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A Case for Mental Health Advocacy in Kerala, India

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A Case for Mental Health Advocacy in Kerala, India Time for Action: A Case for Mental Health Advocacy in Kerala, India. Chinchu C1. 1 - Post Doctoral Fellow, Women’s Studies Centre, Cochin University of Science and Technology, Kochi, Kerala, India Additional Affiliation : Research Consultant, Association for Social Change, Evolution, and Transformation (ASCENT), Kozhikode, Kerala, India Correspondence Address: Chinchu C. Mullanvathukkal, Kaipuzha North (PO), Kulanada (via), Pathanamthitta, Kerala, India - 689503 Email: [email protected] Acknowledgement of financial Support : None Conflict of Interest : None Time for Action: A Case for Mental Health Advocacy in Kerala, India. Abstract Mental health continues to be one of the most neglected areas of public service in India, even in its most developed states like Kerala. Advocacy services in mental health are also inadequate in availability to those in need. This call to action paper argues for a collaborative advocacy-through-action model of mental health advocacy for Kerala, with people’s participation as an important component. Kerala is chosen as the candidate for such a model because of its successful experience in implementing participatory development programmes. The proposed advocacy model can be extended to the whole country based on the feedback received from its initial implementation. Keywords: Advocacy, Kerala, India, People’s Participation, Community Mental Health Time for Action: A Case for Mental Health Advocacy in Kerala, India. Introduction The idea of sustainable development is closely linked to the institutions and processes of public service, in discourses related to development (Leuenberger, 2006). However, with regard to the issue of equity, the focus of such discourses lies mostly on the equity between generations. The issue of equity within a generation is not accorded due consideration (Dalziel & Saunders, 2010; Pearce, 1988). This anomaly has to be examined in the backdrop of findings that globally, inequality is rife, and is on the rise (Alvaredo, Chancel, Piketty, Saez, & Zucman, 2017). In India too, there have been evidence that huge inequality exists and is on the rise as well (Campbell, Ramadorai, & Ranish, 2018). Within the context of the growing realization of the role of psychologists in the public service domain (Chu et al., 2012; DeLeon, 1988), it is imperative that the psychology community take up the mantle of advocacy in the larger interest of the marginalized populations. This call to action paper examines the status of mental health advocacy in India and proposes a scalable model for the advancement of mental health advocacy, with a focus on the least privileged sections of the society. The Mental Health Advocacy Scene in India The role of professional bodies in advocacy is crucial, mainly because of their role in influencing legislative processes (Rieger & Moore, 2002). Given the lack of proper licensing system and regulations in the mental health care sector, professional bodies have an important role to play in the advancement of advocacy in the mental health setting of India. However, the present scenario is an issue for concern. None of the leading professional bodies of mental health professionals, including those of psychiatrists or clinical psychologists have mental health advocacy among their stated objectives, or major programmes. The number of NGOs with advocacy among their objectives is also very limited. Notable organizations working in the sector of advocacy include Action for Mental Illness India (ACMI), which was founded in 2003 and Center for Advocacy in Mental health (CAMH). A small but significant change has been visible in the recent times where advocacy has been mentioned in the agenda of some of the professional bodies in mental health. A notable event was the 44th Annual Conference of the Indian Association of Clinical Psychologists in February 2018, where the theme of the conference dealt with the role of Clinical Psychologists in mental health advocacy. Another important stride came with the presidential address at the 21st National Conference of the Indian Association for Social Psychiatry, which focussed on mental health advocacy. However, these small efforts pale in comparison with the enormity of the issues in mental health sector of India. An advocacy movement which considers the specific requirements and challenges in India is essential for gaining the required momentum towards positive and constructive policy level action. Mental Health Advocacy Needs of India The health care sector of India relies heavily on the private sector. Public health system of the country faces a number of issues including low public health expenditure and poor performance in burden of disease rankings (D’Cunha, 2017). The mental health infrastructure and system of India is equally - if not more – insufficient to cater to those in need (Ganju, 2000). Thus it is imperative that the mental health advocacy movement for India have a design that is different from those in the high income countries with better mental health infrastructure and service delivery systems. The prime focus of such movement has to be on the twin aspects of combatting the treatment gap and fighting the stigma and discrimination associated with mental illnesses. While pressing for actions and programmes, preference should be accorded to the most disadvantaged and vulnerable sections of the society who are susceptible to the problems related to mental health problems (Trani et al., 2015). This includes tribal communities, women from lower socio-economic strata, fishermen community etc. The demand for a focus on the marginalized communities is made because of the inequality that exists in the Indian society, especially with respect to access to essential services including health care. The need to ensure equity in mental health care is evident from findings that underline the relationship between indices of socio-economic status and mental health care access (Alegría, Nakash, & NeMoyer, 2018; Satcher & Rachel, 2017). This relationship warrants more attention in the case of India, where inequality has been on the rise in the recent past (Radhakrishna, 2018). The problem of inequity in India’s health care system has also been previously highlighted (Balarajan, Selvaraj, & Subramanian, 2011) with factors like high out-of-pocket expenses attributed to pulling people towards a vicious circle of ill health and poverty which accentuate each other. Recognising this issue, the National Mental Health Policy of India (Ministry of Health and Family Welfare, 2014) lists equity as its first guiding principle. Community participation is touted as an important component in the mental health care sector of India (Kapoor, 1994). More recently, awareness building and task-shifting to community level have been recommended as important strategies for a radical transformation of the public health scenario of India, especially mental health (Patel et al., 2015; Srivastava, Chatterjee, & Bhat, 2016). However, it has been pointed out that most of the existing community mental health efforts do not practice community participation in its spirit. Hence in view of the large treatment gap that exists in India’s mental health sector, the advocacy efforts should address the importance of participatory methods in community mental health activities. Also, urgent attention should be paid to the most vulnerable and marginalized communities of India, who have been denied proper attention with regard to health services (Khanday & Akram, 2012). A model for an advocacy movement is presented here, with a focus on vulnerability, people’s participation, and ease of implementation. The Case of Kerala The Indian state of Kerala presents an exceptional model in many aspects. It has achieved commendable levels of health indices, literacy, life expectancy etc. comparable to developed nations. The state has achieved this feat with a very low per capita income. The state is ahead in many areas when compared to the Indian union (Parayil, 2000; The Economist, 2010). However, this ‘Kerala model’ of development is not without faults and shortcomings. One important area that has been neglected in the development efforts of Kerala has been mental health. Mental health morbidity in Kerala is at par with the national figure, if not higher, and marginalized sections and women are more vulnerable. The infrastructure availability is also poor, even with a dedicated mental health policy in place (Mohamed, Rajan, Kumar, & Mohammed, 2002; Shibukumar & Thavody, 2017). The mental health of the tribal population is an area of particular concern, with reports of high prevalence of mental illnesses, along with other forms of social evils plaguing them (Shaji, 2018). It is in this context that an advocacy movement becomes relevant in Kerala’s mental health arena. There exists ample evidence for inequity in the health sector of Kerala, despite its overall human development achievements (Jacob, 2014; Subramanyam & Subramanian, 2011). Hence equity assumes importance in the proposed mental health advocacy framework of Kerala. Kerala is capable of executing an inclusive community-based mental health programme given its successful experience in implementation of a participatory development programme (Jos & John, 2002). An Advocacy Model for Kerala As pointed out in the case of Indian mental health sector, an advocacy movement for Kerala should aim to ignite discussions on advocacy first, and incrementally progress towards a self- advocacy model, where those in need of mental health
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