On August 16, The Indian Express reported that the National Medical Commission has constituted a Task Force for the Mental Health and Wellbeing of Medical Students in response to the alarming incidents of 122 suicides by medical students in the last five years. The Commission’s online survey showed that a whopping 27.8 per cent of undergraduate students had mental-health conditions and 31.3 per cent of postgraduate students had suicidal thoughts. Clearly, mental health cannot be neglected anymore — it needs a calibrated policy.
The 2015-16 National Mental Health Survey showed that 10.6 per cent of the above 18-year-old population had such disorders – this includes 16 per cent of those in the productive age group of 30-49 years. The survey revealed that the lifetime morbidity affected 150 million people, with 1 per cent reporting high suicidal risk. The human resources required to deal with the condition and treatment facilities are woefully inadequate. This means that the treatment gap in the country is an extremely disquieting 80 per cent.
It has been apparent for some time now that mental health is low priority for policymakers. Against an estimated need of over Rs 93,000 crore for addressing this challenge, the Union government earmarked Rs 600 crore in 2019 (the allocation in the latest Budget is Rs 1,000 crore, less than 1 per cent of the health budget) of which 93 per cent was for tertiary institutions such as NIMHANS and the psychiatry departments of medical colleges, leaving Rs 40 crores for the District Mental Health Programme and other community-based initiatives. Of this amount, only Rs 2.91 crore was spent.Poor policy attention is often ascribed to the “lack of political will”. However, the more important reason is the substantial knowledge gap – “how-to” intervene and “when-to” intervene are often difficult challenges for policymakers.
The rights-based National Mental Health Policy of 2014 and the Mental Health Act of 2017 did indicate a shift in policy towards ensuring that the mentally ill receive as much priority as those suffering from physical ailments and are treated with dignity. While the policy and the Act delineate a clear vision, there is a lack of clarity on implementation, the financial and physical resources required, and by when.
A common critique of India’s policymaking system is the substantial hiatus between what needs to be done and what is actually feasible and doable. Formulating strategic interventions requires a nuanced understanding of the challenges and constraints within which a system works. Such initiatives require consultation and dialogue among all stakeholders. India’s success in stemming HIV-AIDS can offer lessons in the country’s endeavours to tackle mental health-related challenges. To formulate policy and implement the National Aids Control Programme’s-III’s strategy, the National Aids Control Organisation (NACO) sought the intervention of 20 Technical Resource Groups, with at least 250 representatives from diverse sections of society such as academia and those involved in sex work.
The HIV-AIDS story has lessons in four key realms. One, crafting strategic interventions based on epidemiological evidence drawn from a concurrently operating surveillance system. Two, the importance of modelling different options and the wide array of interventions required in different geographies among different target groups. These exercises provide data related to cost-effectiveness and supply crucial information required for scaling up interventions. Three, advocacy related to systemic issues and removal of stigma – here, parliamentarians, media, judiciary, police and other government departments were involved. Four, engagement with leaders of the community and civil society – this endeavour was allocated 25 per cent of the budget. The programme framers realised that without the active engagement of community leaders, the policy would not touch the lives of the most marginalised, especially the groups which are often stigmatised. The programme was centrally funded. Most importantly, however, the interventions were designed with active participation and dialogue with states and affected communities.
Such an approach is urgently needed to craft an implementable strategy for mental-health patients – like HIV-AIDs patients, their condition is chronic, they require empathy from society and commitment from different government sectors. Mental-health problems are often products of the times: Pressures and stress caused by poverty, growing inequalities of opportunity, the frustrations due to lack of jobs, judgmental and discriminatory environment on account of barriers of caste, gender and religion are powerful triggers which, if left unaddressed, can keep recurring despite medication. In other words, biomedical approaches are not enough to teach mental-health conditions.
Notwithstanding the policy vacuum, civil society has been active.
Good quality research and solid evidence based on models of rehabilitation and care continuum of those with mental disorders is available, thanks to the pioneering efforts of groups such as Banyan in Tamil Nadu, Sangath in Goa and Centre for Mental Health Law and Policy in Pune. Evidence-based strategies such as creating short-stay homes and emergency care centres and peer leader-led interventions need to be studied for scaling up. The Chennai-based Banyan, for instance, focuses on addressing the needs of an estimated 60 lakh homeless and abandoned women, who are mentally ill, through its innovative Home Again intervention. This is a comprehensive strategy consisting of five stages – awareness, rescue, treatment, rehabilitation, and reintegration with family. Public policy focuses on treatment. In contrast, the Banyan model continues to engage with people who have received treatment and helps them to develop the necessary social skills to get reintegrated with society and family.
It is time the government prioritises mental health and implements community-anchored and affordable interventions. In the ultimate analysis, public policy on mental health must be driven by a sense of justice. An autonomous implementing agency along the lines of NACO can help mobilise the required financial and human resources, balance institutional care with community involvement and enable the widening of the effort for addressing the varied needs of affected people at different levels. The constitution of a taskforce to study the mental health of medical students is a welcome measure. Governments at central and state levels, however, need to do more and address mental health challenges of all sections of people.
The writer is a Former Union Health Secretary
