Five-year plans and once-in-a-decade interventions: Need to move from filling gaps to bridging chasms in mental health care in India

INTRODUCTION In a country of 1.33 billion people spread across 29 states and 7 union territories (UTs), 630 districts (with more than 23,000 primary health-care centers - the primary unit for health care), 22 official languages and over a 1000 dialects, a population that is 70% rurally located, nearly 25% illiterate, and about one in five below the poverty line, the challenges faced in the delivery of mental health care can be extremely complex. Added to this complexity, there is yet another often cited reason – that as per the Constitution of India, health is a state subject and not under the control of the central government.[1] There are three broad themes that illustrate the landscape of mental health services in India in contemporary times. First is the theme of judicial activism driving the development of mental health services in the country. The second is the governmental response. The third and overwhelming theme is one of polemics-public or private, community or specialized care, health or social welfare, stand-alone mental health services or integrated services, and finally perhaps, most importantly, center or state. PUBLIC INTEREST LITIGATION AND JUDICIAL INTERVENTION The most notable initiatives that have to some extent shaken off the inertia in mental health-care reform are the public interest litigations (PILs) and the judicial responses that occurred over the last three decades.[2] The first such in the 1980s (Upendra Baxi vs. State of UP and others) concerned the “inhuman treatment of inmates” of a protection home in Agra and argued for their “right to live a life of dignity” as enshrined in Article 21 of the Constitution of India. A number of PILs subsequently followed the issues that were raised included concerns about mentally ill prisoners languishing in jails (Veena Sethi vs. State of Bihar 1982), the state of the public Shahdara Mental Hospital in New Delhi (BR Kapoor and others vs. Union of India 1983 and PUCL and others vs. Union of India and others 1983), the detention of abandoned children and those with mental retardation “in jails for safe custody” (Sheila Barse and others vs. Union of India and Ors 1986). In response, the Supreme Court ordered the monitoring of such homes, directed the National Human Rights Commission (NHRC) to monitor specific mental hospitals, and declared keeping of mentally ill in jails as illegal and unconstitutional, leading to the release of many “noncriminal lunatics” from jails. Another resulting development was the formation of the Institute of Human and Behaviour and Allied Sciences, where the Shahdara Mental Hospital was earlier. The philosophy of care in mental health institutions was perhaps best illustrated in the case of Chandan Kumar Bhanik versus the state of West Bengal in 1988 where the apex court observed: “Management of an institution like the mental hospital requires flow of human love and affection, understanding and consideration for mentally ill persons. These aspects are far more important than a routinized, stereotyped, and bureaucratic approach to mental health issues.”[23] MENTAL HOSPITAL MONITORING As part of the mandate of the Supreme Court in 1997, the NHRC began monitoring the functioning of the mental hospitals at Agra, Gwalior, and Ranchi. The NHRC “used monitoring as a tool of correction and promotion of human rights of persons with mental illness”.[3] In addition to monitoring the functions of the three assigned hospitals, the NHRC also supported an initiative on quality assurance in mental health. This evaluation, undertaken by the National Institute of Mental Health and Neurosciences (NIMHANS) in 1998, included an evaluation of the mental hospitals in the country through questionnaires and personal visits, as well as a review of the existing general hospital psychiatry units and private psychiatric institutions.[4] This landmark project involved sending out questionnaires to directors and superintendents of government and private mental hospitals, principals and heads of departments of psychiatry of medical colleges and general hospitals, personal visits to individual facilities including 37 government psychiatric institutions, 7 private psychiatric institutions, and 23 general psychiatric units throughout the country, and interaction with administrators, staff, patients, and their families. This culminated in a meeting of health secretaries and development of minimum standards of care in mental hospitals.[5] The visits were a déjà vu and déjà lu (already read) of the Bengal Enquiry of 1818, Edwin Mapother's eye-opening report of 1938, and Moore Taylor's survey report of 19 mental hospitals in 1946,[4] all rolled into one. Some of the comments of over a century ago were still pertinent. Many of them “bore more resemblance to a prison than an asylum,” had “open air cages,” and were “disgracefully understaffed.” It was as if “time had stood still.” The blame for the state of the hospitals did not seem to lie with the superintendents, who had met in 1960 in Agra, 1986 in Ranchi, 1988 in Bengaluru, and 1990 in New Delhi, and had raised the same old concerns. The visits to the mental hospitals in 1998 reflected the same. The NIMHANS/NHRC report[4] revealed glaring deficiencies in the infrastructure and functioning of the mental hospitals. High walls, prison nomenclature and practices, poorly maintained premises and gardens, overcrowding, paltry budgets particularly for diet (as low as Rs. 5 per day), lack of cots, toilets, fans, inadequate water, electricity, lighting, predominantly closed wards, cells in operation, lack of specialized services, poor outpatient and emergency services, poor supportive services, mainly involuntary admissions through the courts were the salient findings. Very few had a semblance of organized psychosocial intervention or rehabilitation. Although the hospitals were not rated on a scale of “badness” as Moore Taylor had done about 50 years earlier, they were nevertheless rated as very poor (7), poor (8), average (11), and good (6). Recommendations from this report included conversion of closed to open wards, rearrangement into smaller wards, streamlining of admission and discharge procedures in accordance with the Mental Health Act, 1987, upgradation of facilities, enhancement of human resources and in-service staff training and sensitization, improvement in the diet, better patient amenities, recreational and rehabilitation facilities, encouragement of voluntary admissions and development of specialized services for children, elderly, substance use, and prison populations. The report noted that general hospitals had the potential for taking over the primary locus of psychiatric care. However, the limited review of general hospital psychiatry units (only 27 of the 87 facilities contacted responded to the questionnaire and 23 were visited) also revealed many lacunae, including the lack of human resources, poor infrastructure, low priority for psychiatric facilities and patient amenities, lack of inpatient beds, lack of emergency care, frequent staff transfers, and a lack of collaborative engagement between different specialties. The team visited only seven private psychiatric facilities, four of which were managed by a religious order or nongovernmental organizations (NGOs). These generally showed better standards of functioning compared to the government facilities. In summary, the NIMHANS/NHRC report of 1999[4] argued for “enlarging the scope of mental health services through the expansion of general hospital psychiatric facilities and community care, a continuum of services from primary to tertiary care, community participation in policy and service development, and intersectoral collaboration.” It urged that mental hospitals transform from custodial to therapeutic centers from closed institutions to postgraduate training centers by affiliation with medical colleges/universities so that they could become more open, transparent, and progressive in their functioning. The report envisaged that mental hospitals would remain an essential locus of care, along with general hospital psychiatric units, community-based mental health services, and nongovernmental agency involvement. It mentioned the important role of professional mental health bodies, the need for training and research in mental health, and the need for periodical review of legal provisions. At that time, the Mental Health Act of 1987 and the Persons with Disabilities Act of 1995 had been operational (and are still). The NHRC report of 1999 was a “defining moment”[5] in highlighting the state of mental health services in India. However, the report, like many others before it may have disappeared into oblivion, had it not been for the Erwadi tragedy. On August 6, 2001, a fire extinguished 25 mentally ill persons who had been chained and kept in confinement in a faith-based institution in the Ramanathapuram district of Tamil Nadu. The Supreme Court took Suo Moto notice and directed the Union Government to conduct a survey on an all-India basis to identify registered and unregistered facilities and ascertain if the NHRC recommendations had been followed. A PIL (Erwadi–Saarthak) followed soon after.[2] GOVERNMENTAL STOCKTAKING AND THE NATIONAL MENTAL HEALTH PROGRAMME IN A NEW AVATAR Pursuant to the orders of the Supreme Court, the Directorate General of Health Services (DGHS) undertook a stock of the mental health services in the country. This report[6] reiterated some of the earlier concerns: human resource shortages, poor infrastructure, poor facilities, and lingering custodial atmosphere in the psychiatric institutions. It urged that “we rid ourselves of the obsolete notions of the inevitability of institutionalized psychiatric treatment and think innovatively.” The DGHS report also reviewed the National Mental Health Programme (NMHP), launched in 1982 and re-strategized in 2003. The original programme envisaged making mental health care available, accessible, and affordable to all; utilization of the primary health-care infrastructure and integrating mental health care with general health care and with existing community development and welfare.[6] The re-strategized NMHP was intended to be multi-dimensional, have a nodal agency co-ordinate the District Mental Health Programme (DMHP), strengthen medical colleges’ departments of psychiatry, modernize and streamline mental hospitals to make them tertiary centers of excellence with “a dynamic social orientation,” strengthen Central and State mental health authorities, and strengthen research and training aimed at building actionable databases. This report concluded that the picture emerging from the database with respect to mental health laws and services across the country is “not a happy one.”[7] To reach a goal of one psychiatrist and 1.5 clinical psychologists/psychiatric social workers/100,000 population, this report indicated a deficit of 7477 psychiatrists, 12,926 clinical psychologists, and 17,118 psychiatric social workers. To ensure 1 psychiatric nurse per 10 psychiatric beds, the report calculated that 4036 psychiatric nurses were required, but the availability and deficit of qualified psychiatric nurses were unclear.[7] The financial allocation to mental health increased across successive 5-year plans (5-year economic plans by the Government of India). There was a nearly 8-fold jump in the budget between the 9th and 10th 5-year plans. However, in the absence of systematic, particularly administrative planning, the funds were not adequately utilized. MENTAL HOSPITAL REFORM: CHANGES OVER A DECADE The NHRC continued to be engaged with the mental hospitals, particularly the ones mandated to its care. A decade after the quality assurance study, a re-evaluation of the state of mental hospitals through a follow-up questionnaire, review of the reports of the special rapporteurs of the NHRC and DGHS reports indicated several positive trends.[8] These included a reduction in involuntary admissions, better living conditions, greater budgetary allocations, and relatively more engagement with the community. However, human resource shortages, inadequate rehabilitation facilities, “closed ward” structures, and mentalities were persisting in some of the hospitals. Hospitals with continuous monitoring did significantly better than those that were not under the gaze of overseeing bodies in the state or by the NHRC.[8] ADDRESSING THE HUMAN RESOURCE CRUNCH Meanwhile, the Government of India, during the 11th 5-year plan, funded 11 centers of excellence (“upgrading and strengthening identified existing mental health hospitals/institutes for addressing the acute workforce gap and providing state-of-the-art mental health care facilities”). It funded several postgraduate departments of psychiatry across the country and offered upgradation of the psychiatric departments of government medical colleges and general hospitals. Twenty-nine state-run hospitals received budgets for modernization.[9] The last decade also witnessed an increase in postgraduate MD seats to produce more psychiatrists (with the engagement of the Medical Council of India and special relaxation of norms). However, while the initiatives were laudable, the “slow work of projects funded under the manpower development schemes and a lukewarm response in taking up the scheme of manpower development points towards dearth of leadership in the mental health sector in the country and the danger of continuing with business as usual.”[9] RIGHTS: COMPLIANT LEGISLATION The United Nations Convention on the Rights of Persons with Disabled (UNCRPD) was ratified by India in 2007 and this had ripple effects in the country. The Mental Health Care Bill with a greater emphasis on the rights of persons with mental illness was formulated to replace the Mental Health Act of 1987, introduced in the Rajya Sabha in 2013, where it has been passed with amendments on August 8, 2016 and is in the process of ratification by the Lok Sabha. The Rights to Persons with Disabilities Bill, for compliance of existing disability legislation with the UNCRPD, was introduced in the Upper House in 2015. India was the first country in the South-East Asian region to release a mental health policy in 2014.[10] The results of the first National Mental Health Survey are to be released later this year. Although there were occasionally blowing winds of change, the pace of change was slow and inconsistent. The first PIL, more than three decades old in the Supreme Court of India, has continued to be the basis for continuing directions of the Supreme Court. The apex court had directed the NHRC to monitor the mental health institutions/systems in the country and advised that it could be approached again, if further directions were needed in the matter. The NHRC approached the Supreme Court in 2013, requesting direction to overcome the deficiencies that existed in mental health care despite its interventions.[2] NEWER JUDICIAL INITIATIVES In response to the appeal from the NHRC (a continuation of the Upendra Baxi PIL of 1981), the apex court directed the states to fill out a proforma questionnaire with questions on the overall aspects of mental health care in the state, along with information about psychiatric institutions, medical college and general hospital departments of psychiatry, NGOs, and the DMHP.[2] These questionnaires had been prepared by NIMHANS and submitted by the NHRC. A four-member technical committee (TC) comprising three psychiatrists was constituted by the NHRC to appraise the apex court of the deficiencies in mental health care in the states, based on the analyzed questionnaires and two other These included an on the mental health care services by the special rapporteurs of the NHRC who visited different states to ascertain the issues to the care of the mentally as well as the report of the up at the of the Supreme Court by the of Health and and constituted by a union the State Health of the state mental health state human rights in some states, and THE THE NATIONAL HUMAN The most of the based on the submitted by the states was the lack of and information on the as well as resources for mental health care in many states and The report can that the priority to mental health is if a from the Court in the country and a can still not off the and the into one on from the existing of a of mental the report that there may be at persons with mental illness in need of psychiatric care, from many others in not to mental on the state of persons care, a of the population is treatment in A part of the was the of service This did not treatment to be one can that the gap is more than as by the for As per the the population was well below the of The in the private medical and district hospitals had not been This may be by the that some of the psychiatric institutions have their A relatively private sector is from four This to be a and its participation in the health-care is not well The number of in the of mental health is of better than a decade but for the country. The inadequate of mental health services is also illustrated by a lack of of information on the mentally which is emerging as a population of there are a few rehabilitation facilities in the private to be to and there are facilities in the public Another glaring is the absence of in such as and which have of mental health This was out in earlier The to strengthen postgraduate training in psychiatry has to an addition of This would an existing of about psychiatrists, from the report which psychiatrists, to a of psychiatrists per The of clinical psychologists, psychiatric social and psychiatric nurses are far the are far than for human resources in mental The need for psychiatry has been and The noted that the Medical Council of India in had the and this was not respect to mental hospitals, a but of lie in the psychiatric institutions throughout the country. Many have been to patient care. The committee noted in many hospitals, with infrastructure, living facilities, and services had and about of the specialized services had been However, of human resources, lack of and and in the monitoring by bodies continued to the last two decades have witnessed improvement in most hospitals, the that some still to have deficiencies is reflected in the reports of human rights by the Human Rights The persisting of and need for rehabilitation is by the initiative of the National Commission for Although states such as have the population in psychiatric institutions through availability of admissions with and and such as the in and are is is a lack of for rehabilitation with of the It is to be that of the rights of persons with mental illness can in and Mental health and are for Although the Mental Health Act has been in 1987, and state was to the there are still states which have not done or have if they have the years later and at a a mental health-care is on the nodal for mental health Mental Health have been identified in most states, state mental health plans have not been of the of the NMHP was to mental health care with general health care. India is to have up a at the on and in in to mental health in the of However, to be done on the in this with the that are with a mental and mental illness is with an increased of It is important that are and into integrated and continued care. THE HEALTH It was envisaged that the would all the districts in the country by In the was to have been in of in and in of the have been and of the in and concluded that the programme was at the district not at the primary health-care with better of mental illness in districts compared to However, several have been of the which inadequate leadership at the state, and district and other administrative and It has also been that mental health care delivery to have and also to be at through the of the social A THE three decades after the of the NMHP in India, the philosophy of mental health care and the remain there have been some about most have to be between the service and service and between and and between psychiatrists in the public and private for a continuum of care have been by of the of different of community care the of resources on psychiatric institutions. of existing community care that good psychiatric institutions are a and their to other such as MENTAL HEALTH IN In a country like India, people to that there to be a of services, to in the absence of social and of of care, all in a to of an quality of care. of mentally ill make a to the and for and mental health-care In India, of the persons with mental illness are still by The and to from treatment in mental health to and the in mental health service delivery in India. and of a and need and and need to be and