A Nudge In The Right Direction: Subsidization Of Mental Healthcare In India

NEED FOR MENTAL HEALTHCARE IN INDIA

Whether one would like to acknowledge it or not, India has a serious unspoken problem. In 2019, we averaged 351 deaths daily due to suicide, which has been seen to be high among young Indian women and Indian youths and these could be boiled down to various issues, such as educational success, anxiety, substance abuse, distress, economic insecurity, pressure from traditional Indian families, to name a few, and all of these compromise mental health for individuals in India. Health is crucial for discerning one’s sense of well-being and the ability to cope with daily stress inducers. It’s no wonder the World Health Organization (WHO) deemed India’s mental health levels to be depressingly low when it’s believed that one out of seven citizens of India is afflicted with some variant of mental illness. As of 2015, the statistics showed that there is only 1 psychiatrist for 343,000 citizens. Hence, it would not be crazy to infer that India suffers from a mental health epidemic. There has always been a wave of unawareness, disregard, misconceptions, stigmas and ignorance around the issue of mental health in India, as well as a lack of equivalence to the importance of physical health that, generally, is deleterious to the overall mental health of people in India. The stigmas attached to mental healthcare often lead to association with terms like ‘crazies’ or ‘lunatics’ or ‘retards’ or even ‘mental’, which have denigrating connotations, hence rendering a sense of shame and apprehension to be open about it. But, where can some of this be traced to? There’s a lot of economic recession in the country and the way it impacts the job market, further damages the quality of life and in turn, deteriorates the mental health of people. This means that even when austerity measures are implemented, spending in the public sector is scrutinized more, so much so that mental healthcare expenditure, which is already not taken too seriously, is often slashed. Subsequently, these cuts often hurt those who experience enduring mental health issues, who are already at a disproportionate risk of marginalization.

There have been some attempts to destigmatize mental health. Movies like Dear Zindagi, Karthik Calling Karthik, Taare Zameen Par and Judgementall Hain Kya attempt to shed a light on these issues. Nevertheless, one would still see that even if a light is being shed upon this, there'd have to be a lot of follow-up action.

These are some of the reasons that prove that India needs mental healthcare in India on a war-footing basis. Robust mental health is a silent partner in the public policy discourse and, thus, measures must be assessed to do whatever it takes to make it as recognized as possible in India, even if it means subsidizing it, being necessitated by mental healthcare in India and underpinned by the magnitude of socioeconomic disparities. In a country that has an affinity towards medicine as a career, where even undergraduate medical courses in India don’t focus on psychiatry, the problem seems to be at the root.

In 2014, India established the National Mental Health Policy to arm citizens with universal mental healthcare. The Quality Rights Project was established in Gujarat to ameliorate access to mental health services and this was implemented by the Ministry of Health and Family Welfare of Gujarat and the Centre of Mental Health Law and Policy. The incentive is to change attitudes of health workers towards intellectually impaired individuals and, essentially, render holistic care. What could be modified is for individuals to be seen beyond their mental illnesses.

NEED FOR SUBSIDIZATION

“All people with mental disorders have the right to receive high-quality treatment and care delivered through responsive health care services. They should be protected against any form of inhuman treatment or discrimination.”

– Mental Health Legislation and Human Rights, WHO

According to a survey conducted by WHO in 2020, approximately 7.5% of Indians suffer from some kind of mental disorder and this number will keep hiking if the nation’s authorities don’t address mental healthcare awareness as the crucial issue it is. For the longest time, mental disorders have prevailed as the ‘elephant in the room’. Even now, when conversations regarding mental health are finally gaining prominence in social media and tele-counselling has

made the expertise and access of professionals just a call away, people who need it the most still lack awareness about the special provisions created for them. The lower socio-economic groups are one of the most vulnerable to mental health issues. If left untreated, the consequences of depression and other disorders, compounded by poverty can lead to crimes and, thus, increase the social disparity. To the unaware, mental healthcare seems inaccessible and expensive. To ensure that MHC facilities reach the lower socio-economic groups, there needs to be efficient implementation of the District Mental Health Programme (DMHP) and compulsory subsidization in all public hospitals, along with the recruitment of well-trained professionals.

CURRENT PRIVATIZED MENTAL HEALTHCARE

From our interviews, we received an insight into the monetary aspects, as well as some potential flaws in privatized Mental Healthcare (MHC). Some practitioners work under organizations that have fixed rates. The private practitioner charges by the hour, also considering aspects like the city of practice, the expertise of the practitioner and the complexity of the case. According to a wellness counsellor based in Mumbai, there is a misapprehension that all mental healthcare services are expensive, which discourages people from approaching professionals. On an estimate, therapy sessions consisting of 45-50 minutes start from ₹500 and go upwards depending on the nature of the case. Some practitioners offer pro-bono services either independently or as NGO volunteers. At the same time, there is also the case of pseudo-psychologists who aren’t licensed nor highly qualified but still practice privately online or use social media. Another misconception that exists is that government-sponsored MHC and psychologists may not be as effective, in terms of quality. The wellness counsellor discovered, during their position as an observer at a government hospital, that most psychologists there were highly skilled in conducting diagnoses and assessments and gave effective treatment options. One point of contention in government MHC and privatized MHC is that the former may not be able to give the patient the aesthetic environment, the personal attention or rapport building a private practitioner can, due to time constraints and surplus patients.

According to the National Mental Health Survey 2016, it’s estimated that 10% of the Indian population suffer from mental disorders and are in dire need of treatment, while 70% to 92% of these people are unable to access good quality healthcare services. Despite many developments in the MHC landscape over the years, we see that the gap between people who are psychologically distressed and professionals who can help them is glaringly wide, and this is why subsidization needs to be implemented at all levels.

EXISTING GOVERNMENT POLICIES

In consonance with the Sustainable

Development Goal 3, put forth by the WHO, the Mental Health Act, 2017 was a momentous milestone in the evolution of Mental Health Care in India. In effect, the Mental Health Care Act is,

"An Act to provide for mental healthcare and services for persons with mental illness and to protect, promote and fulfil the rights of such persons during delivery of mental healthcare and services and for matters connected therewith or incidental thereto.”

The COVID-19 lockdown was the harbinger of a new era in Indian MHC when the IRDAI (Insurance Regulatory and Development Authority of India) compelled all insurance companies to introduce policies for people suffering from mental disorders by October 1 2020. The Ayushman Bharat Health and Wellness Centres has facilitated free preventative care and treatment at more than 1.5 lakh health and wellness centres across the nation for an expanded range of illnesses, including mental illnesses, as well as covering up expenses up to ₹500,000 per family for lower socio-economic groups, as revealed through census data. With 17 mental disorder and addiction packages, this scheme covers ECT (Electroconvulsive Therapy), RTMS (Repetitive Transcranial Magnetic Stimulation) and blood tests. However, these insurance facilities are only applicable to public sector hospitals and not private ones, while many government hospitals have opted out of this arrangement by asserting their own mental schemes (Singh, 2019). The District Mental Health Programme under the NMHP, implemented in 1996, releases immense grant-in aids for the modernization of Government Mental Health Hospital as well as upgradation of medical colleges. However, to ensure efficient implementation of these programmes and policies, a collaborative care model with a tele-psychiatric mobile van (for example, one in Pudukkottai, Tamil Nadu), better financial planning and holistic training for practitioners should be put into effect (Pandya, Shah,.2019).

WILL SUBSIDIZATION WORK?

It is possible for private health insurance, for example, to be subsidized by the government by efficiently allocating resources in the budget, which would be a sustained investment in public health? There can also be included in employer-sponsored plans, for example, fringe benefits, though it would generally be more advantageous to make it available to all employees. All of this is to say that at face value, subsidizing mental healthcare in both the private and public sector in India is good for the people, but that being said, it does open a can of worms and a whole lot of unanswered questions:

• Would non-citizens be covered?

• Would long-term care be covered, even if it took years or would this indicate only short-term care?

• Would taxes be raised to finance this subsidization?

• Is it possible to transfer private expenditure to the public sector to cover these costs?

• Will there be a cross-subsidy of healthcare and how long would unprofitable care in the long run sustain?

SUGGESTIONS

The goal of subsidization is to create more access to mental healthcare in India. Active policy intervention and allocation of resources by the government is the only way that can be achieved. Stigmatization of mental health is still an issue today, despite the best efforts to shatter pre-conceived notions, so measures must be taken to educate and sensitize people, especially from the lower strata of society, where there exists a series of misnomers on what mental health is. That being said, it’s not enough to simply educate the masses, but vindication can be established by formulating a peer-to-peer network, so individuals know they’re not alone in what they experience, fear and what they’re insecure about. Furthermore, the inclusion of mental healthcare in insurance schemes and plans on a more mainstream scale may also help destigmatize mental healthcare. One way this could be done is by having an accredited social health activist (ASHA) in many areas. The ASHA idea was instituted by the Ministry of Health and Family Welfare in India. This is all contingent on there being effective budget allocation for healthcare, which could also be used to create awareness through campaigns and programmes. Currently, the National Mental Health Program only has a budget of ₹50 crores. The other glaring issue is having a disproportionate doctor-patient ratio, as this gap is an impediment to direct mental healthcare to the masses in India. To deliver services as prescribed in the National Mental Health Policy, it is fortunate that technological advances are abundant in India, where a majority of the youth is technologically competent and adept at using smartphones. Telemedicine is a promising start and we already have ISRO and the Apollo Telemedicine Networking Foundation partnering up to connect hospitals to colleges and disaster relief camps. This means that even in sparsely populated places or in remote areas, mental healthcare becomes that much more accessible. Thus, mobile consultations seem to be a viable solution to expand on. Smartphone applications can help promulgate various symptoms, such as depression, trauma, stress, anxiety, substance abuse, mania and much more. This is the way ahead.

REFERENCES

Llamba, R. L.(2020, February26). What India must do to solve its mental health crisis?ETHealthworld. Retrieved from https://health.economictimes.indiatimes.com/news/industry/what-india-must-do-to-solve-its-mental-health-crisis/74314862

Mental health care in India: Restoring hope and dignity. (2015, October). Retrieved from https://www.who.int/features/2015/mental-health-care-india/en/. Geneva: World Health Organization.

Mental health. (2019). Retrieved from https://www.tatatrusts.org/our-work/healthcare/mental-health. Tata Trusts.

National Mental Health Programme. (n.d.). Directorate General of Health Services Ministry of Health and family services. Retrieved from https://dghs.gov.in/content/1350_3_NationalMentalHealthProgramme.aspx. Government of India.

Pandya, A., Shah, K., Chauhan, A., & Saha, S.(2020). Innovative mental health initiatives in India: A scope for strengthening primary healthcare services. Journal of Family Medicine and Primary Care, 9(2), 502–507. doi:10.4103/jfmpc.jfmpc_977_19

Singh, O. S.(2019, March). Insurance for mental illness: Government schemes must show the way. PubMedCentral (PMC). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6425797/#:%7E:text=Mental%20Health%20Care%20Act%2C%202017,as%20is%20available%20for%20treatment

Sharma, K. S.(2018, October10). We need more mental health care professionals in India. Entertainment Times. Retrieved from https://timesofindia.indiatimes.com/life-style/health-fitness/health-news/we-need-more-mental-health-care-professionals-in-india/articleshow/66146320.cms.

World Health Organization. (2012). QualityRightstoolkit. WHO Quality rights Tool Kit. Retrieved from https://www.who.int/mental_health/publications/QualityRights_toolkit/en/.

Yellowlees, P. W., &Chan, S. C.(2015, October). Mobile mental health care—An opportunity for India. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4683818/. National Center for Biotechnology Information