India’s mental health policy is progressive and radical in its approach, yet may falter without effective implementation. By Raelene Kambli
Back in October last year, it was felt that mental health, ignored for decades in India, has finally got the deserved attention. The then Union Health Minister, Harsh Vardhan unveiled the Mental Health Policy on the occasion of National Mental Health Day organised by the government. This marked a significant shift with the introduction of access targets for mental health services, emphasis on early interventions and standards for the provision of liaison and registration of psychiatry as well as the announcement of more money.
While launching the policy Dr Vardhan said, “The bi-directional relationship of mental ill health and poverty is evident in many reports, including the World Disability Report, 2010, that places persons with mental disabilities at the bottom of the pyramid. This alerts us to what could become a health crisis with damaging consequences for society. He also pointed out that earlier laws governing the mentally ill, the Indian Lunatic Asylum Act, 1858, and Indian Lunacy Act, 1912, ignored the human rights aspect and were concerned only with custodial issues. Hence, the government introduced the Mental Health policy.
Express Healthcare seeks to understand the need for the policy, its impact on the industry and patients and its implementation, one year down the line.
Firstly, let us understand the need for a policy as such.
Demand-supply gap
Globally, mental disorders account for about 160 million lost years of healthy life. Of this, atleast 30 per cent can be easily averted with existing interventions. However, in India, experts see a growing incidence of mental illness which need urgent attention. World Health Organisation had predicted that about 20 per cent of India’s population would suffer from some form of mental illness by 2020. Moreover, the country has only about 3,500 psychiatrists.
“Seven per cent of India’s population suffers from mental disorders and over 90 per cent remain untreated. There is less than one psychiatrist available for every four lakh people. The scene is worse in rural areas. India’s allocation for mental healthcare is less than one per cent of the health budget,” informs Dr Prashant Goyal, Consultant Psychiatrist, Sri Balaji Action Medical Institute.
The National Mental Health Program, MoHFW, GOI lists down some stats on the mental health scenario in India (See table on page 32).
Consequently, there is a compelling need for good governance of mental health in India that is backed by a radical policy framework. Now, let us understand how the mental health scenario is dealt with, worldwide.
The global scenario
As stated in WHO’s Mental Health Atlas series 2014, 68 per cent of WHO Member States have a stand-alone policy or plan for mental health; 51 per cent have a standalone mental health law. In many countries, however, policies and laws are not fully in line with human rights instruments, implementation is weak and persons with mental disorders and family members are only partially involved. Levels of public expenditures on mental health are very dismal in low and middle-income countries (less than $2 per capita). A large proportion of these funds go to inpatient care, especially mental hospitals. Globally, the median number of mental health workers is nine per 100,000 population, but there is extreme variation (from below one per 100,000 population in low-income countries to over 50 in high-income countries). The median number of mental health beds per 100,000 population ranges below five in low and lower-middle income countries to over 50 in high-income countries; equally large disparities exist for outpatient services and welfare support.
Such is the global scenario for mental health governance. What about India? Is the Mental Health Policy 2014, justified in its provisions?
Mental Health Policy provisions
The draft policy calls for recognition of mental disorders and a more accessible and holistic treatment of mental illnesses. It also pushes for decriminalisation of attempted suicide. Taking a fresh look of the available health services for mental illnesses, it lays down the guidelines for mental healthcare and recommends changes in the law that criminalises suicide, now considered a major cause of death among people with mental illness. The policy additionally spells out specific roles to be played by the Central Government, the state governments, local bodies and civil society organisations.
A progressive policy
Some experts are of the opinion that India Mental Health Policy is a blend of various global principles, put together to suit the Indian context. They state that the policy is progressive and sensitive to the social impact of mental illness, like stigma and poverty.
Dr Neena Sawant, Consultant Psychiatrist, Global Hospitals Mumbai, says, “The policy has tried to bring in benefits for mentally ill people and their families and has decriminalised attempted suicide. It has emphasised on improving the mental healthcare facilities in the country.”
Dr Priyaranjan Avinash, Senior Psychiatrist, ePsyClinic.com, elaborates, “The policy is going to benefit people with mental illness, in ways that the current act could never do. Advance directives and nominated representatives are some of the provisions which will bring a sense of autonomy to patients. Also, the approach of the policy towards inclusion of psychiatric illnesses in the list of illnesses for the purpose of insurance, may take the financial burden off the shoulders of already disadvantaged people with mental illnesses.”
Another notable provision under the policy is the recognition that a caregiver should receive monetary and tax benefits. This shows that the policy also draws attention to the largely-neglected need to support caregivers, who are almost always family members in India.
Dr Avinash further lists down some of the provisions that will be proved beneficial to patients:
- Advance directives: Capacity to make mental healthcare and treatment decisions, shall have a right to make an advance directive in writing, specifying the way the person wishes to be/ not to be cared for and treated for a mental illness.
- Nominated representatives: Right to choose a nominated representative, who can take mental health treatment and care decision on behalf of the person with mental illness.
- Mental Health Review Commission/ Board
- Mental health professionals: The definition has been widened to include psychologists, psychiatric social workers, psychiatric nurses, etc.
Harini Ramachandran, Co-founder, School of Excellence, an organisation for Neuro-Linguistic Programming, mentions that the policy also has provisions that recognises alternative therapies like yoga etc, as a treatment method for mental health, which according to her is certainly a good move toward dealing with mental illnesses.
Giving a perspective on regulating the industry to bring a positive change, Dr Avinash feels that the provision of de-licensing the mental health establishments that do not comply with the norms will go a long way in making the system a less corrupt one. On the same lines, Mrinalini Ellen Shinde, Clinical Head, 1to1Help.net informs that this new policy has made stringent rules for gaining license and registration of psychiatric clinics and practices which is indeed a good move by the government. She goes on to say that this move will regulate the industry and also prevent malpractices.
Well, if there are interesting benefits for patients provided in the policy, there are some drawbacks too.
Scope for improvement
“There are several deficiencies beginning with a very broad definition of mental illness to the surveillance system to regulate psychiatrists. ‘Mental Health Review Commission’ for the whole nation and ‘District Mental Health Review Boards’ for each revenue district would be the review boards who would be vested with powers to regulate the professional conduct of psychiatrists. This would definitely make the psychiatrists uncomfortable. In section 90, it is laid down that the Commission will appoint an expert committee, who would prepare a ‘guidance document’ to tell psychiatrists regarding assessment and treatment decisions. This would mean that psychiatrists would have to take lessons from the expert committee,” informs Dr Sawant.
“Some of the loop holes include no financial provision for upgrading of resources and the implementation of the provisions. Mental health establishments are still under the scrutiny of many authorities and commissions which will discourage private sectors from getting into mental health delivery. Admissions at a mental health establishment are still going to remain vastly involuntary, with the provision of supported admissions,” adds Dr Avinash.
Moreover, Dr Vasant Mundra, Consultant Psychiatrist, PD Hinduja Hospital & Medical Research Centre informs that certain areas such as unclear process for gaining license to set up psychiatric wards within hospitals is very detrimental to healthcare providers. Similarly, Shinde points out that there isn’t enough transparency in the process for registration and licensing. “If the government can make the process more transparent then we can eliminate middle men and avoid corruption”.
So how do we plug these loopholes?
Learning lessons
Industry experts suggest that there should be a multifaceted approach to deal with this problem. “Strategies to fight mental illness call for a complex array that will deal with its multifaceted effects and civil society must do its part as much as the government. Mental health and its ramifications affect every country and section of the society. Unfortunately, official recognition of the incidence of the same in India has been more on paper than in practice,” believes Dr Goyal.
Laying emphasis on the importance of the mental health policy, Professor Dinesh Bhugra President, World Psychiatric Association stresses, “It is important that mental health policies are taken seriously. Patients with mental illness have the right to services which are equitable and fair and need appropriate resources. The mindset needs to be changed, bearing in mind that one in four adults in their lifetime will develop mental illness. Furthermore, there is evidence that more than half of the mental illnesses in adulthood starts below the age of 15. Schools need to teach children at an early age on how to identify and manage stress and pressures. Rapid urbanisation and globalisation have increased rates of mental illness and also changes in family and social support. Hence, there is a need for better awareness.”
Furthermore, he goes on to cite an example from Gujarat which can be replicated in other states as well. ”There is an unusual example in Gujarat where nurses and doctors attend a dargah where patients with mental illness and their families go to pray. So, there are models of good practice and they need better exposure and application elsewhere. The state has better training facilities for medical students and also for students doing BAMS and homoeopathy courses, elaborates Bhugra.”
Dr Avinash gives some recommendations to improve the scenario in four major areas:
- Capacity building: The shortage of trained mental health professionals in India is huge. As long as we don’t have enough of them, no policy or bill is going to make the mental health situation in India better.
- Funding: The government needs to hike the allocation of funds for health in general, and mental health in particular.
- Medical education: The medical education curriculum needs to be modified to be more inclusive. There is a need for exhaustive training of medical graduates in the field of psychiatry and mental healthcare.
- Approachable: A country as vast in size and diversity as India, needs to have a kind of system where everyone has easy access to a trained mental health professional providing evidence-based, quality mental health services. With increase in Internet connectivity, cyber consultation, can definitely fill the vacuum that we have.
Lastly….
Well, the Mental Health Policy has been radically drafted in many areas, yet its implementation won’t be a cake walk. Also, there are some glitches that cannot be ignored and needs immediate attention. Nevertheless, the move to consider mental health as an important healthcare need reflects the government’s willingness to overhaul the non-existent mental healthcare system, at least on paper. Yet, the delay in tabling the policy in the Parliament also raises questions on the government’s commitment in this area.
Looking at the urgent and genuine need for an effective policy on mental health, it is to be hoped that all the stakeholders come together and ensure that the policy comes into effect as soon as possible.
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