“But I’m Essential”: My Mental Health Wish List for Budget Session 2021

Although I’m almost sure that none of my wishes would be fulfilled by the government, I am still writing this article.

During the last week of the year 2020, The Atlantic magazine published an article by Olga Khazan entitled The Problem With ‘Uber for Therapy’. The article began by describing the firing in November of seven mental-health coaches employed by AbleTo, a company “which provides mental-health services to people through apps, video chats, and calls, like Uber for anxiety.” As their manager informed the mental health coaches about the termination on a Zoom call, Khazan describes, they “listened in stunned silence. Finally, one of [them] cried out, in a reflexive koan of pandemic anxiety, “But I’m essential!”

As the COVID-19 pandemic engulfed the globe and lock downs became a norm, ‘essential workers’ and ‘mental health’ quickly came under the spotlight. The workers received public appreciation. The Indian government and other institutions launched several telephone helplines. Several bodies prepared lists of mental health professionalswho were willing to provide free services to anyone in need. But despite their services being absolutely necessary during the once-in-a-century pandemic, thousands of health professionals around the world were let go as their roles “no longer fit the business models” of employers.

To me, ‘essential but unemployed’ mental health professionals became a profound paradox of the year 2020.

In India, there was no such paradox as no central government had ever paid much attention to mental health and hence, the professionals in the field had come to expect virtually nothing from the governments. However, this year may be — and must be — different. If a pandemic — which woke up millions of people each day to realities of mental health crises within their four walls — cannot force a government to pay attention and allocate significant resources to mental health sector, then nothing ever can. On this note, here are my minimum expectations from Union Budget 2021:

1. Financial allocation: So much ink has been spilled to lament negligible public expenditure on mental health that the facts have become cliché.

The budget allocation for National Mental Health Programme (NMHP) — which is run “to ensure the availability and accessibility of minimum mental healthcare for all” with a focus on “the most vulnerable and underprivileged sections of the population” — during the financial year 2020–21 was only Rs 40 crore. For a population of about 138 crore! 29 paise for every citizen! (in case you forgot, the coins of and under 25 paise are no longer legal tender). The mental health budget is less than 0.5% of the government’s total health budget. This consistent under investment has led to severe deficit of mental health establishments, clinical psychologists, psychiatrists and other personnel in our country. Moreover, as Government’s Economic Survey 2021 shows, such little public expenditure on health leads to high out of pocket expenditure and poverty. The proportion of out of pocket expenditure on health in India is one of the highest in the world. Also, while on one hand, we keep repeating that India needs many more mental health professionals, ironically, the existing ones (particularly fresh graduates) find it extremely difficult to find desirable employment!

The fact is that we need a substantial allocation for mental health sector. How much exactly though? A 2019 paper in Indian Journal of Psychiatry estimated that the government needed to spend Rs 94,073 crore annually to implement Mental Healthcare Act 2017 (MHCA 2017). A National Academy of Psychology statement last year asked for at least Rs 50,000 crore allocation for mental health in Budget 2020.

Given the competing priorities due to the impact of COVID-19 pandemic, I’d go even lower: just Rs 10,000 crore for the NMHP. In my view, that would be a good start.

2. Insurance and Data: In a country, where the per capita income is Rs 1,26,968, insurance has to be one of the primary ways to pay for medical treatments. After the MHCA 2017 mandate that “every insurer shall make provision for medical insurance for treatment of mental illness on the same basis as is available for treatment of physical illness” and Insurance Regulatory & Development Authority’s instructions, the insurance companies have at least removed mental illnesses from the exclusions in their offerings.

However, the treatments for mental disorders are different from those of physical illnesses in many ways. There are issues such as the duration of hospitalization may be long, even extending to months; when the “treatment is given involuntarily, and it is complicated by issues of noncompliance, which may lead to multiple relapses and increased number of hospitalizations;” pre-existing mental illnesses; post-hospitalization care; outpatient services such as psychotherapy and counselling; coverage of post-suicide attempt treatment; and confidentiality in case of sharing medical records with the insurer.

What’s a good way then to provide insurance cover for mental illnesses? We do not have answers because we do not have appropriate data. Even during the pandemic, the government did not collect any data on mental health problems faced by the people. This negligence needs to stop and the government must focus on collecting good quality data, since without data, the policies framed are at best good-intentioned hodgepodge. I hope the Finance Minister Nirmala Sitharaman pays attention to issues of insurance and data in her budget speech. (Actually, I have no hope of that happening but still hoping.)

3. Mental health helpline: The need of a 24/7 mental health helpline became starker during the pandemic. So much so that multiple ministries of the government launched their helplines. Let us build on this foundation and launch a three-digit helpline. Last year, the United States Federal Communications Commission approved 988 number for their country’s national suicide prevention helpline. Instead of long 1800 numbers, we too need a short three-digit number so that it is easy to remember and can be dialled quickly for immediate help and assistance. Also, let’s not have overworked and underpaid staff for the mental healthcare helplines.

4. Discussion in Parliament on mental health: The discussions and debates in our Parliament are usually focused on unemployment, rising inflation, economy, corruption, national security, etc. The closest Parliament comes to discussing mental health is when talking about farmers’ suicides, but even in those debates, I have never seen an MP mentioning the words “mental health” (which is also appropriate as farmers’ suicides have more to do with poverty and debt than the mental health). There is a vital need for our lawmakers to talk about mental health in Parliament. For once, can we have such a discussion?

5. National Commission for Allied and Healthcare Professions Bill 2020: We know that in India, psychology profession is not regulated (except clinical psychology under Rehabilitation Council of India). As a result, there is no quality control in curricula & training, no standardization, and the worst of all, anyone can call themselves a psychologist/counsellor. Moreover, many other medical specialties are not regulated. To solve this issue, the government brought in Allied and Healthcare Professions Bill, 2018 and then its revised version National Commission for Allied and Healthcare Professions Bill 2020 (NCAHPB 2020).

Despite government’s good intentions, the Bill is a death warrant for mental health. It doesn’t like the term “mental health” and prefers “behavioural health sciences,” but that would cause conflict with, inter alia, MHCA 2017 and National Mental Health Policy. Psychology is not an independent category and there is an acute under representation of psychologists in the NCAHPB 2020. The titles used for professionals are not standard. There is no provision to recognize current mental health practitioners with MA/MSc Psychology degrees and years of experience as licensed professionals. It appears that no psychologists were consulted by the government and the Parliamentary Standing Committee on Health & Family Welfare. It also appears that the government has attempted to impose realities of other medical professions on psychology, and consequently, we have a Bill which would spell doom for psychologists. Therefore, I hope the government withdraws the NCAHPB 2020 during the Budget Session and starts work to bring a legislation for an independent National Psychology Council.

This is my mental health wish list for the Budget Session 2021. While as a realist I understand how none of these wishes would be fulfilled by the government, I still choose to hold on to a faint hope that mental health shall finally find its rightful place on our policymakers’ agenda. Otherwise we would have to listen to the Finance Minister’s speech in stunned silence as she completely ignores mental health and helpless listeners can then only cry out, in a reflexive koan of pandemic anxiety,

“But mental health is essential!”

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[This article was first published here before the presentation of Union Budget 2021-22.]