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Mind Matters: a Perspective on the Mental Health Landscape in India

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Mind Matters: a Perspective on the Mental Health Landscape in India Mind matters: A perspective on the mental health landscape in India Understanding challenges in the Mental Health ecosystem in India and how they limit health equity Background country’s total population. The mental MH assumes a crucial position in the Indian health burden in the country has been health care landscape, not only because of its Mental health (MH) forms an integral rising consistently, almost doubling its magnitude and implications, but also constituent of an individual’s overall share in the total disease burden because of its indiscriminatory reach across health, substantially affecting all areas of since 1990. diverse socio-demographic profiles. Besides life. Globally, mental disorders have been Despite its immense scale, the mental a vast treatment gap of more than 60 one of the leading causes of disease 3 health ecosystem in India has received percent , mental health in India faces deep- burden in terms of years lived with inadequate government focus and has rooted systemic and stakeholder-specific disability (YLDs1). Developing countries, been underserved in regulation and inequities, vis-à-vis other disease areas. such as India, are at a higher risk as funding. Globally, MH treatments are The significance of mental health has come health care systems are already stressed. proportionally underfunded, compared to to the forefront in the wake of the pandemic, The scale of mental disorders in India is their share in health issues, with median triggered by factors such as lockdowns, staggering—accounting for nearly 15 government health expenditure on mental economic hardships, and job insecurities. The percent of the global mental disorder health being less than 2 percent.2 In India, pandemic has shone a spotlight on the burden. this deficit is even more pronounced with a importance of mental health in the country In India, mental disorders are amongst ~0.05 percent2 budgetary allocation in and offers an opportunity to expand the the leading causes of non-fatal disease 2021–22. depth and breadth of India’s mental health burden and affect ~14 percent of the ecosystem. *Notes: 1YLD represents years of healthy life lost due to disability or ill-health, 2% of funds allocated towards Mental Health out to the total healthcare budget, 3Except for epilepsy 1 Mental Health perspectives Prevalence of mental health burden in India 14 percent of the 15 percent of the ~200 Mn country’s population is global mental health Overall mental health 14% estimated to be suffering 15% burden is shouldered burden in India (2017) from mental disorders by India Impact on India’s economy >1 Tr USD ~20% ~2.4K is the estimated economic loss 1 predicted by WHO arising out of of economic loss from NCDs DALY per 100,000 mental health conditions in India during 2012–2030 is expected population of India between 2012 and 2030 to come from mental health Societal barriers >60% of the general public associate >70% derogatory terms with mental disorders, ~40% of the general public associate mental according to a study of the general public are wary of having health with the term “stigma”, someone afflicted with a mental health according to a study disorder in their neighbourhood, according to a study Gaps in the ecosystem Mental health allocation2 in the health budget over the last five years vs. <0.1% ~5 percent allocation in developed countries Funding ~6% Actual utilisation of funds allocated to NMHP in 2019–2020 (~2.5 crore of 40 crore utilised) Psychiatrists per 100,000 population available, as opposed to the ~0.75 conservative estimate of three Psychologists/social workers per 100,000 population available in India Capacity ~0.07 vs. more than 30 in the US *Notes: 1DALY the sum of the years of life lost to due to premature mortality (YLLs) and the years lived with a disability (YLDs), 2Allocation to NMHP (National Mental Health Programme) 2 Mental Health perspectivesMental Health – Key perspectivesInsights Lines of enquiry of the study State of mental Initiatives and Emerging role of Role of key Key challenges health in India bold bets technology stakeholders • Further, widespread stigma and • Further, the issues of awareness trigger Challenges discrimination inhibits long lead times from the onset of the While a multitude of challenges exist acknowledgement of MH disorders and disorder to diagnosis, the time delays across the MH ecosystem, we have active care seeking are longer especially in rural areas narrowed down our findings to the major • There is a limited understanding of • Another key impediment is the lack of meta-challenges and those that further social determinants of health and their accessibility and awareness of various exacerbate the inequities in the system. implications on MH. Awareness and diagnostic and self-care tools, especially We have found that there are select support depends on such socio-cultural in rural areas challenges that impact certain aspects of factors the patient pathway in addition to more • PHC1 and lay workers2 can expand reach systemic challenges that impact the overall • While digital channel adoption has been and provide primary diagnoses. mental health ecosystem. augmented by COVID-19, it is still However, lay workers are overburdened underdeveloped and at a nascent stage, and not trained and incentivised Challenges across the patient pathway especially in rural areas sufficiently 1. Awareness • Additionally, patients are highly reliant on general practitioners for care, who • There is a lack of mental health literacy The ability of people to deal with MH are not trained and aware of MH and basic awareness on what is mental issues is dependent on socio-cultural factors and the society that they are a part disorders health, what constitutes mental illness, of. For example, in many restrictive and how to treat it societies, women are expected to 3. Treatment accommodate and suppress their issues • The inability and difficulty in recognising and are not given an opportunity to visit • Due to the disproportionate emphasis signs/symptoms of MH disorders makes any professional for MH help. on biomedical approach, there is a lack it difficult to acknowledge their Public care provider of focus on psychosocial interventions. presence Furthermore, there is no holistic • Additionally, MH is not publicised unlike 2. Diagnosis approach to care delivery as other non-communicable ailments. The psychiatrists and psychologists work in lack of discourse on MH at scale inhibits • Diagnosis is constrained due to limited silos the normalisation of the topic capacity and lack of access to mental health professionals (especially in rural areas) The problem is that the services are biomedical in approach, whereas stressors MH symptoms are often not visible. People lie in psychosocial realm. However, the are unable to identify the presence of MH Long duration has elapsed between the Allied and Healthcare Professions Act places ailments. They are sidelined as temporary time the patient first identifies the counsellors in subordinate positions as and attributed to circumstances, e.g., problem and visits a professional for the compared to other healthcare professionals depression is confused with sadness. first time.…the issue is much more severe in rural areas for instance in depression - lumped with homeopaths and ayurvedic Psychologist the lead times are 12 months (metros), 2-3 professionals. years (non-metros). Research institute Public care provider *Notes: MH – Mental Health; 1PHC – Primary healthcare; 2Lay workers – community workers like ASHA and Anganwadi workers 3 Mental Health perspectives • COVID-19 has boosted tele-mental Systemic challenges across • Digital solutions are being used to heath service adoption, but gaps stakeholders tackle capacity issues; however, they are remain. Moreover, the reach is limited in 1. Policy implementation rudimentary, have operational issues, rural areas due to inadequate digital and are not scalable infrastructure • The National MH Act 2017 is a progressive act; however, its • Finally, capacity building is limited due • The widespread stigma also impels implementation and adoption has been to inadequate focus on MH in the patients to seek religious assistance limited. There is a lack of MH boards at medical curriculum. Additionally, there is (e.g., faith healers) over medical the state and district level to drive the a dearth of institutions carrying out professionals agenda research on MH, which could provide evidence for MH initiatives • There is a lack of support structures for • Further, there is inadequate government family and care-givers of the patient focus on multiple fronts, from 3. Funding • Furthermore, there is a lack of holistic regulation and implementation of the • Lack of long-term funding affects the mental health support structures in Act to appropriate funding and budget feasibility of multiple MH initiatives. corporates. Employees are sceptical utilisation Continuity and scalability of initiatives is about reaching out for help • Although the MH Act mandates limited due to inconsistent funding from insurance providers to cover mental the private sector health along the same lines of physical • Government funding is largely focussed Corporates are beginning to change their illness, poor implementation and on communicable diseases, funding attitude towards MH, but many still do not enforcement has resulted in perennial have policies and support mechanisms. Also, allocation from the health care budget corporate employees are apprehensive to avail lack of insurance cover for patients on MH is miniscule (<0.1 percent1) care as they believe it will adversely affect their evaluation at work. Mental health is a state subject and Public care provider there is a lack of awareness and Funding mechanisms are not patient, in knowledge at the state level to utilise terms of measuring the trajectory and the funds effectively. tangibility of initiatives, and often shift 4. Rehabilitation and measurement Donor agency focus away due to changing priorities, which impedes the continuity and • Measurement of patient progress is a scalability of the initiatives. challenge due to the lack of specific 2.
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