Community-based mental health services in India: Focus on improvement of Mental Health Services in Low- and Middle-Income Countries (LMICs)

Abstract

Global estimates by WHO suggest that around 12% of global burden of disorders are accounted by the mental and behavioural disorders. Low- and middle-income countries (LMICs) account for almost three quarters of this global burden of mental and behavioural disorders and majority of the population have no access to mental health services. Thus, public health measures are of extreme importance and should be a development priority. Public health measures with the integration of the mental health services in the primary health systems offers the most sustainable and effective model for the LMICs with low resources. The National Mental Health Programme (NMHP) was launched in 1982 as a major step forward for the mental health services in India. Despite efforts to energise and scale up the programme from time-to-time progression in the development of community based mental health services and in achieving the desired outcomes in India has been slow. There is an urgent need to have a fresh look at the implementation of the programme with focus on achieving sustainable improvements in a time limited manner.

Full Text

 

  1. Introduction

Global estimates by WHO suggest that around 12% of global burden of disorders are accounted by the mental and behavioural disorders.[1] There have been suggestions that this may be an underestimation considering the interconnectedness between mental illness and other socioeconomic condition especially in low- and middle-income countries (LMICs) which account for almost three quarters of global burden of mental and behavioural disorders.[2, 3] An estimated 197·3 million people have mental disorders in India.[4] Additionally, there is a significant treatment gap present in both the developed and the developing countries with a vast majority of patients lacking any access to treatment facilities for mental and behavioural disorders. [2] Thus, public health measures are of extreme importance and should be a development priority especially in LMICs including India.[5] The progress on this can be assessed by presence of an official policy, programmes or plans for mental health, budgetary allocations, dedicated mental health workforce, availability of essential psychotropic medications in primary care; increased treatment coverage; reduced suicide rates and protection of human rights of mentally ill.[3]

 

  1. Historical Perspectives

Historically, in India, the psychiatric patients have been cared for by the family members in the community as there were no formal community psychiatry services. Community psychiatry barely existed in British India. The first psychiatric outpatient service, precursor to the present-day general hospital psychiatric units (GHPU), was set up at the R.G. Kar Medical College, Calcutta in 1933 by Ghirindra Sekhar Bose. This was followed by similar set-ups in Bombay (1938) and Patna (1939). However, for both mental health and general health care, many people, did not have access to Western medical institutions and relied either on the traditional sector or Western-trained private practitioners. [6] The spread of community services can be traced back to early 1950s in India.

While there was a drive for deinstitutionalisation in the western world based on the principles of human rights to care for these patients in the community, institutionalisation was not a major issue in India as the number of psychiatric beds available were less.[7] Thus, an important difference between the western countries and India regarding the development of community services was that the latter approach was supported primarily to make up for inadequate hospital-based services in contrast to concerns for human rights in the West. Some of the earliest experimentations in community care before the advent of the formal services involved making provision for the family members to stay along with the patients in tents in the hospital premises for treatment due to shortage of available beds for admission at mental hospital, Amritsar by Dr.Vidya Sagar in 1952.[7]  In the later decades, many new initiatives were taken which laid down the foundations for the community psychiatry in India. In 1964, a weekly community mental health service was started in Comprehensive Rural Health Services Project (CRHSP), Ballabgarh by All India Institute of Medical Sciences (AIIMS), New Delhi. This was followed by establishment of community mental health services at Raipur Rani in Haryana under the aegis of Postgraduate Institute of Medical Education and Research, Chandigarh and World Health Organization and Sakalwada in Karnataka in late seventies.[7] These programs were forerunners of the National Mental Health Programme (NMHP) in India, which now includes community clinics in primary health centres (PHCs) supported by mental health professionals at the district level, training of medical and multipurpose health workers, school mental health initiatives, home based follow up services by the nurses and organisation of psychiatric camps.

 

  1. National Mental Health Programme (NMHP)

The National Mental Health Programme (NMHP) was launched in 1982 as a major step forward for the mental health services in India. It had three key objectives including ensuring the availability and accessibility of minimum mental healthcare for all, encouraging the application of mental health knowledge in general healthcare, and promoting community participation in the development of mental health services. Despite being a ground-breaking initiative, the initial phases of the implementation of the programme were marred with difficulties. Among the factors contributing to initial failures were unrealistic targets, absence of adequate staff resources, inefficient administration, failure to develop indicators to address objectives, inadequate emphasis in creating awareness among users and uncoordinated, fragmented efforts by various stakeholders and inadequate budgetary support. [7] One of the important achievements of the programme in the initial decade of its initiation was recognising a district model for providing mental health services with satellite primary health centres (PHCs) providing mental health services. [8] This district model was subsequently expanded to four districts.

The Program was re-strategized in 2003 to include two schemes, viz. ‘Modernization of State Mental Hospitals’ and ‘Up-gradation of Psychiatric Wings of Medical Colleges/General Hospitals.’ The Manpower development scheme became part of the Program in 2009. Under the first scheme 15 existing mental hospitals/ institutes/ Med. Colleges were upgraded to start/ strengthen courses in psychiatry, clinical psychology, psychiatric social work & psychiatric nursing. Under the second scheme, 39 departments in 15 Government Medical Colleges/ Government Mental Hospitals were supported in starting / increasing intake of students in postgraduate (PG) courses in mental health. [9]

  • District Mental Health Programme (DMHP)

The District Mental Health Programme (DMHP) was launched as an extension of the NMHP in 1996 building on the success of the Bellary model in Karnataka, based on the realization that the mental health services should be primarily dispensed through the already existing primary health facilities as creating a parallel infrastructure was not immediately feasible in terms of the infrastructure and manpower. Thus, the existing manpower in these Primary Health Centres (PHCs) like doctors and paramedical workers were trained to provide mental health services. There was a component of referral services to district hospitals for the patients suffering from severe mental disorders. [7] In the period up to 2002, the DMHP was gradually extended to 25 districts in 20 states of India. [10] As of now, 241 districts (out of 718 districts in India) [9] are covered under the scheme & it is proposed to expand DMHP to all districts in a phased manner. District Mental Health Programme forms the core of and envisages to provide the mental health services at the community level. Table 1 lists the components of the DMHP. [9]

Box 1

District Mental Health Program:

Ø Service provision: Provision of mental health out-patient & in-patient mental health services with a 10 bedded inpatient facility.

Ø Out-Reach Component:

1.     Satellite clinics: 4 satellite clinics per month at CHCs/ PHCs by DMHP team

2.     Targeted Interventions:

3.     Life skills education & counselling in schools,

4.     College counselling services,

5.     Workplace stress management, and

6.     Suicide prevention services

Ø Sensitization & training of health personnel: at the district & sub-district levels

Ø Awareness camps: for dissemination of awareness regarding mental illnesses and related stigma through involvement of local PRIs, faith healers, teachers, leaders etc

Ø Community participation:

1.     Linkages with Self-help groups, family and caregiver groups & NGOs working in the field of mental health.

2.     Sensitization of enforcement officials regarding legal provisions for effective implementation of Mental Health Act

 

  1. National Mental Health Policy

A robust and comprehensive mental health policy is important to drive the growth of mental health services and systems.[11] The National Mental Health Programme (1982) and the Mental health Act (1987) provided the implicit policy directions for community and institutional mental health care in India till the middle of the last decade. India’s Mental Health Policy group was formed in May 2011. The National Mental Health Policy of India titled “New Pathways, New Hope” was released by the Ministry of Health and Family Welfare, Government of India in October 2014. [12] The policy is inclusive in nature and incorporates an integrated, participatory, rights and an evidence-based approach encompassing both medical and non-medical aspects of mental health. The strategic areas identified for action are effective governance and accountability, promotion of mental health, prevention of mental disorders and suicide, universal access to mental health services, enhanced availability of human resources for mental health, community participation, research, monitoring and evaluation. It stresses on the delivery of the mental health services within the existing health care system using the Primary Health Care approach based on the principles of universal access, equitable distribution, community participation, intersectoral coordination and use of appropriate technology. It also recognises that these services should be comprehensive and address the needs of persons with mental illness, their care providers and health care professionals.

  1. Legislation

Dedicated mental health legislation legally reinforces the goals of mental health policies and plans. [13] Legislation is also important to prevent the abuse and violation of the rights of patients with mental illness. As early mental health legislation was primarily drafted to safeguard the public from dangerous patients by isolation, welfare of the patients was always a secondary consideration.  As a paradigm shift has occurred globally to rights-based approach for persons with disability including mental disability (e.g., UNCRPD, 2006),[14] the same was reflected in the mental health legislation in the Mental Healthcare Act (MHCA 2017), which superseded the Mental Health Act (MHA 1987). The new act is progressive, and rights based but mainly focuses on the rights of the persons with mental illness during treatment in hospitals with limited discussion on the continuity of treatment in the community and about the role of the family and the community in the management of individuals with mental illnesses. [15]

MHCA 2017 has been critiqued for failing to address the Indian cultural sensitivities related to the involvement of the family in treatment decisions. [15] The family is a key resource for the management in Indian society due to cultural tradition of interdependence and treating teams also depend heavily on the active involvement of the family members.

Mental health legislation must engage and work in tandem with legislation for people with disability like Rights of Persons with disabilities Act, 2016 [16] and National Mental Health Policy of India, 2014 [12].  The Rights of Persons with Disabilities Act, 2016 includes mental illnesses and lays stress on full and effective participation and inclusion in the society, non-discrimination, accessibility, equality of opportunity and protection of rights of children with disabilities. [16] In LMICs where the majority live in poor socioeconomic conditions, greater benefits and welfare measures like job reservation and housing schemes for patients with mental illness is needed.

 

  1. Other Approaches to Community Mental Health in India

Some other significant approaches to the community mental health in India have been the camp approach, school mental health, initiatives by NGOs, interventions by the media and telephone helplines.

There has been a long tradition of the camp approach for the people living in the far-flung areas with limited access to the health services. The duration of these camps can vary but most are usually single day in motorable places to a few days in places with limited road access. Such camp approach has been used to treat mental health conditions including addictions too. The camp approach to community mental health has also been utilised at the time of natural disasters from time to time. [7]

Initiatives in school mental health have included life skills education programme for children and adolescents with sensitising the schoolteachers about mental health problems prevalent in children and adolescents.

Non-Governmental Organisations (NGOs) have been engaged in delivering mental health services with innovative models depending on the local needs of the population. There is also a provision in National Mental Health Programme (NMHP) for the state governments to execute activities related with mental health in partnership with Non-Government Organizations/Agencies as per the guidelines of the NRHM in this regard. [9]

 

  1. Roadmap for the future: Lessons for LMICs
    • Budgetary Considerations

One of the primary reasons for the initial shortcomings after the launch of the National Mental Health Programme, 1982 was the shortage of allocated funds. Lack of specified budget for mental health in a nation’s health budget is a major impediment for services development. [17] Another major difficulty which has been seen in India is underutilization of the allocated funds [18] because of multiple factors ranging from difficulty in employing mental health manpower to inability to execute infrastructure projects in a time limited manner. Redtapism and lack of a coordinating nodal agency can also be a major hurdle in expediating the execution of the projects. Hence, ring fencing the allocated funds to be used exclusively for mental health services along with a nodal agency to ensure the same may go a long way in ensuring proper utilisation of the allocated funds for mental health. [19]

 

  • Mental Health Service Delivery:

The recommendation to deinstitutionalise mental health and to adopt a primary health model for the service delivery has been longstanding. [20] While institutionalisation has been seen as a major challenge in the west after rights-based approach to the mental health was adopted, it was never the same in India along with other LMICs. [7] Hence, a straight adoption of the same in the LMICs may not have similar desirable effects on the overall service provision in these countries. As there is already a dearth of mental health resources in these countries, existing mental hospitals and institutions can serve as referral centres along management of patients with severe mental illnesses, insufficient social support, and medicolegal cases [21] while the transition to predominantly community-based services is being planned and implemented. The current policy of strengthening and upgrading the existing mental hospitals to ‘Centres of Excellence” along with provisions to strengthen the mental health training being inbuilt into the National Mental Health Programme will provide the essential building blocks for a successful community-based services as envisioned. [9] However, time to time reappraisal of the set goals, achievements thus far and course corrections are essential and the mechanisms ensuring the same must be inbuilt into the programme to prevent skewed development. In recent years, the overall scope of the mental health services and a significant reduction in stigma has been achieved but that comes with the caveat that these services are essentially concentrated around urban and semiurban areas.

 

  • Mental Health Workforce

The factors contributing to the shortage of mental health professionals in LMICs are urban concentration, preference for private practice and brain drain. [1, 5] Retaining the mental health professionals is a greater challenge along with ensuring their equitable distribution.  Minimising brains drain and retaining the professionals in the public sectors must be accorded high priority by means of financial incentives, favourable working conditions and provisions for career advancement. [22] Also at the same time it should be ensured that the enhanced training capacities are adequately utilised by ensuring equal professional opportunities for the trained personnel. It has been envisioned in the district mental health programme to train the existing manpower in the PHCs like doctors and paramedical staff to provide mental health services. Non- Specialist health workers have contributed to the services delivery and played an important role in detection, diagnosis, treatment, and prevention of common and severe mental disorders as a part of a complex stepped care approach. There should be more provisions for their in-service training to deliver effective services to the general population. [22]

 

Another important approach to improve the service provision to the general population is to improve the psychiatry education and training at the undergraduate medical courses level. [19] The ability to independently diagnose and treat mental disorders and to be able to make appropriate referral decisions will improve the service provision at much wider scale with visible improvements.

 

  • Mobilisation of Community Resources

In many LMICs, faith healers, religious leaders, and practitioners of alternate system of medicine are often the first point of contact for patient with psychiatric disorders before mental health services. [23] Efforts to educate and sensitise this subgroup of population about the importance of diagnosing, treating, and maintaining a regular follow up can help in better delivery of mental health services in the community. There services can specially be sought during time limited intervention like camp services as they can mobilise many people in a limited time in far flung areas. Community campaigns to increase the awareness about the psychiatric illnesses and to decrease associated stigma should also be given importance as stigma and discrimination against people with mental health problems are important barriers to identify and treat mental disorders.[24] Family members are essentially the primary caregivers in most LMICS and can contribute to detection, treatment seeking, and management of family members with mental disorders [22]

 

  • Integration with primary care

Currently, the integration of the community mental health services with the primary health care is the most viable method to provide mental health services in most LMICs but there still significant shortcoming in achieving this goal. [25] The main barriers to this integration include already overburdened PHCs with limited staff, multiple tasks, patient load, multiple concurrent programs, lack of training, supervision and referral services and non-availability of psychotropics in primary health care system. [20] In this context, alternative mechanisms for programme delivery like National Health Mission which subsumes National Rural Health Mission and National Urban Health Mission in India should be considered. There have also been suggestions to integrate mental health care with services for other chronic conditions which are relatively better performing or alternatively with other systems like social care and education. [26]

 

  • Mental Health Research

The WHO’s Mental Health: Global Action Programme envisages multidimensional research efforts in LMICs to improve mental health situation. [27] There is a wide gap in the research efforts in the developed countries viz a viz LMICs in mental health and this divide has not decreased over time. [28] There is also an absence of impact of the research on the policy and practice of mental health due to disconnect between the researcher and the community. [29] Attention needs to be focussed on a systemic approach to debate the relevance of research questions, involvement of all stakeholders at appropriate levels including policymakers, practitioners, advocacy groups and community at large and to generate resources and funds for the same. [29, 30, 31]

 

 

  1. Conclusions

 

Although there has been slow progression in the development of community based mental health services and in achieving the desired outcomes in India, its importance cannot be understated. There is a huge burden of mental disorders with significant treatment gap in India. [2, 4] Public health measures with the integration of the mental health services in the primary health systems offers the most sustainable and effective model for the LMICs with low resources. Despite the National Mental Health Programme being into effect since 1982, it has only been able to partially achieve the desired mental health outcomes.[8] It is important to continuously assess the performance with independent audits and periodic reviews to identify the problems at the earliest to initiate the corrective measures.[32] Thus, there is an urgent need to have a fresh look at the implementation of the programme with focus on achieving sustainable improvements in a time limited manner.

 

 

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About the authors

Gagan Hans

All India Institute of Medical Sciences, New Delhi, India.

Author for correspondence.
Email: gaganhans23@gmail.com

MD Psychiatry

India

Pratap Sharan

Email: pratapsharan@gmail.com

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Copyright (c) Hans G., Sharan P.

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