment will follow. Attitudes which hinder recognition and appropriate helpseeking can be counteracted by information which is already readily available in the public domain. This would also help in strengthening the preventive aspects of care. The large treatment gap that exists in India and particularly in the rural areas will come down when awareness increases. The increasing need based on increasing awareness will in turn lead to strengthening of the existing services and improvement in the mental health infrastructure.
The DMHP faces difficulties pertaining to implementation due to the lack of workforce and resources. There have been multiple innovative approaches to tackle the problem of inadequate workforce. One such initiative at the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, involved the training of accredited social health activist (ASHA) workers to fill the gap. Since 2016, ASHA workers in Karnataka are being trained additionally at the NIMHANS to identify and deal with the mental health issues. The ongoing training includes teaching ASHA workers how to recognize common severe mental health problems such as schizophrenia, anxiety, depression, and alcohol abuse along with teaching them how to refer patients to a professional at the primary health-care level and also to provide basic counseling. The community intervention programs such as the Thirthahalli (Community Intervention Psychotic Disorders) programme and the Turuvekere (TURUVECARE) Programme require a special mention in this regard.
NGOs have made tremendous strides in mental health promotion and care and have a definite role to play in meeting mental health needs in India. The strength of mental health NGOs does not lie in their ability to reach out to the millions of persons with mental disorders, but in evolving and perfecting quality programs and models which have the characteristic of replicability. Through innovation and accountability, NGOs can provide models for the public health-care system to emulate and partner. Involving the mental health NGOs in the delivery of NMHP should be a priority and this would go a long way in reducing the treatment gap, especially in the rural India.
The MHCA 2017 aims to provide the individual with a right to access mental health care and treatment from mental health services run or funded by the appropriate government. The provision to reimburse an individual for services availed from a private mental health in the absence of public mental health services and bringing mental illness under medical insurance policy, treating it at par with physical illness, is a step in the right direction. As per the Act, the government should integrate mental health services into general health-care services at all levels of health care including primary, secondary, and tertiary health care and in all health programs run by the appropriate agency. It is also important to study and document the impact of including GHPUs under the purview of the MHCA 2017. There is also a need for better integration of the MHCA 2017 with the existing NMHP and DMHP programs.
The technological advancements in the field of delivering mental health care should be studied closely. Telepsychiatry holds the potential to solve the enormous and intertwined problems of underdiagnosing and undertreating persons with mental illness and the lack of trained workforce at grassroots level. The NIMHANS-ECHO project and the Virtual Knowledge Network show the potential to better the implementation and delivery of mental health services in the rural part of our country.
| Conclusion|| |
The National Mental Health Survey called for the significant strengthening of existing NHMP and, its key implementation arm, the DMPH.
The rural mental health services are often neglected and need immediate attention considering the burden of disease and treatment gap. Identifying the economic, social, and political barriers to the utilization of the existing services would strengthen the delivery and utilization of these services. The mental health professional should be at the helm of leading and heralding the changes needed. This provides us with the challenge, as well as an opportunity. After all, “the future of India lies in its villages.”
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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