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Page 1: National Mental Health Programme: Time for … · Web viewNational Mental Health Programme: Time for reappraisal Mohan Isaac Professor of Psychiatry School of Psychiatry and Clinical

National Mental Health Programme: Time for reappraisal

Mohan IsaacProfessor of Psychiatry

School of Psychiatry and Clinical NeurosciencesThe University of Western Australia, Perth, Australia

(Formerly, Professor and Head, Department of Psychiatry, NIMHANS, Bangalore)

(Chapter from Kulhara P et al “Themes and Issues in Contemporary Indian Psychiatry” New Delhi, Indian Psychiatric Society, 2011)

Level 6, W Block, Fremantle Hospital, Fremantle, WA 6160, AustraliaTel: ++ 61 8 9431 3467, 9431 3474, Fax: ++ 61 8 9431 3407

E-mail: [email protected]

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National Mental Health Programme: Time for reappraisal

Introduction

India was one of the first countries in the developing world to formulate a national mental health programme. As early as 1982, the highest policy making body in the field of health in the country, the Central Council of Health and Family Welfare (CCHFW) adopted and recommended for implementation, a National Mental Health Programme for India (NMHP)1. More than 35 years have passed since this historic adoption and much has changed in the fields of health care delivery as well as population mental health in India. It is worthwhile to review the progress of implementation of the programme and consider how relevant the initial formulations are in the context of current scenario of mental health in India. This paper will provide a historical perspective of the genesis and evolution of NMHP, describe its current status, critically appraise the existing situation, the progress, successes and failures in this area and then discuss where we go from here i.e. what further needs to be done and future direction for sustainable growth and development of this area.

Genesis and evolution of the National Mental Health Programme for India

By the 1970s, community surveys of mental disorders carried out in different parts of the country had shown that all types of mental disorders were widely prevalent in India.2 Comprehensive and authoritative reviews of the situation of psychiatric disorders in developing countries including India by Neki and Carstairs highlighted the gross neglect of mental disorders in developing countries due to a variety of reasons which included pervasive stigma, widespread misconceptions, grossly inadequate budgets for health care including mental health and acute shortage of trained mental health personnel. It was pointed out that in developing countries; basic mental health care should be decentralized and integrated with the existing system of general health services. 3, 4

There are at least five important factors which contributed to the drafting of the national mental health programme for India during the early 1980s.

1. “The organization of mental health services in developing countries” – a set of recommendations by an expert committee of the World Health Organization. 5

The strategy of integrating mental health into primary care services was strongly endorsed by an Expert Committee set up by the World Health Organization to make recommendations about ways and means of delivering mental health services in developing countries which had acute shortage of trained mental health professionals. Some of these recommendations made during the mid 1970s are very relevant even today and have been repeated and reemphasized by numerous expert groups and international organizations, subsequently... For example, the expert committee recommended that:

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“Basic mental health care should be integrated with general health services and be provided by non-specialized health workers, at all levels.”

“…. countries should, in the first instance carry out one or more pilot programmes to test the practicability of including basic mental health care in an already established programme of health care in a defined rural or urban population”.

“…. training programmes, including simple manuals of instructions for training of health workers should be devised and evaluated”

2. Starting of a specially designated “Community Mental Health Unit” at the National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore – 1975 6

Mental health needs assessment and situation analysis in over 200 villages situated around the rural mental health centre at Sakalwara in Bangalore rural district covering a population of about 100,000 (average population covered by a primary health centre in most states of India during the 1970s) were carried out by the community mental health unit of NIMHANS. Simple methods of identification and management of persons with mentally illness, mental retardation and epilepsy in the rural community by primary care personnel were developed.7 Pilot training programmes in basic mental health care for primary health care (PHC) personnel were conducted in various primary health centres such as Anekal, Malur and Solur in Bangalore, rural, Kolar and Tumkur districts in Karnataka state.8 Draft manuals of instructions in mental health

care for PHC personnel were written and pilot tested.9,10 Simple mental health educational materials which could be used by multipurpose health workers in rural areas were also developed. A variety of methods for evaluating the training in mental health provided to PHC personnel were developed and tested. 11,12,13,14 Based on the pilot experiences from its rural mental health centre, the community mental health unit at NIMHANS developed a strategy for taking mental health care to the rural areas through the existing primary health care network.15

3. World Health Organization (WHO) Multi-country project: “Strategies for extending mental health services into the community” (1976-1981)

The propose model of integrating mental health with general health services and providing basic mental health care by trained health workers and doctors as an integral part of primary health care received substantial support from a multi-country collaborative project initiated by the WHO and carried out in 7 geographically defined areas in 7 developing countries, Brazil, Colombia, Egypt, India, Philippines, Senegal and Sudan. The department of psychiatry at the post graduate institute of medical education and research in Chandigarh was the centre in India and the model was developed in the Raipur Rani block in Haryana state.16, 17, 18

4. The “Declaration of Alma Ata”- to achieve “Health for All by 2000” by universal provision of primary health care (1978)

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The emergence of the concept of primary health care during the 1970s provided a radically new way of formulating health care policy particularly in developing countries of Africa, Asia and Latin America. A major international conference onprimary health care organized in 1978 by the WHO and UNICEF in Alma-Ata in the then Soviet Union (now Almaty, capital of Kazakhstan) urged all governments, health and development agencies, and the world community to “protect and promote the health of all the people of the world”. The famous “Health for All by 2000” slogan was born and primary health care was declared the bedrock of health care provision globally. According to the Alma-Ata declaration, primary health care is "essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-determination" (Declaration of Alma-Ata 1978).19 ‘Primary health care’ was essentially an approach to the provision of basic health services.

5. Indian Council of Medical Research – Department of Science and Technology (ICMR-DST) Collaborative project on ‘Severe Mental Morbidity’

During the late 1970s and the early 1980s, the Indian Council of Medical research (ICMR) and the Department of science and Technology (DST) of Government of India funded a 4 centre collaborative study to evaluate the feasibility of training PHC staff to provide mental health care as part of their routine work. This evaluation of a mental health intervention strategy involving primary care personnel was carried out for one year covering a population of 40, 000 in a primary health centre at four centres, one each from the South, North, East and West of the country, Bangalore, Patiala, Calcutta and Baroda. At the end of one year period about 20% of the actual cases were identified and managed by the PHC personnel under the overall supervision of the centre staff. 20, 21, 22

The above factors contributed in no small measure to the drafting of the NMHP. The draft of the NMHP, written by an expert drafting committee which consisted of some of the leading, senior psychiatrists in India then was reviewed and revised in two national workshops attended by a large number of mental health professionals and other stakeholders during 1981-82, before its final adoption by the Central Council of Health and Family Welfare (CCHFW) in August 1982. The objectives of NMHP were: (a) to ensure the availability and accessibility of minimum mental healthcare for all in the foreseeable future, particularly to the most vulnerable and underprivileged sections of the population; (b) to encourage the application of mental health knowledge in general healthcare and in social development; and (c) to promote community participation in the mental health service development and to stimulate efforts towards self-help in the community. The approach to achieve these objectives was diffusion of mental health skills to the periphery of the health service system and integration of basic mental health care into general health services. Towards achieving the objectives, a set of actions as well as several ambitious targets with specific timelines were proposed.

What happened after NMHP 1982?

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While the adoption of the national mental health programme document in 1982 by the CCHFW (and recommendation of its implementation) was a great achievement, there were numerous issues which were left unclear. Most importantly, no budgetary estimates or provisions were made for the implementation of the programme. There was lack of clarity regarding who should fund the programme – the federal government of India or the state governments who perpetually had inadequate funds for health care. Although the draft of the programme was discussed in great detail by the mental health profession and revised before its final adoption by the CCHFW, there was a very lukewarm response and in some instances, almost rejection of the programme by psychiatrists. Great doubts were expressed about the feasibility of implementing the programme in larger populations and in real world settings as almost all the pilots and feasibility projects were carried out by only research and training institutes and in smaller populations of up to 40, 000. Important concerns such as, can results obtained by ‘highly motivated’ personnel in a small population be replicated in ordinary health care settings, are experiences from 40,000 population translatable to the total population (15 to 20 lakhs) of the administrative unit of a district, were raised by many. The need for planning the implementation of the programme at a district level was highlighted.

The progress of implementation of NMHP during the past 28 years (from 1982 to 2010) can be considered under the following five specific periods when various significant developments occurred. 1) 1982-1990 – Development of the pilot district mental health programmea at Bellary district in Karnataka

Realizing that the NMHP was not likely to be implemented on a larger scale without demonstration of its feasibility in larger populations, the National Institute of Mental Health and Neuro Sciences developed a programme to operationalize and implement the NMHP in a district. Bellary district with a population of about 20 lakhs, located about 350 kms away from Bangalore was chosen for the pilot development of a district level mental health programme. This project was undertaken with the active support of the directorate of health and family welfare services, government of Karnataka and the Bellary district administration.

Medical officers and health workers from all the primary health centres in the district were trained in mental health care in a staggered and decentralized manner.23. They were also supported, supervised and provided with additional on-the-job training. Besides training for all primary care staff, the other components of the district mental

health programme at Bellary were: provision of 6 essential psychotropic and anti epileptic drugs (chlorpromazine, amitryptaline, trihexyphenidyl, injection fluphenazine deaconate, phenobarbitone and diphenyl hydantoin) at all primary health

centres and sub centres, a system of simple mental heath case records, a system of monthly reporting, regular monitoring and feed back from the district level mental health team. At the district head quarters, the mental health team consisted of a psychiatrist, clinical psychologist, a psychiatric social worker and a statistical clerk. The psychiatrist ran a mental health clinic at the district hospital to review patients

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referred from the primary health centres. The psychiatrist could admit up to 10 patients at the district hospital for brief in patient treatment, if and when necessary. The mental health programme was reviewed every month at the district level by the district health officer during the monthly meeting of primary health centre medical officers. During the period 1985 – 1990, the feasibility of delivering basic mental health care at the district, taluk and primary health centre levels by trained primary health centre workers was demonstrated in whole district of Bellary in Karnataka State. 24, 25, 26, 27.

2) From the late eighties to 1996 – Training of trainers and sensitization workshops

Despite showing that, with appropriate support from the state health department, primary health centre workers can be trained and supervised to identify and manage certain types of mental disorders and epilepsy along with their routine work at the primary health centres, the climate in the country amongst senior health planners and administrators as well as public health and mental health experts were not ripe wider implementation of the NMHP. Most mental health professionals were disinterested in public health aspects of mental health. The country office of the WHO supported a programme of training mental health professionals to become trainers of primary care staff and programme mangers of NMHP. Funding was also made available for holding nation wide sensitization programmes for senior health administrators.28 State level health administrators, planners and mental health professionals from all the States and Union Territories were sensitized to implement the national mental health programme in their respective states, through series of workshops. It was suggested that modest and viable mental health care programmes be developed in each state and union territory. However, states and union territories themselves were unable to initiate any meaningful programmes due to various constraints, most notably, paucity of funds.

A national workshop organized by NIMHANS, in collaboration with Ministry of Health and Family Welfare, Govt. of India involving the health departments all the states and union territories in February 1996, strongly recommended that National Mental Health Programme should be activated by sanction of adequate funds from Central Government (Plan funds). The workshop further recommended that District Mental Health Programmes should be implemented in each state/union territory and the “Bellary programme” as developed by NIMHANS could serve as a prototype. The emphasis should be in involving the families in looking after the mentally ill and special emphasis should be given to poor, weaker and underprivileged sections of the society. The workshop also suggested various requirements and components such as human resources, equipments, beds etc for such a District Mental Health Programme.

The Ministry of Health and Family Welfare, Govt. of India formulated District Mental Health Programme (under National Mental Health Programme) as a fully centrally funded 5 year pilot scheme with a total outlay of 115.9 lakhs of rupees for five years (28.5, 21.5, 20.7, 21 and 24 lakhs of rupees during the 1st, 2nd, 3rd, 4th and 5th years of the scheme respectively) in 1996-97. The programme was to be implemented in two phases, the Phase I was to be taken up during 1996-97, and the Phase II was to be a continuation of the programme during the IX Five Year Plan period (1997-2002).

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Thus, a budget line for implementation of the DMHP as a major component of the NMHP was created in 1996; 14 years after CCHFW approved the NMHP. DMHP was to be implemented as a fully “centrally supported” project

3) 1996-97 to 2002 (IX Five Year Plan) – Wider implementation of the District Mental Health Programme

The District Mental Health Programme was launched during 1996-97 in four districts – one district each in Andhra Pradesh, Assam, Rajasthan and Tamil Nadu. The programme was extended to 7 more states during 1997-98 – the states of Arunachal Pradesh, Haryana, Himachal Pradesh, Punjab, Madhya Pradesh, Maharashtra and Uttar Pradesh. The programme was subsequently expanded to one district each in the States of Kerala, West Bengal, Gujarat and Goa and the union territory of Daman & Diu during 1998-99, Mizoram, Manipur, Delhi and union territory of Chandigarh during 1999-2000, and Tripura and Sikkim during 2000-2001. Kerala and Assam started the programme in a second district during 1999-2000, Andhra Pradesh took up their second district and Tamil Nadu started the programme in 2 more additional districts during 2000-2001. The district mental health programme was initiated in 27 districts spread all across the country, situated in 20 states and 2 union territories. The total budget allocation for the implementation of NMHP during the IX plan period was rupees 28 crores.

The objectives of the fully centrally funded District Mental Health Programme (under National Mental Health Programme) scheme were as follows: i) To provide sustainable mental health services to the community and to integrate these services with other services, ii) Early detection and treatment of patients within the community itself, iii) To see that patients and their relatives do not have to travel long distances to go to hospitals or nursing homes in cities, iv) To take pressure off mental hospitals, v) To reduce the stigma attached towards mental illness through change of attitude and public education, and vi) To treat and rehabilitate mentally ill patients discharged from the mental hospital within the community.

The steady expansion of the district mental programme all across the country during the IX plan period was also facilitated by a variety of other factors such as:

i) Further recommendations and resolutions by the CCHFW. For example, the sixth meeting of the CCHFW held in April 1999 made the following observations and resolutions: a) “The central council notes with concern that mental health problems are on the increase and that this has been a neglected area so far. As mental health and physical health are both integral parts of health, mental health should be integrated with physical health” b) “More states and UTs should actively participate in the district mental health programme initiated by the centre” c) “At least one district in each state and in the larger states, one additional district for every ten districts should ideally be covered under this programme in a phased

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manner” d) “To achieve this objective, the council recommends that higher budget allocation may be made for this programme”

ii) The publication of an influential report by the National Human Rights Commission of India (NHRC) on “Quality assurance in mental health”29

iii) The wide media publicity, public out cry and intervention by the Supreme Court of India following the Erwadi tragedy wherein 26 chained mentally ill persons were accidentally killed in a fire accident that took place in Erwadi Dargah in Ramanathapuram district of Tamil Nadu state in August 2001.30

4) 2002 to 2007 - X Five Year Plan period

While the DMHP implementation grew from a few districts to 27 during the period 1996-2002, this coverage represented less than 5% of the districts in the country. Therefore, the Ministry of Health and Family Welfare, Government of India reviewed the NMHP implementation through a series of meetings with mental health professionals involved in DMHP and various other stake holders. One of the thrust areas identified for increasing access to mental health care during the X Five Year Plan period (2002-2007) was the expansion of DMHP to 100 more districts. The need to restrategize the NMHP from a single pronged to a multi-pronged programme and to strengthen facilities and services at secondary and tertiary levels of mental health care provision to support the growing DMHP was also recognized.31

The Planning Commission of India approved a budget of 190 crores during the X Five Year Plan for a five pronged strategy to continue implementation of NMHP. The five strategies adopted were: i) Expand the DMHP to 100 districts ii) Upgrade and strengthen the departments of psychiatry in government medical colleges / general hospitals attached to medical colleges to improve treatment and training facilities. Better mental health care facilities at general hospital and medical college hospital settings was expected to bring down the load on mental hospitals iii) Modernize and transform mental hospitals to improve patient care and reduce / prevent long stay iv) Stronger emphasis and funding for activities providing mental health information, education and communication (IEC activities) to communities and v) Support research and training on issues related to the implementation of NMHP. Support to Central and State mental health authorities to effectively fulfill their role of monitoring mental health care and implementing the Mental Health Act 1987 and funding for an independent mid-course evaluation of the DMHP scheme were also provided for during the X Plan period.

An audit of DMHP carried out by NIMHANS in 200332 in the 27 districts where the programme was started during 1996-2002 showed that there were numerous problems and bottlenecks in the actual implementation of DMHP. The efficiency and the effectiveness of the programme varied widely between districts and states / union territories. A variety of factors such as the motivation and commitment of the nodal officer and the programme staff, interest and administrative support of the state health authorities (which include senior officers of Directorate of Health Services, Directorate of Medical Education, Principal of Medical College, Head of the District Hospital etc.) and absence of an effective Central Support and Monitoring mechanism at the Government of India level could be attributed to the differential effectiveness. District mental health clinics and inpatient facilities for the mentally ill were established only in 15 of the 27 districts. In districts where the programme was functioning adequately, mental health services were decentralized to the district level,

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if not to the PHC level with partial integration of these services with general health services. Mental health services were started in a lot of places where none existed. While adequacy of funds was never a constraint, accessing the available funds posed enormous administrative and bureaucratic problems. The audit highlighted the need to i) develop an operational manual for the DMHP ii) review the content, curriculum and method of training the PHC personnel iii) provide continued support, supervision and on-the-job training for PHC personnel after the initial training iv) review the priority conditions covered by the DMHP and make necessary amendments to include common mental disorders v) enhance IEC activities vi) monitor the programme regularly and develop time bound targets vii) incorporate aspects prevention and promotion of mental health such as life skills training and counseling in schools

During the X Plan period, grants were provided for up gradation of psychiatry departments of 75 government medical colleges /general hospital psychiatry wings and 26 mental hospitals. DMHP was under implementation in 123 districts throughout the country. One of the major hindrances to the effective implementation of DMHP was the non-availability of trained, motivated mental health professionals such as psychiatrists, clinical psychologists, psychiatric social workers and psychiatric nurses. The numbers of these professionals trained annually in the country is limited contributing to the acute shortage of trained human resources in mental health.

5) 2007 onwards - IX Five Year Plan, The current phase

Dealing with the acute shortage of trained human resources in mental health is the main thrust of the current (XI) Plan. A major chunk of the approved total budget outlay for mental health of Rupees 408 crores, more than threefold increase from the previous X Plan, is for setting up 10 Centres of Excellence in the field of Mental Health in different parts of the country. These centres are being established by upgrading and strengthening identified mental health institutes, mental hospitals and departments of psychiatry. The centres will focus on training psychiatrists, clinical psychologists, psychiatric social workers and psychiatric nurses.33 Government medical colleges would also be supported for starting post graduate courses or increasing the intake capacity for post graduate training in mental health. The existing districts where the DMHP is under implementation will continue to be supported as also the other programmes initiated during the X Plan namely modernization of state run mental hospitals, up gradation of psychiatric wings of government medical colleges/general hospitals, IEC activities and research on issues relevant to the NMHP.

Appraisal of the existing situation

As the implementation of NMHP and in particular, the DMHP, its community mental health programme aimed at enhancing access to basic mental health care in rural areas, expanded steadily across the country during the past two Five Year Plan periods, several questions were often raised: Isn’t it time for a reappraisal of the NMHP? Is the main approach of the NMHP namely integration of mental health with primary care still the right approach, appropriate to the current situation of mental health in the country? How effective is the DMHP component of NMHP? What evidence is available for the usefulness of DMHP? Is the DMHP cost-effective? Has there been any independent evaluation of the DMHP? While answers for all the

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questions are not readily available, there are numerous published papers and various types of reports which provide some of the answers.

1) Is the main approach of the NMHP namely integration of mental health with primary care still the right approach?

During the past two decades, several international organizations including the World Health Organization and many expert committees’ recommendations have repeatedly emphasized the soundness of the approach to integrate mental health with primary health care as a major relevant strategy for mental health care delivery in developing countries. An evaluation of this strategy in low and middle income (LAMI) countries by the WHO in 2001 pointed out that while it was difficult to assess the success of existing primary care mental health programmes, such integration was “the only realistic option”, due to continuing resource constraints in LAMI countries.34 The World Health Report in 2001 which was specifically devoted to mental health, highlighted the need to integrate mental health into primary care especially in low and middle income countries.35 More recently in 2008, a joint WHO and WONCA report reaffirmed the urgent importance and advantages of integrating mental health into primary care systems around the world.36 This report shows that integration is achievable in all countries and provides detailed case studies of best practices from across the world which includes the DMHP in Thiruvananthapuram District of Kerala State, India. The theme of the most recent World Federation of Mental Health - World Mental Health day on 10 October 2009 was “Mental health in primary health care: enhancing treatment and promoting mental health”. In 2008, thirty years after the “Health for All by 2000 AD” Declaration of Alma Ata in 1978, WHO again reiterated the significance of “Primary Health Care” in strengthening health systems in LAMI countries.

An extensive and authoritative review of the situation of mental health care across the globe in 2007 - the Lancet Global Mental Health series, unequivocally recommends that “….. mental health should be recognized as an integral component of primary and secondary general health care, particularly in low and middle income countries”37.

Several other influential international reports such as the Institute of Medicine, USA,

report on “Neurological, Psychiatric & Developmental Disorders - Meeting the Challenges in the developing world” in 2001 and the “Disease control in developing countries– Mental health” project report have recommended the strengthening of existing systems of primary care services in developing countries to provide services for persons with mental disorders.38,39 A recent programme launched by the WHO in response to the Lancet’s “Call for Action”, with the objective to scale up care for mental, neurological and substance abuse disorders in low and middle income countries, the mhGAP (mental health Gap Action Programme) has developed evidence based guidelines of interventions for a number of mental and behavioural disorders to be used by the primary health care personnel of LAMI countries.

2) How effective is the implementation of NMHP?

There have been several publications and reports which have looked at different specific aspects of the implementation of NMHP. Most reports suggest that the implementation is far from optimal and the reasons are numerous. Widespread

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misconceptions about the causation and management of mental disorders continue to be rampant in most parts of the country. Stigma towards mental disorders is rife and may contribute to underutilization of mental health services where they are provided. Utilization of public health service especially from primary health centres is generally low in India. Integration of mental health adds another set of chores to the already overwhelmed primary care clinicians and other personnel. Time available to assess and counsel patients is very limited in primary health centres “Doing more takes time” and “dispensing pills” is simply not enough. Patients routinely seen in primary care settings are patients with co morbidity, sub threshold disorders and multiple somatic complaints, many of whom are chronic. Depression often presents as chronic pain, chronic fatigue. PHC doctors need to acquire new skills through practical guidance, in addition to gaining new knowledge through didactic teaching. Most doctors need help in managing medically unexplained somatic symptoms, which their mental health training may not have provided.40Although there was gain in knowledge, doctors were unable to manage patients with mental disorders on their own. There was need for greater liaison with the district team.41

A variety of lacunae in the current implementation of NMHP have been reported. These include: i) absence of full time programme officer for NMHP in many states ii) inadequacies in the training for PHC personnel iii) inadequate record maintenance iv) non-availability of basic information about patients undergoing treatment at various centres (regularity of treatment, outcome of treatment, drop-out rates etc) v) difficulties in recruitment and retention of mental health professionals in the DMHP vi) non-involvement of the non-governmental organizations (NGO) and the private sector vii) inadequate mental health educational and community awareness activities viii) absence of programme outcome indicators and monitoring ix) inadequate technical support from mental health experts.42 As the NMHP primarily focuses on rural areas, the need for decentralized mental health care in urban areas has been highlighted. Drawing data from an 18 month clinical ethnographic study of the Kanpur DMHP in Uthar Pradesh, Jain and Jadhav observe that the programme relies heavily on the pharmacological treatment of psychiatric disorders at the exclusion of community participation and psychosocial approaches. They contend that “psychotropic medication has become the embodiment of India’s community mental health policy” and argue that “community psychiatry has, in practice, become an administrative psychiatry focused on effective distribution of psychotropic medication”43

While funding itself has not been a problem, delayed receipt of funds, irregular dispersal of funds, administrative blocks in the full utilization of available funds and a variety managerial issues have bogged down the proper implementation of the NMHP in many states and Union Territories. A former senior consultant to the Ministry of Health and Family Welfare, Government of India on mental health notes that “Even adequately funded programmes sometimes fail due to factors such as top-down approach to planning divorced from ground realities, poor governance, managerial incompetence, unrealistic expectations from low- paid and poorly motivated primary care staff”44

3) Is there any evidence for the effectiveness of primary care mental health?

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A comprehensive review of effectiveness of primary care mental health services in developing countries as varied as Botswana, Guinea Bissau, Iran, Nicaragua, Nepal, Tanzania and India noted that adequate data on long term effects were not available from any of these countries to make meaningful interpretations.34 While mental health training programmes for primary care personnel may bring about improvements in mental health knowledge and attitudes, there is only little evidence of changes in actual practice of health workers. Although diagnostic sensitivity of trained workers increases, there is no evidence if such improvements result in better outcomes for patients. Many reports mention the numbers of patients with various mental disorders identified and treated in primary care but do not provide any information on long term clinical outcomes. Most training programmes consist of short courses focusing on diagnosis and pharmacological management without much emphasis on skill acquisition and application in clinical settings.45 Numerous other factors such as erratic drug supplies, high rates of attrition of trained staff, lack of continued on-the-job training and inadequate support and supervision also influence the effectiveness and long term sustainability of primary care mental health programmes.

A review of the current practice in delivering care to adults with common mental disorders in primary care settings of low income countries, point out that “much remains unknown, undocumented and unshared”.46 Whether primary care staff can improve outcomes for these disorders is yet to be established widely. While there is evidence that epilepsy can be treated effectively by primary care staff, evidence for effective management of severe mental disorders is limited and largely inadequate.34

Even though the majority of persons with common mental disorders who receive treatment in developing countries, just as in developed ones, do so in general or primary care settings, only a very small proportion of such persons receive minimally adequate treatment.47,48 This inadequacy of service seems to reflect both the lack of adequate training for primary health care providers and the pattern of health service delivery in those settings. A large cross-national WHO collaborative study suggests that primary health care service in developing countries is often characterized by lack of continuity of care and poor record keeping.49, 50

The most convincing evidence for the effectiveness of the DMHP comes from North Kerala. During the past few years, the DMHP is being implemented in the five districts of Kozhikode, Kannur, Malappuram, Kasargod and Wayanad under the overall co-ordination of the Institute of Mental Health and Neuro Sciences (IMHANS), Kozhikode, Kerala – an institution selected by the Ministry of Health and Family Welfare, Government of India for elevation as a Centre of Excellence in mental health during the current 11th Five Year Plan. Persons requiring inpatient treatment for severe mental disorders from all the above districts are generally admitted to the mental hospital located in Kozhikode. The annual number of admissions in Kozhikode mental hospital in 2005 was 2622. The total annual

admissions in the hospital steadily came down to 1836 in 2009. Similarly, the total annual outpatient follow-ups of discharged patients too came down from 31802 in 2005 to 24610 in 2009, while the total annual number of new outpatient registrations went up from 2243 in 2005 to 2944 in 200951

4) Has there been any independent evaluation of the DMHP?

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One of the major criticisms of the NMHP and particularly its DMHP component was that it was not independently evaluated before its larger scale expansion during 10 th

and 11th Plans. Such an independent evaluation was commissioned by the Ministry of Health and Family Welfare, Government of India and was carried out the Indian Council of Marketing Research (ICMR), a division of Planman Consulting (India) Private Ltd, New Delhi during 2008-2009. The terms of reference for the evaluation included, besides objective and critical assessment of the DMHP, providing recommendations and suggestions for improvements in implementation and future expansion of the programme.52

20 districts (4 each from five zones of the country – East, West, North, South and Central) and 5 non-DMHP districts (control) were selected for the evaluation. The beneficiary districts were chosen proportionately from those started during the 9th and 10th Five Year Plans. Primary data was collected from 15th October to 15th November 2008. Perceptions of medical professionals, beneficiaries (patients) and community

members were systematically obtained. 60 respondents from the beneficiaries, 30 respondents from the community and 10 respondents from the health system, a total of 100 respondents from each district (total respondents from 20 districts = 2000) were interviewed. Various aspects of the programme including sanction and utilization of funds, recruitment and retention of personnel, quality and effects of training, nature of IEC activities, availability of drugs, satisfaction with quality of services and community awareness of mental health were evaluated. While the report ovides numerous recommendations and suggestions, perhaps one of the most important recommendations is: “It was observed that implementation of DMHP has resulted in availability of basic mental health services at district / sub-district level. As such it is recommended to expand this programme to other districts of the country”

A wide variety of administrative and managerial bottlenecks were identified by the evaluation. It was observed that irregular flow of funds had affected the implementation of the programme adversely. There were significant delays in initiation of the programme even after the release of funds in some districts. Shortage of trained and motivated mental health professionals and difficulties in retaining recruited staff were problems in many states. Low utilization of funds, meant for training and IEC activities was noticed in many districts. It was observed that most beneficiaries (61%) accessed the district hospital as their first point of contact for availing mental health services. Community Health Centres (CHC) (8.7%), Primary Health Centres (7.6%) and sub-centres (2.3%) were accessed to a much lesser extent.

Future of NMHP

For a country as large as India, with a population of about 1.3 billion and extremely limited number of trained mental health professionals, the much maligned basic approach of the NMHP continue to be an acceptable and feasible method of extending basic mental health services to the length and breadth of the country. However, the approach needs a major technical and operational review by mental health and public health experts and certain corrections following the review. The main component of the NMHP namely the district mental health programme was developed in Bellary district more than 20 years ago and has not changed much since then. The situation

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across the country is so varied in different states and union territories that “one size will not fit all”. Local issues should be identified, and feasibility of programme implementation assessed. Appropriate local modifications to the basic programme will have to be made in different parts of the country.

For more efficient and quick countrywide implementation of the programme, many of the salient recommendations of the recent independent review of the DMHP will have to be seriously considered.52 To make mental health care more accessible to those who most require them, the services will have to be strengthened at the sub-centre, PHC and CHC levels. NMHP is currently a fully centrally funded Plan programme. To ensure continuity of the programme beyond the 11th Five Year Plan, the financial responsibility for the programme will have to be gradually shifted to the state governments and mental health services will have to be integrated in the State and District Implementation Plan. There is an urgent need to enhance the capacity in the country to train mental health professionals. The various staff positions in DMHP will have to be made more attractive to motivate and retain professional staff. The DMHP staffs also require training in programme management and organizational activities. Appropriate non-pharmacological interventions will have to be introduced into the programme and the PHC staff trained adequately. The community participation and ICE components of NMHP need strengthening. Plans and proposals are most likely to lead to action, only if they are accompanied by: detailed specifications and clear instructions of what needs to be done, what the likely barriers are to implementing the proposal, how these barriers could be overcome and how progress towards specific goals could be measured. Besides everything else, a set of specific, measurable outcome indicators for the DMHP will have to be urgently developed and used for regular and continuous reporting and morning of the programme.

One of the proposals for better implementation of NMHP is its integration with the National Rural Health Mission (NRHM). NRHM was launched by Government of India in 2005 to carry out necessary architectural correction in the basic health care delivery system for better delivery of primary health care. NRHM contributed to a major increase in public expenditure on health in the country. The mission focuses on decentralization and district management of health programmes. By induction of management and financial personnel into district health system, NRHM efficiency is enhanced. NRHM focuses also on community participation and ownership of assets and aims to enhance capacity of panchayat raj institutions to own, control and manage public health services. The mission promotes access to improved healthcare at household level through the female health activist who is referred to as “Accredited Social Health Activist” (ASHA). Every village/large habitat will have a female Accredited Social Health Activist (ASHA). Planning for integration of DMHP with the National Rural Health Mission will contribute numerous advantages to the DMHP such as optimal use of existing infrastructure at various levels of health care delivery system and sustenance of DMHP beyond the expiry of the period of central assistance by its integration in the district health system. An integrated IEC under NRHM, involvement of NRHM infrastructure for training related to mental health at the district level, use of NRHM machinery for procurement of drugs to be used in DMHP and building of credible referral chains for appropriate management of cases detected at lower levels of the health care delivery system are all additional advantages of integration of DMHP with NRHM. Specific details and mechanisms of such integration will need to be developed.

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Currently there is almost no involvement of the private and non-governmental sectors in the NMHP. Collaboration and partnerships with these sectors will have to be developed. The growing number of carers and users (of mental health services) organizations will have to be actively involved in further planning and implementation of NMHP. Ultimately, there will have to be a “whole of government” response to the numerous problems in the field of mental health care.

REFERENCES

1. Director General of Health Services (DGHS): National Mental Health Programme for India. New Delhi, Ministry of Health and Family Welfare; 1982

2. Gururaj G., Isaac M.K. Psychiatric epidemiology in India: moving beyond numbers. In Agarwaal S.P, Goel D.S, Ichhpujani R.L, et al (eds); Mental Health- An Indian perspective (1946-2003). New Delhi: Elsevier for Directorate General of Health Services, Ministry of Health and Family Welfare; 2004: 37-61.

3. Neki J.S. Psychiatry in South-East Asia. British Journal of Psychiatry. 1973; 123: 257-269.

4. Carstairs G.M. Psychiatric problems in developing countries. British Journal of Psychiatry 1973; 123: 271-277

5. World Health Organization. Organization of mental health services in developing countries. Technical Report Series 564. Geneva: World Health Organization. 1975

6. Isaac MK (eds). A decade of rural mental health centre, Sakalwara. Bangalore: National Institute of Mental Health and Neuro Sciences; 1986

7. Kapur RL, Isaac MK. An inexpensive method of detecting psychosisand epilepsy in the general population. The Lancet 1978;1089.

8. Isaac MK, Kapur RL, Chandrasekar CR et al. Mental health delivery in rural primary health care - development and evaluation of a pilot training programme. Indian Journal of Psychiatry 1982; 24:131-138

9. Srinivasa Murtthy R, Chandrasekar C.R., Nagarajiah et al. Manual of mental health care for multi-purpose workers.Bangalore: National Institute of Mental Health and Neurosciences; 1988.

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11. Sriram T.G, ChandrasekarC.R, Moily S et al. Standardisation of multiple-choice questionnaire for evaluation medical officers training in psychiatry. Social Psychiatry and Psychiatric epidemiology 1989; 24:327-331.

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(Technical monograph on ICMR research studies in India). New Delhi; Indian council of Medical Research, 2005: 5-7

23. Isaac M.K, Srinivasa Murthy R, Chandrasekar C.R et al. Decentralised training for PHC medical officers of a district - the Bellary approach. In Varghese A (eds) Continuing Medical Education Vol. VI. Calcutta: Indian Psychiatric Society; 1986.

24. Isaac MK. District Mental Health Programme at Bellary. Community Mental News – Issue No. 11 and 12. Bangalore: Indian Council of Medical Research – Centre for Advanced Research on Community Mental Health; 1988.

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