The story so far: August marked the 41st anniversary of the National Mental Health Programme (NMHP), a government initiative to address the burden of mental disorders. In the previous Monsoon Session of Parliament, the Ministry of Family and Health Welfare (MoHFW) reaffirmed its dedication to improving access to quality mental healthcare services across the nation, saying that the Central government was currently working on a “mission mode” to address mental health as a public health issue. In reply to a question in the Lok Sabha, the Health Ministry said a section of the NMHP, targeting districts, had been approved for execution in as many as 738 districts.
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How did the national mental health strategy come into being?
The British Raj in 1943 formed a committee to assess the state of health in the country and provide recommendations to improve the public health system. The panel, known after its chairman, senior civil servant Joseph Bhore, published its two-part report in 1946; it is considered a landmark health policy document, charting a course to develop contemporary public health delivery system in the country.
The report shed light on the unfavourable conditions prevalent in the country at the time. Notably, it shone a spotlight on the issue of mental well-being in pre-Independent Indian society. “The physical and mental health of an individual are interrelated and no health programme can be considered complete without adequate provision for the treatment of mental ill-health and promotion of positive mental health,” it said.
The provision for institutional care for those with mental illnesses in India was 130 times less than in England. The Committee concluded that chronic starvation or malnutrition, tropical fevers, anaemia and frequent childbirth in women unfit for motherhood were primarily responsible for a large number of breakdowns in the country.
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In its recommendations, the Bhore Committee proposed a mental health programme and an investigation into the needs of various provinces. The panel identified two urgent needs to be addressed through a dedicated programme: an improvement in existing mental health facilities and training for health workers. To achieve this objective, the Committee proposed to increase hospital beds and mental health institutions across the country, train human resources and establish a mental health department in the then-proposed All India Medical Institute.
Post-Independence efforts
In Independent India, to develop mental healthcare as part of general healthcare, the Mudaliar Committee of 1962 put forth a plan for district mental health units, while also emphasising on the training of health personnel and public mental health education. It advocated for operationalising in-patient and outpatient departments in hospitals, establishing specialised psychiatric mental health institutions and developing psychiatric clinics with a capacity of five to six beds in each district.
The Srivastava Committee of 1974 focused on community support at primary levels. The same year, an expert committee of the World Health Organisation (WHO) met to discuss the status of mental health services in developing countries, which the panel concluded was a matter of concern. Following this, a seven-country project ‘Strategies for Extending Mental Health Care (1975–1981)’ was launched to implement the recommendations of the health body. The seven countries were India, Brazil, Colombia, Egypt, Philippines, Senegal and Sudan. A formal resolution urging member countries to develop a national mental health programme was adopted in the 1979 meeting of the Mental Health Advisory Group of WHO in the Philippines.
How does the NMHP respond to mental health needs?
India was one of the few developing countries to create a programme to address the lack of adequate mental health infrastructure. The NMHP was launched in August 1982 to deal with the “heavy burden of mental illness in the community and the absolute inadequacy of mental health care infrastructure” in the country. There were reportedly less than 1,000 psychiatrists in the country at the time.
The programme was implemented by the Ministry of Health and Family Welfare (MoHFW) through a three-tier public healthcare delivery system. Its aim was to ensure availability and accessibility of minimum mental healthcare for all, with a focus on the most vulnerable and underprivileged sections. The NMHP encouraged the application of mental health knowledge in general healthcare and social development, and stressed community participation.
A specific strategy was formulated including special training for existing staff of primary and community health centresfor the treatment of mental disorders. Regulatory institutions like the Central Mental Health Authority (CMHA), and State Mental Health Authority (SMHA) were to be used to eradicate stigma towards the mentally ill and protect their rights.
Ten years after the launch of NMHP, the government launched the District Mental Health Programme (DMHP) under its aegis. It was carved out to focus on early detection and treatment, provide training to general physicians for diagnosis and treatment of common mental illnesses and raise public awareness. It sought to provide community mental health services and integrate mental health with general health services through the decentralisation of treatment from specialised hospital-based care to primary healthcare services.
The programme was first implemented in four districts and expanded to 27 districts by the end of the 9th Five Year Plan (1997–2002). As of July, the DMHP is being implemented in more than 700 districts across the country.
In 2003, the NHMP was revamped as part of the 10th Five Year Plan. The revised plan sought to upgrade the psychiatry wings of government medical colleges and general hospitals and modernise state mental hospitals, while expanding DHMP coverage to around 100 districts.
A manpower development scheme was subsequently added to the programme to improve training infrastructure. The scheme proposed to set up centres of excellence in mental health by upgrading existing institutions and hospitals and strengthening post-graduate training departments of mental health.
The DMHP was also revised in 2008 to include life skills education and counselling in schools and colleges, and to provide suicide prevention and workplace stress management services.
The Centre launched the National Mental Health Policy in 2014, an extension of the NMHP, with a vision to promote mental health, prevent mental illnesses, enable recovery, promote de-stigmatisation and desegregation, and ensure socio-economic inclusion of persons affected by mental illnesses.
India adopted the National Health Policy in 2017, which identified mental health policy as one of its focal areas. It sought to add more specialists through public financing and establish a network of community members providing psycho-social support, to strengthen health services at the primary level.
What progress has been made so far?
India contributes significantly to the global burden of mental disorders. The prevalence of mental disorders in adults over the age of 18 years is about 10.6%, and more than 80% of those who need mental healthcare are unable to access treatment due to a shortage of specialists and adequate infrastructure, as per the National Mental Health Survey (NMHS) in 2016. To put this in perspective, India had around 9,000 psychiatrists practising in the country in 2017, or 0.75 psychiatrists per a lakh of people; the desirable number is at least three per 1,00,000.
Undoubtedly, the NMHP has been a crucial milestone in India’s journey towards better mental health care, but the 40-year-old programme must reflect social, economic and demographic changes and an evolving mental healthcare system to improve health outcomes nationally.
In a recent paper on India’s response to mental healthcare, the MoHFW’s think tank, the National Health Systems Resource Centre, highlights challenges faced by the NMHP in terms of human resources, finances, accessibility, utilisation and governance. The authors argue that the programme model focused only on pharmacological interventions and not psychosocial aspects of treatment. “It excluded community/stakeholder participation in the planning and implementation process further attributed to its poor performance. Currently, its implementation at the sub-district level and below is sub-optimal,” it says.
Citing a report of the National Health Mission, the paper states that planning of IEC (information, education and communication) strategies was done at the State level with minimal involvement of districts. Fragmented responsibilities across levels and poor coordination contributed towards the poor performance of the programme, it adds. There have also been issues related to coverage and provision of treatment for people with mental illnesses. For instance, mental disorders such as substance use disorders and child and geriatric psychiatric disorders were excluded from the programme.
The programme was further affected due to a shortage of funds. In the financial year 2019, the budget allocated to the NMHP was reduced from Rs 50 crore in FY18 to Rs 40 crore. In subsequent years, the total healthcare budget was increased by 7% (FY20) and 137% (FY21), but the funding for NMHP remained unchanged.
What is the way forward?
The devastating impact of the COVID-19 pandemic has added to the mental health burden of the country. Mental healthcare services must be made easily accessible, especially for those in urgent need.
More psychiatric units are required at the sub-district level for effective dissemination, the National Health Systems Resource Centre notes in its 2022 report. Further, additional human resources are needed on the ground for preventive and curative strategies.
“HR where available, may be rationally deployed and responsibilities may be distributed carefully between genders to ensure effective screening, control and management of mental health diseases. While ASHAs may be trained to screen individuals for common mental health conditions, a new cadre of community mental health workers (CMHW) may also be created at the PHC level for screening and facilitating treatment as recommended by policymakers,” the report adds.
Community participation is also crucial; more stakeholders can be roped in to spread awareness about mental health and the government programme. The programme also needs a robust monitoring system to facilitate mid-course corrections.
On issues related to the flow of finances, their utilisation and accessibility, the paper calls a resource allocation of Rs 40 crore for States and Rs 83.2 lakh for the DMHP for 692 districts (as of 2020-21) ”insufficient.” It calls for additional funds to provide optimal health services aligning with NMHP goals— to ensure the availability and accessibility of minimum mental healthcare for all.
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