Strengthen mental health services for universal health coverage in India

In India, an estimated 15 crore (150 million, 12.5%) of people are in need of active interventions for mental illnesses. Of these, nearly 1.2 crore (12 million) are living with serious mental disorders. On account of the shortfall of specialist and health services for mental illness, treatment is unavailable or inaccessible even for those who actively seek health care. There is nearly one trained psychiatrist for every 250,000 people, and overall mental health workforce (psychiatrist, clinical psychologists, and psychiatric social workers together) availability is <1 per 100,000 population.[1] 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 for hospitalization.[2] The distribution of mental health workforce and facilities is also skewed toward major cities, which leaves no surprise that local healers and nonqualified providers are the first point of care seeking even for serious mental health conditions in India.[3]

The current situation exists in spite of a series of policy and programmatic interventions in the last three decades, i.e., the National Mental Health Programme, 1982; the Mental Health Act, 1987; and the District Mental Health Programme (DMHP), 1996.[4] Recently, the first National Mental Health Policy of India was released[5] and the Mental Health Care Bill (MHCB) was passed by the Indian Parliament to replace the Mental Health Act of 1987.[6]

In the intervening period, midcourse corrections and policy actions such as reorganization of DMHP in 2003 were witnessed. Attempts were made to create additional training capacity for mental health workforce through creation of centers of excellence, and attention was given to community-based mental healthcare and expansion of DMHP. By early 2017, DMHP was covering nearly 339 districts i.e., almost 50% of all districts in India.[7]

In a research paper published in this issue of the journal, Kumar et al.[8] report the degree of disability associated with mental health conditions and linkage with other health conditions in the general population. This study was conducted in a small geographical area, which is a key limitation of the findings, especially when the National Mental Health Survey 2015–2016 report is available and provides information on epidemiology, and health systems challenge on mental health in India.[1] Nonetheless, research including epidemiological, operational, and implementation studies has an important role in influencing policy process and improving health services provision and needs to be promoted and financially supported.[9]

The study by Kumar et al. underlines that the mental illnesses are often associated with disabilities.[8] In addition, both mental illnesses and disabilities are health and social challenges. The mental illnesses are among the leading causes of ill health and disability worldwide. Neuropsychiatric disorders are prevalent in every region of the world and account for nearly one-third of the disabilities in the world. In India, an estimated three out of four people with severe mental disorder experience significant disability at work, social, and family life.[1] An estimated 2.7 crore (27 million) people or 2.1% of Indians were living with one or other types of mental disabilities in 2011.[10] All of these are sufficient reasons to take immediate, urgent, and sustained actions on both mental health and disability.

In 2017, there has been a renewed global attention on mental health. The World Health Day 2017 theme was on depression and provided an opportunity for a comprehensive appraisal of mental health services in any country.[11] Depression and many other mental disorders are often considered “invisible disorders.” It is estimated that 33–57 million people are living with depression in India, at any given point of time.[1,11] Recently, the issue of depression came to mainstream public discourse when Indian celebrity Deepika Padukone discussed about her personal struggles to cope with a spell of depression.[12]

A few years back in 2001, the World Health Organization had estimated that depression disorders were the fourth leading cause of the global disease burden and projected that these disorders would be the second leading cause by 2020, only behind ischemic heart disease. The report in 2001 also projected that depression would likely be the leading cause of disability worldwide by 2020.[13] However, the efforts since then at global level have not been commensurate to the magnitude of challenge.

There have been major scientific advances in psychiatry. Most mental and behavioral disorders can now be successfully treated and a few can be prevented as well. Much of this prevention, cure, and treatment are affordable.[1,13] However, nearly two-thirds of people with a known mental disorder never seek help from a health professional.

One potentially effective opportunity to increase policy attention and interventions is 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.”[14] UHC has been listed as a key objective in the recently released National Health Policy (NHP)-2017 of India, as well.[15]

To accelerate provision of services for mental health and disabilities alongside advancing UHC in India, following could be given attention.

1. Use UHC as platform to advance mental health services: There is overall shortage of health services in India and the provision of mental health services is one of the most scarce areas. There is an ongoing dialogue on developing an “essential health package” (EHP) for various levels of services as part of UHC in India. This opportunity to develop EHP should be used for expansion of health services for mental health and disability at all levels of care and from the very beginning

2. Strengthen mental health institutes and trained workforce through innovations: The problem of insufficient mental health workforce has to be tackled, by strengthening existing mental health institutions and increasing trained workforce with attention on equitable distribution. The policy suggestion in new NHP[15] to move toward midlevel health-care providers could be an effective approach. In addition, these gaps can be filled by innovative mechanisms and use of other ongoing programs and community-based engagement in health sector in India. Another approach could be the use of India's strength in information and communication technology and telemedicine to increase access to mental health services in areas with limited availability of mental health workforce (more specifics in suggestion below)

3. Scaling up of the National Urban Health Mission (NUHM) is an opportunity: The NUHM was launched in May 2013 and is being scaled up in India.[16] This is an opportunity to make provision of disability and mental health services integrated at all steps as urban health services are being scaled up and urban-primary health centers are being established. This becomes highly relevant as there is a high prevalence of mental health conditions in urban settings

4. Engage communities in delivery of health services: The community-based interventions have become acceptable and are the core approaches to both disability and mental health services in India. The linkage between all community-based initiatives of different government programs needs to be harmonized including the role of Accredited Social Health Activists in the National Health Mission and Mahila Arogya Samiti in NUHM, among others

5. Explore AYUSH practitioners for appropriate interventions: Achieving good mental health in the community requires a lot of preventive and promotive health services. Opportunities provided in the indigenous system of medicines to address mental illnesses, and the possible collaboration between Ministry of Health and Family Welfare with Ministry of AYUSH has to be explored, harmonized, and the experience documented. In this direction, the promotion of Yoga and other services could be useful.

6. Develop and agree on roadmap and accelerate expansion of DMHP in entire country: Policy prescriptions are of limited use unless translated into actionable and measurable steps. There is a need for developing a detailed mental health implementation plan as proposed in the National Mental Health Policy 2014.[16] DMHP needs to be integrated with overall mechanisms for noncommunicable diseases program and then expanded rapidly to all districts of India, with an approved roadmap in a time-bound manner

7. Increase financial allocation and develop mechanisms to prevent people from becoming poor while accessing mental health services: Globally, devoting 1% of total health budget by government, for mental health services, is an acceptable norm and India falls below this norm.[2] Mental health is a line budget item only in two states in India (Kerala and Gujarat).[1] For mental health patients in India, the monthly cost of treatment and travel to access healthcare has been estimated to be nearly Indian Rupees 1000–1500 a month.[1] This fact is a sufficient justification for rapid expansion of mental health services and increase in the government funding. Both actions would help in reducing “out of pocket expenditure” by people and can prevent people falling into poverty because of health related expenditures. These are also in line with broader objectives of NHP 2017 to achieve UHC in India.

The present study's findings are a reminder for important issues which otherwise tend to be forgotten.[8] The NHP 2017 has concrete and actionable points on mental health such as to (a) accelerate creation of specialists through public financing, (b) establish network of community members to provide psychosocial support to strengthen mental health services at primary level facilities, and (c) leverage digital technology where access to qualified psychiatrists is difficult.[15] This is a quantum jump from previous NHP, which had focused mainly on treatment of common mental health issues and strengthening institutions.[17] If the proposals in the NHP 2017 are implemented, these would address key challenges in mental health services in country.

An interesting phenomenon in low- and middle-income countries is that while policy documents are very well drafted and the appropriate announcements are made; soon thereafter, the action points are forgotten or not put in action. For example, the Mental Health Act of 1987 was not adopted by any Indian state for many reported limitations.[4] Therefore, a quick transition from policy to implementation phase is crucial. The policy makers and program managers have to use all possible mechanisms to piggyback and accelerate implementation.

On 27 March, 2017, the lower house of Indian Parliament, the Lok Sabha, passed the long awaited MHCB, which had already cleared been by its upper house, the Rajya Sabha, in August 2016.[5] The MHCB is considered to be a progressive legislation with provisions such as guaranteeing the right to better healthcare for people with mental illnesses and decriminalizing suicide, to list a few. The MHCB, once approved by the President of India and notified in the Gazette of India, will become an Act and would provide an useful statutory basis for proposed initiatives. Most importantly, while Indian government has not yet committed itself to the “right to health” and follows incremental assurance-based approach in NHP 2017, “right to mental healthcare” is a bold step in the MHCB. The implementation of the “right to mental health” provision could define the future of “right to health” in India.

The health services for disability and mental illnesses should be considered public goods and the government needs to invest more in these in a timely manner. The ongoing discourse on UHC – also envisioned in NHP-2017 – provides an important opportunity to expand all health services rapidly and at all levels of care. UHC will not be achieved without provision of health services for disabilities and mental illnesses.

There appears a momentum on mental health services in India as far as policy and legislative provisions are concerned; however, programmatic implementation needs to be accelerated. There is a perceived need for “doing something and doing something now.” The launch of NHP 2017, ongoing discourse on UHC, passing of the mental healthcare bill, appears to be the “grand confluence” of policy, legislation, and good will. This momentum and the unprecedented juncture in the history of mental health in India should be utilized to take concrete actions on mental health and disability and to advance UHC in India.