Mental health, as important to well-being as physical health, is also the most neglected health concern. In 1979, the World Health Organisation (WHO) called on all member states to develop a National Mental Health Programme (NMHP). In 1982, India was one of the first countries to do so. In 1987, India passed the National Mental Health Act to deal with more complex issues of mental illness.Yet, from 1990 to 2017, the burden of mental illness in the country increased from 2.5% to 4.7% of the total disease burden. In 2017, an estimated 197 million Indians, roughly one in seven, had some kind of mental illness. The treatment gap, defined as the proportion of people who don’t get treatment when they need it, is remarkably high. A study that looked at 24,371 adults in eight districts across several states estimated a 95% treatment gap. India’s National Mental Health Survey reports a treatment gap of 83% for all mental disorders. In low- and middle-income countries, people underreport mental issues due to ignorance and stigma (fear of discrimination); this is also the main reason for the low levels of perceived and expressed treatment needs and up to 99% of the treatment gap.When people actively seek care, supply-side factors such as service availability, accessibility and affordability significantly determine the outcome. In India, the referral pathway is not defined for most diseases, including mental illnesses. Most people living with a mental illness (PLMI) receive general care because of the staggering gaps in the availability of mental health professionals relative to actual need. According to the WHO, India has only 0.2 psychiatrists per 100,000, compared to the global average of three. The corresponding figures for other professionals, such as psychologists, social workers and nurses, are no better. Different official sources give differing numbers of active mental health professionals, such as psychiatrists, in the country, implying a lack of tracking mechanisms.The direct cost of mental health care is incapacitating, mainly due to the complex and lengthy pharmacological and non-pharmacological treatments and physical comorbidities. For example, in 2010, an average Indian household spent an estimated $925 per year in direct and indirect care costs on dementia, compared to an average annual per capita income of $1,205. The direct cost for all mental illnesses in 2015–16 ranged from Rs 500 to Rs 2,250 per month, with an average of Rs 1,000.Indirect costs such as travel expenses and lost wages also remain high. More than 40% of PLMI travelled at least 10 kilometres to access publicly funded care in 2009. They face challenges like disability, low productivity, absenteeism and unemployment. On average, a PLMI loses 5–24 productive days per month due to a disability. Each quarter, caregivers reported up to 20 days of absenteeism and 17 days of social isolation.Also read: Five Issues That Are Hurting the Indian EconomyThese costs put a big strain on family finances and make it hard for people, especially the poor, to get the care they need. Some households cannot afford to pay at all and have to forego care, which explains a part of the treatment gap. In 2014, 6.4% of total households that did not seek medical advice for all types of illness cited weak finances as the main reason. We can reasonably extrapolate this proxy measure of foregone care to mental illnesses. More commonly, high expenditures on seeking care cause impoverishment, and poverty is also a significant risk factor for mental illnesses. Depression, anxiety and suicide rates negatively correlate with income levels and employment status. Evidently, among people with low incomes, mental illness is more likely, and the treatment gap is higher by 1.5–3 times than among those with the highest income. In India, the prevalence of depression (experienced in the last two weeks) is 3.4% in the lowest income quintile compared to 1.9% in the highest quintile.One way to ease supply-side distress and reduce OOP expenditure is to increase the government expenditure on mental health. However, the ring-fenced resources for mental health, as part of the country’s total health budget, states and union combined, have always been less than 1%. In the Union health budget, more than 90% of the allocation for the mental health goes to three tertiary care facilities under the administrative control of the Union government in Bengaluru, Tezpur and Ranchi, and the remaining is spent on NMHP. NMHP is a centrally-sponsored scheme, which means Centre and states finance it together. However, in practice, it is not possible to track the states’ contribution to the NMHP and nearly all the expenditure by the state governments is on tertiary care in state-level mental hospitals and psychiatry wards in the government medical colleges.The NMHP budget, as a share of Union health budget, is falling consistently, from 0.44% in 2010 to 0.08% in 2022. The NMHP supports modernisation and upgrade of psychiatry hospitals and the psychiatry wings of state hospitals, as well as workforce development. The budget for this activity under NMHP is allocated under the head of tertiary care programmes with other national programmes. In 2018-19, this amount was Rs 51 crore, and Rs 40 crore each year from 2019–20 to 2022–23, a pittance by any measure. In turn, usage is even lower, just 5% to 25% of the allocations. Such wide gaps in allocation and expenditure reflect implementation failures. Most likely in 2023-24, too, the budget for NMHP has not changed or rather declined. Because the total budget for other national programmes under the said head has come down from Rs 500 crore to Rs 289 crore. All this while psychiatry departments in state institutions remain severely underfunded and understaffed.Prevention and decentralised care are the most desirable strategies to control diseases. So, as part of the NMHP, the Government of India (GoI) introduced the District Mental Health Programme (DMHP) in 1996 for community-oriented services. DMHP has grown from four districts in 1996 to 704 districts in 2020. Budget allocations kept increasing from Rs 28 crore in the IX Plan (1997–2002), Rs 139 crore in the X Plan (2002–07), Rs 1,000 crore in the XI Plan (2008–2012), and Rs 1,265 crore in the XII Plan (2012–17). If implemented well, DMHP can improve the care and socialisation of PLMI and the general population. However, most state governments have not committed funds after the initial five years of funding support from the GoI.Also read: Study Says A New Lens Is Needed to Look at Mental Health of Indian MuslimsAlso, outreach provisions haven’t taken off as planned due to administrative snags and a lack of workforce. Between 2015 to 2020, average national utilisation rate under DMHP is just 38.11%. Only 10 states or UTs have used more than 40% funds under DMHP while 14 states have used less than 25%. Therefore, the DMHP has been reduced to delivering psychiatric services in district hospitals. Since 2013–14, DMHP is subsumed under the National Health Mission, a jointly funded Special Purpose Vehicle in health by states and union governments and since 2015 DMHP has awaited new guidelines.India ratified the UN Convention on the Rights of Persons with Disabilities in 2007 and enacted the Mental Health Care Act (MHCA) in 2017. To stop discrimination, the law contains wide ranging rules covering several rights for PLMIs and enabling clauses to augment the provisioning of care for PLMI. It proclaims that PLMIs have the right to care without discrimination, and it is the responsibility of government to ensure it. Hopefully, the law can alleviate demand-side reasons for the treatment gap, strengthen the supply of care, and improve mental health outcomes.Governments are ensuring the integration of mental health into all levels of care. Psychological counselling features prominently among the services of the Health and Wellness Centres. Pradhan Mantri Jan Arogya Yojana covers hospitalisation for the most typical psycho-neuro procedures. In 2022, the GoI has started a national programme to develop 23 telemental health centres with inaugural budget of Rs 121 crore which become Rs 133 crore in 2023.Budget allocations and utilisation reflect the low priority given to mental health and implementation failures, and the two reinforce each other viciously. Various sporadic efforts to change the status quo are not a standard substitute for planned and unified framework of efforts, which is crucial to break this vicious cycle. Yet, one can be optimistic as the country works to improve its health system to achieve universal health coverage, the MHCA 2017 and other initiatives will likely improve the situation for PLMI.Arun Kumar Tiwari is a public health professional with expertise in health financing.
