The Dismal State of Expenditure on Mental Health
Forget providing adequate funds to the mental health sector, the governments don't even spend the minuscule allocations
It is a cliché to state that the mental healthcare sector is acutely underfunded in India. Many articles and social media posts point out this reality every year, especially around the presentation of the Union Budget in Parliament. These articles and posts, some of them written by me, painstakingly inform readers about the negligible funds allocated to mental health. But no one tells us how much of those meagre allocations are spent by the authorities. The purpose of this article is to address this gap as far as the National Mental Health Programme (NMHP) is concerned.
The NMHP has two components: the District Mental Health Programme (DMHP) and the Tertiary Care Programme. The allocation figure usually reported in the media after the presentation of the Union Budget is actually of the Tertiary Care Programme component. Table 1 below presents the utilization rates of this component of the NMHP from the Financial Year 2015-16.
As you can see in the Table 1, in the last three Financial Years, the budget allocated for the Tertiary Care Programme has never been fully used. In fact, the expenditure did not touch double digits in 2018-19 and 2019-20. Even during the year of the COVID-19 pandemic, when the reports of mental health issues rose astronomically, the allocation was reduced from Rs 40 crore to Rs 27.36 crore. Hence, the utilization (data not publicly available yet) cannot be more than 68.4%. (As per the Demand for Grants 2021-22 report submitted by Standing Committee on Health & Family Welfare to the Parliament on March 8, 2021, the Government had spent only Rs. 9.07 crore. Therefore, the expenditure possibly did not touch double digits during the COVID-19 pandemic also.)
Let us come to the rarely reported District Mental Health Programme (DMHP) now. The DMHP component was added to the NMHP in 1996 (if you did not know: the government launched the NMHP in 1982). The objectives of the DMHP are:
To provide mental health services including prevention, promotion and long-term continuing care at different levels of district healthcare delivery system,
To augment institutional capacity in terms of infrastructure, equipment and human resource for mental healthcare,
To promote community awareness and participation in the delivery of mental health services, and
To broad-base mental health into other related programs.
Under the DMHP, the Government of India provides financial assistance up to Rs. 83.20 lakh to each supported district for “early detection, management and treatment of mental disorders/illnesses.” Currently, 692 districts of the country receive this financial assistance.
Chart 1 below illustrates the expenditure under the DMHP. It shows (a) the funds allocated by the Government of India to the states, (b) the funds utilized by the states and (c) the percentage of utilization.
Let us go over some of the salient features of expenditure under the DMHP:
No state government of India has spent 100% of the funds allocated to it under the District Mental Health Programme in the last six years. In fact, no state has spent even 80% of the budget. (Whenever I use the term ‘state/states,’ it includes the UTs also unless otherwise specified.)
There were 222 instances of budget allocation to 37 states in the last six years (37x6 = 222). Only 15 times, the utilization has been 100% or more. That means, in 93.24% of the cases, the state governments did not spend the entire budget allocated to mental health.
West Bengal has the highest utilization percentage of funds under the DMHP at 79.29%.
Only five states of the country have had expenditure rate over 50% — West Bengal (79.29%), Andhra Pradesh (77.87%), Chhattisgarh (63.61%), Karnataka (62.1%) and Sikkim (52.99%).
Only ten state governments have reported expenditure over 40% — the five listed above and Gujarat (48.12%), Tamil Nadu (47.58%), Dadra and Nagar Haveli (44.01%), Meghalaya (42.88%) and Uttar Pradesh (40.9%). It means that 27 states of India did not spend even 40% of the budget allocated under the District Mental Health Programme between 2015-16 and 2020-21.
The National Capital Territory — Delhi — has had the lowest expenditure under the DMHP. Out of Rs 761.83 lakhs allocated in the last six years, Delhi government spent only Rs 0.06 lakh, with the utilization rate standing at 0.000079%. (Since Chart 1 reports figures only up to two decimal points, it shows Delhi’s utilization as 0%.)
In the last six years, 14 state governments did not spend even one-fourth of the total budget allocated under DMHP. These states are Haryana (24.88%), Goa (22.75%), Jammu & Kashmir (20.93%), Himachal Pradesh (20.85%), Daman & Diu (20.51%), Bihar (20.09%), Arunachal Pradesh (15.31%), Punjab (13.69%), Tripura (12.74%), Jharkhand (12.05%), Uttarakhand (11.85%), Andaman & Nicobar Islands (5.49%), Telangana (4.68%) and, already mentioned in the last point, Delhi (0.000079%.)
In January this year, Kerala government was in the news for allocating Rs 64 crore for mental health care. But under the DMHP, Kerala’s utilization rate has been paltry 37.42% in the last six years. Only once has the state come close to spending 100% of the allocation, when, during 2017-18, it spent Rs 99.07 lakhs out of budgeted Rs 100.00 lakhs.
Between 2015-16 and 2020-21, the Government of India allocated Rs 52,101.77 lakhs to states under the District Mental Health Programme. During this period (till 31.12.2020), the states spent only Rs 19,856.56 lakhs. The national utilization rate comes out to a disappointing 38.11%.
The national expenditure rate has never touched 50% in any of the last six years. It was 39.33% in 2015-16, 31.16% in 2016-17, 42.43% in 2017-18, 45.18% in 2018-19, the highest 47.84% in 2019-20 and 21.81% in 2020-21 (till 31.12.2020).
As you can see, the expenditure under the Tertiary Care Programme and the District Mental Health Programme is in an extremely poor state, to say the least. But the mental health advocates and civil society have rarely paid attention to it.
As for lawmakers, the Parliamentary Standing Committee on Health & Family Welfare has taken note of this situation. The Committee, while talking about the Tertiary Care Programme component, said in its Demand for Grants 2021-22 report that:
“The Committee observes that Rs. 50.00 crore was allotted at BE [Budget Estimates] 2018-19 under the NMHP and the same was reduced to Rs. 40 crore in BE 2019-20 and BE 2020-21. However to make things worse, the actual expenditure was Rs. 2.01 crore, Rs. 2.51 crore and Rs. 9.07 crore in 2018-19, 2019-20, 2020-21 respectively. The Committee expresses its deep concerns over the gross underutilisation of funds under National Mental Health Programme followed by dwindling trend of allocation of funds. The Committee is of the view that a constant underutilization over the years under this head clearly points towards the Ministry's inability to comprehend the magnitude of mental health burden in the country. Various studies have highlighted the high prevalence of mental illness in the country but no substantial progress has been achieved to facilitate a robust mechanism for delivery of mental healthcare services. (sic)”
It further wrote:
“The Committee points out that Ministry did not launch any specific programs pertaining to mental health during Covid-19. According to WHO about 7.5 per cent Indians suffer from some mental disorder and WHO predicted that by 2020, roughly 20 per cent of India will suffer from mental illnesses. The Committee is of the view that unprecedented condition during the pandemic would have considerably increased the prevalence of depressive disorders and mental illness in the country. The Committee desires the Ministry to conduct a study to assess the prevalence of mental illness, depressive disorders and suicide death rate in the country including the impact of the pandemic on the mental health of the population. (sic)”
Concerning the District Mental Health Programme, the Committee said that “the system is not well established and gaps exist in the delivery of care on the ground level. The irony is that many states have not framed the State Mental Health Rules and Regulations and thus this programme has not been operationalised throughout the country at the seamless pace. (sic)”
The sad fact is that often, the government does not take seriously such observations made by a Parliamentary Standing Committee. Hence, it does not act to improve the situation.
The mental health sector in India faces a double whammy. On the one hand, the budget allocations for our mental health are minuscule. And on the other, the governments do not care to spend those amounts either. Unless we speak up, this deplorable situation not is going to change.
Do have any feedback for me? If yes, please leave a comment.
Thank you Ajay for bringing this into the forefront. As always, this article too is very insightful. It's indeed sad to know the current state of affairs around the utilisation of funds for mental health in our country. I have some questions about it and would like to hear more from you and others who are into policies related to mental health. ( I'm not sure how relevant they may be, or if they have already been addressed. I'm also not aware of the way these function, and hence thought it'd be good to know more and be informed).
1.Can you throw light on the number of MH professionals working in DMHP, vacancies and recruitment, task shifting and service utilisation?. Though 600+districts have DMHPs, how many of them are actually functional with respect to provision of mental health services?
2. What are the ways in which MH professionals can be part of different committees to enhance the utilisation and involve in research about the same? ( I reckon that you have addressed some of these in one of your previous articles about "participating in public consultation on laws and policies and writing to MLAs/ MPs") How can we push the govt to consider the observations of the Parliamentary standing committee like you have mentioned?
Your articles and work on this have been very helpful to indulge in critical and reflective thinking. Wishing the best for more to come!
Thank you so much for this article. So well researched and explained. My question is on what basis are funds allocated to each state? For example the funds allocated for West Bengal is very less. States smaller in size and with much less population have been allocated more funds. Does the Central government unanimously decide this or do states get a say regarding this?