GIVE MENTAL HEALTH ITS DUE

12th Five Year Plan of Action

THE HERE AND NOW

STRATEGY, SERVICES, SHORTCOMINGS & SUGGESTIONS

BACKGROUND / CONTEXT READING

The following documents are to be read before progressing.

WHO MENTAL HEALTH ATLAS (INDIA)

NMHP A time for reappraisal

ICMR evaluation of DMHP

NIMHANS evaluation of DMHP Part 1 , 2,3

Mental health By the People Mental, neurological and substance abuse disorders: Strategies towards a systems approach Mental Health Care & Human Rights

CAG audit of mental health sector in Kerala CEHAT review of healthcare in India

NEED : FROM PLANS & PAPERS TO PROGRESS

There is no doubt that mental disorder and mental deficiency are prevalent on a wide scale. The number of persons suffering from varying degrees of mental disorder who may not require hospitalization but should receive treatment and of those suffering from mental deficiency is likely to run into several millions. The existing provision for the medical care of such persons is altogether inadequate and unsatisfactory. Each State health administration, through its mental health organisation, should attempt collection of information. It is estimated that hospital accommodation should be available for 800,000 mental patients but the existing provision is a little over 10,000 beds for the country as a whole. Radical improvements are required in the existing mental hospitals in order to make them conform to modem standards. Provision should also be made for all the methods of diagnosis and treatment I n d i a s 1 st F i v e Y e a r P l a n

~ 50 years and 8 plans later

3.4.129 It is estimated that 10 to 15% of the population suffer from mental health problem. Qualified professionals providing mental health care are few and the outreach of services in rural area is very low. The National Mental Health Programme was initiated by the Government of India in 1982 with the objective of improving mental health services at all levels of health care (primary, secondary and tertiary) for early recognition, adequate treatment and rehabilitation of patients with mental health problems within the community and in the hospitals. However, the Programme did not make much headway either in the Seventh or Eighth Plan. Mental Hospitals are in poor shape. The States have not provided sufficient funds for mentally ill requiring inpatient treatment. The Supreme Court has directed the Centre and the States to make necessary provision for these hospitals so that the inmates do get humane and appropriate care. 3.4.130 The Mental Health Act, 1987, which came into force with effect from April 1993, requires that each State/UT set up its own State level Mental Health Authority as a Statutory obligation. Majority of the States/ UTs have complied with this and have formed a Mental Health Authority. 3.4.131 The Central Council of Health & Family Welfare reviewed the progress and resolved that the National Mental Health Programme should be accorded due priority and fullscale operational support (including social, political, professional, administrative and financial back up) are provided. Indias 9th Five Year Plan

DMHP : MENTAL HEALTH HORIZONTAL INTEGRATION SO FAR

100

crores of

NMHP

funds

unutilised

from

2000-2010 (across

five year plans)

STATED OBJECTIVES

Mental Health presence at the primary care level based on Bellary Model piloted by NIMHANS To provide PHC system with tools to manage mild-moderate mental health presentation To diminish stigma by normalizing mental health problems Provide increased capacity for Mental Health system to manage more serious problems

DMHP : NO EVIDENCE-BASED SELECTION

NMHP & DMHP : MAJOR FLAWS

ONLY 9 OUT OF TOP 50 DISTRICTS ( WITH HIGHEST DISTRIBUTION O F P E O P L E W I T H M E N T A L D I S A B I L I T Y ) A R E C O V E R E D B Y D M H P ( ON PAPER)

What is happening in most states under the name of DMHP is NOT the DMHP (i.e. specialist-driven at district HQ and/or mobile camps instead of PHC staff-driven) Why have states not renewed DMHP programme after one term? Why have some states renewed particular districts and not others? Should central funding be phased out over 3 terms as per NIMHANS recommendation instead of 1 term? Evidence shows that when a State Nodal agency is appointed to monitor implementation, only districts closest to the facility benefit from these efforts, as the agencies face resource crunch in monitoring districts further from the base. Blackout states like Bihar, Uttaranchal have no DMHP till date. Mental Health officials resent providing services for patients from other states/districts. Given lack of interest / involvement by State governments, should DMHP be made a Central Sector Scheme instead of a Centrally Sponsored Scheme?

DMHP : PROVISION vs PREVALENCE

( BASED ON MENTAL DISABILITY FIGURES IN CENSUS 2001 DATA )
As highlighted in ICMR DMHP research significant population groups accessing DMHP include people with mental retardation, substance abuse and epilepsy along with mental health problems.

DMHP

NEEDS

FULL

NRHM

I N T EG R AT I O N

Instead of channeling NMHP funds through NRHM framework a tighter integration with NRHM PIP & monitoring would be desirable. Equivalent monitoring and attention to detail for all NCD schemes including NMHP as other NRHM components. This would prevent incidents like the UP fiasco of fund diversion. For better governance and transparency, State Health Societies should be incorporated as Section 25 companies. Ditto for medical procurement agencies on lines of TNMSC. (That should be the norm for any nonprofit initiative in India exceeding an outflow of a crore p.a. with RTI accountability if public funding is involved)
PPP Proper guidelines for implementing social sector PPP do not exist and need to be formed to prevent breakdowns. Credible NGOs who fulfill transparency norms to be empanelled. Civil society / NGO initiatives to be incorporated in health resource mapping to present a comprehensive picture and promote an informed distribution of resources. Preferred funding schemes for established, pre-existing NGOs to be implemented by empanelled TPA assistance in reporting and accounting. This is to be an essential component of every funding scheme along with M&E percentage.

Overarching National Health Mission to include public sector companies manufacturing essential generic drugs / medical supplies on the LOCOST model
Similarly National Health Mission to ensure inclusion of mental health coverage at least in health insurance schemes run by public sector companies.

FUNDING FAILURES : INEQUITABLE BUDGETS, FINANCIAL DISARRAY

Programmes need to be run by managers, not health professionals who will aggressively market schemes & engage empanelled TPAs to assist partners in proposal / reports / accounting

Online submission of reports / UC to solve missing-in-the-corridors-of-Nirman Bhavan mystery.

Mental Health budgeting exercise on lines of gender-budgeting with ring fencing & rollover of unspent resources to a National Mental Health Fund till action syncs with budget & policy. Contracted operations on an advance installment basis to prevent program stress / suspension due to delayed fund release

HUMAN RESOURCES : MAKING THE BEST USE OF WHAT WE HAVE

HUMAN RESOURCES : SHORTCOMINGS & SOLUTIONS

PROBLEM : SHORTAGE OF PERSONNEL / LACK OF REGULATION & QUALITY MONITORING/ INADEQUATE TRAINING

Situation analysis current numbers, rate of increase p.a. vs attrition. Incentive retention plans as suggested by NIMHANS study.
Central council registration. Set up similar licensing/regulatory councils for psychologists, counsellers, psychiatric social workers, allied sector professionals etc Enrolment of PHC trained doctors for free distance education with DPM certification. Similar initiatives for civil society pioneers in this area like SHODHGRAM / Jamkhed etc and certified add-on course to provide career growth options for ASHAs. Contract private psychiatrists for urban -> rural tele-psychiatry under ISROs HEALTHSAT network Training of law enforcement agencies & correctional agencies (including civilian staff) as a component of community policing programmes under aegis of BPRD EMRI to offer emergency mental health services and train personnel accordingly Rural bonding year at end of MBBS norm with compulsory community psychiatry rotation BRMS - Rural medical practitioners to have community psychiatry included in curriculum. RMA & RHP graduates to get training with additional psychiatry qualification, certification & deployment.

SUM UP : STRATEGY SHORTFALLS SO FAR

Disproportionate mental health budgeting (~ 2% of health budget. (Detailed analysis in Basic Needs study on Indias mental health financing) Poor utilisation of funds, erratic implementation. 100 crore saved by the GoI in 10 years (2000-2010) in revised budgets that are drastically scaled down shadows of initial trumpeted outlays. Half-hearted, scattered approach to human resource problems Illogical, uncertain adoption by state government with high dropout rate Poor target choice : Only 9 DMHP districts figure in top 50 districts with mentally disabled population Stigmatised, excluded, undercounted, underrepresented, underserved vulnerable population in crisis NMHP-DMHP is no magic bullet. Instead the DMHP is a critical part of the NMHP which has barely scratched the surface of the mental health service spectrum.

FUTURE POSITIVE (NMHP=DMHP+X)

ACKNOWLEDGING A SPECTRUM OF SOLUTIONS WITH A TRIAGE SERVICE MIX

BEYOND TERTIARY CARE : DYNAMIC MENTAL HEALTH PROGRAMMES

Apart from the thrust on DMHP, National Mental Health Programme should initiate interventions across the service spectrum. Areas requiring immediate action would include:

Suicide (with focus on Farmer Suicides)

School/adolescent stress-related MH problems

Regions with military /militant presence People in vulnerable situations (disaster zones, homelessness) National Missing People Resource Centre & online database with registered access

Substance abuse
Alternate pathways Bottom up welfare interventions by PRI 24/7 Mental Health Information + Crisis Helpline (Multilingual)

SUICIDE
After Attempts : Support system for suicide attempters / those who have considered suicide National 24/7 helpline Training of police in appropriate postvention

Survivor guilt, complicated grief, terminal Peer support Suicide Anonymous and plug-in programme for substance abuse target groups
Hospital Counselling services for those with chronic physical illness, terminal illness and their support networks and recently bereaved PTSD programmes via NIDM

NCD? - AGRARIAN SUICIDE EPIDEMICS

AGRARIAN SUICIDE EPIDEMICS

#1 RISK GROUP OCCUPATIONAL MENTAL HEALTH

RISK REDUCTION : Seasonal suicide / Pre-drought interventions with FRF / INFAM etc SUICIDE BELT FOCUS Maharashtra, Karnataka, Andhra Pradesh, Madhya Pradesh & Chhattisgarh Water resource management : Hydrogeological mapping, AIBP micro-irrigation, and Watershed development, Knowledge transfer: NABARD ACABC training, Kisan call centres, VASAT academies, Relief measures : non-bank debt relief , Crop insurance , focus areas for long term credit delivery mechanisms, Seed replacement programme, grain silo sites, DMHP priority site, SURVIVOR / THOSE LEFT BEHIND RELIEF : psychological autopsy linked with NCRB district wise data, counselling, mentor-driven crop management, zero interest loans, education scholarship for children

FINANCIAL MEASURES : loan recovery seasonally instead of monthly, financial inclusion & literacy, economy of scale, co-operative farming schemes STRATEGY : Geographical distribution feed into NCRB data / Warning signs recognition awareness / Community SOS alerts to DMHP health visitor to save those suspected of suicidal ideation / Options to offset succession anxiety / migration help for younger family members or alternative income generation training / Postvention training for general medical professionals and police.

SCHOOL MENTAL HEALTH, STRESS & SUICIDES

Q: A:

Empowering adolescents with life skills education in schools: SCHOOL MENTAL HEALTH PROGRAM : DOES IT WORK?
Srikala B, Kishore KK, 2010 http://www.ncbi.nlm.nih.gov/pubmed/21267369

SCHOOL MENTAL HEALTH, STRESS & SUICIDES

Target from start of 4th std onwards + focus on those not promoted Bullying awareness campaign on respecting differences Ragging interventions Exam stress family awareness

Spillover of family problems family counselling Beyond career counselling : Counselling in education CyberPresence & Patrolling : kid-friendly language for awareness
National suicide helpline 24/7 by GoI Stop causing suicides Prevent Proactively drive : Teacher training Adolescence education programme (AEP) integration with allied behavioural health factors

VULNERABLE POPULATIONS :
STRESSFUL / VIOLENT / ISOLATED ENVIRONMENTS

VULNERABLE POPULATIONS :
STRESSFUL / VIOLENT / ISOLATED ENVIRONMENTS

Wandering / Homeless support net gaps

Defence forces Jail (especially those sectioned under IPC 309) Custodial institutions , refugee camps

Strong armed presence (official/unofficial) J&K, NER, Chhattisgarh etc Every disaster zone to become a DMHP zone. PTSD and allied programmes with NIDM after any tragedy
Victims of crime rape, child abuse, families of murdered etc

ADDICTION & ABUSE

MHA war on cross border trafficking in Punjab & NER triangle

Targeted intervention programme for Punjabs addiction crisis/ NER Addiction / Substance abuse : Need for psychosocial intervention and tight integration with NRHM. Workforce planning / preparation & Policy reform bridging health and social welfare departments Addict in the family training

BCC awareness strategies

Integration of DMHP, NRHM with addiction policy and NACO HIV strategy

A SYNCRETIC STRATEGY TOWARDS WHOLISTIC MENTAL HEALTH : GUNASEELAMs UNIQUE RESPONSE TO THE ERWADI TRAGEDY

AYUSH & ALTERNATIVE PATHWAYS

National Conference with range of practitioners / belief systems on possibilities of convergence of services

Can AYUSH professionals prescribe psychiatric medication?

Evidence based research needed. Starting with awareness about work done by NIMHANS Ayurvedic department so far. Model wholistic mental health services / facilities at faith healing loci using the dactar-dava-dua model

BOTTOM UP INCLUSION VIA PRI

Anganwadi usage for afternoon dementia clubs = carer respite

Health / care attendant employment via NREGA Janani Express type transport arrangements for DMHP / dementia clubs Equitable disabled & stakeholder representation in process, policy, participation Workplace & welfare facilitation RCH & Post Partum Depression

KNOWLEDGE TRANSFER : INFORMATION SYSTEMS & RESEARCH

SAMPLE STUDY SUGGESTIONS

Its awful that O N L Y O N T H R O T T L I N G

O F F U N D S D U E T O PA R L I A M E N TA RY C O M M I T T E E I N S I S T E N C E that the 2

AYUSH standalone efficacy vs convergence

Performance of DMHP graduates through system Unsound mind defining, distinguishing and anti-stigma/discrimination policy recommendations

studies on NMHP were conducted !

Start with Planning Commission SER dept EVERY DMHP CENTRE STUDY PAPER VS PRESENCE

Violence, mental health and incarceration

Feasibility of mental health court. Employment of people with mental health issues as corporate HR diversity programmes. Need for a SUBSTANCE ABUSE plan as a separate stream of the NMHP on evidence of PHC clientele. Divorce because of mental health. Feasibility of family mental health court / mediation agency for issues like consent, guardianship etc

NEEDED : COMPREHENSIVE MAPPING FOR PPP

INFORMATION

& TRANSPARENCY

NEEDED : BETTER RTI RESPONSE & PROACTIVE D I SC LO SU RE MOHFW PATCHY RTI TRACK-RECORD TO BE ADDRESSED. Sample details of the RTIs filed on 22nd March 2011 with no response :

State Mental Health Authority- wise list of all Hospitals, Nursing Homes, Rehabilitation Centres, and NGOs that have applied for license since 1980 and the current status of their licenses. Total number of seats allocated to Psychiatry in the Central/ State government run/aided medical institutions in 2010. Total number of students in all government run/ aided medical institutions who have taken Psychiatry as their specialization in 2010. The total number of DMHP Clinics in India, Names of these clinics district-wise, and names and number of functional clinics district-wise, ALL the Government run Institutes in the country for persons with Mental Illness, as per Questionnaire in the NATIONAL HUMAN RIGHTS COMMISSION (NHRC) report (2008) on Comprehensive Mental Health Care Monitoring developed by NIMHANS

AWARENESS
ICMR study showed overwhelming effect of IEC on mental health awareness. With neuropsychiatric conditions projected contribution to global burden of disease and disability , government authorities have NO MORE EXCUSES to avoid a national mass media mental health awareness campaign. INDIAS HEALTH PRIORITIES SEEM TOTALLY

ACTION

PLAN

DISCONNECTED FROM FUNDING LOGIC.

Visibility within Health & Social Welfare departments communication acronym list of health reports doesnt include NMHP! Rural Communication Strategy by Social Marketing Consultant
IEC Schemes / Facilities available / Disability recognition and benefits Campaign - Workplace facilitation

BCC - lover suicides / Divorce due to mental illness / recruitment

Multilingual mental health 1 stop portal (with anonymised DMHP data via NRHM reporting structure) and mental health dictionary in Indian languages

THE LAST WORD

FURTHER NEGLECT OF INDIAS MENTAL HEALTH NEEDS, WILL BE NOTHING SHORT OF PARIAH POLICY-MAKING AND ECONOMIC EUGENICS

GIVE MENTAL HEALTH ITS DUE

12th Five Year Plan of Action