Examining the Examiners: Mental Health Care and Its Mismanagement in Contemporary Times
Part III and Summary of my critical analysis of Parliamentary Standing Committee report on ‘Mental Health Care and Its Management in Contemporary Times’
This article is the third and last part of my review of the Report. You can read the Part I here and Part II here.
For easier reading and to save your time, I have provided a summary of the recommendations and criticism of the Report below. You may scroll down to read it.
Chapter III: National Mental Health Programme and Mental Healthcare Infrastructure
On 25th January 2023, the National Human Rights Commission said its officials had visited all 46 government run mental healthcare institutions across the country. It said all of the institutions “are in deplorable conditions and depict a very pathetic handling by the different stakeholders. The inhuman and deplorable conditions of the mental health institutes recorded by it across the country, present sorry states of affairs amounting to infringement of the human rights of mentally ill patients. The cured patients are being kept illegally in the hospitals. There is acute shortage of doctors and staff.”
Taking a note of this report, the Parliamentary Standing Committee on Health and Family Welfare asked the Union government to “put concerted efforts to strengthen the infrastructure, capacity, and facilities and upgrade these institutions to generate more human resources” and make them “centres of academic research”.
National Mental Health Programme
The National Mental Health Programme (NMHP) was established in 1982 to provide mental health services at the primary level. The District Mental Health Programme (DMHP) was included in the NMHP in 1996. In 2009, the government added the Manpower Development Scheme under which it has established/approved 25 Centres of Excellence and 47 postgraduate departments in mental health specialities of psychiatry, clinical psychology, psychiatric social work, and psychiatric nursing.
District Mental Health Programme
As per the Report, the DMHP is being run in 704 districts across all 36 states/UTs of the country. In every DMHP team, there should be one psychiatrist, one clinical psychologist, one psychiatric social worker, one psychiatric nurse, one community nurse, one monitoring and evaluation officer, one case registry assistant and one ward assistant. The Report does not tell us if all the covered districts have the required staff.
Further, the government reported that as of 11th October 2022, out of the operational 1,21,649 Ayushman Bharat Health and Wellness Centres (AB-HWCs) in the country, 23,505 AB-HWCs (19%) were providing mental, neurological and substance use (MNS care services.
The Committee however said the funds allocated for the primary and secondary mental health facilities were far lower than required, adding that the expenditure (public and out-of-pocket) for treating mental illnesses was comparatively lower if mental issues could be screened early at the primary health centre and community health centre levels.
It asked the government to allocate more funds to mental healthcare schemes and “develop improved monitoring systems to oversee the functioning of the DMHP and to generate reliable data on the functioning of the DMHP.”
One question the Committee did not raise (and is not often considered in mental healthcare funding discussions) is that none of the states/UTs fully spent funds allocated to them under the DMHP in at least last ten years. Between 2014 and 2020, only five states had spent over 50% of the allocated funds. Delhi government’s performance was the worst and its expenditure stood at 0.000079% of the budget.
Human Resource in Mental Health
The Director, NIMHANS told the Committee that there were about 9,000 psychiatrists in the country. The Rehabilitation Council of India reported the number of clinical psychologists to be 2,840. The Government said it did not maintain data of mental health professionals.
Citing an Indian Journal of Psychiatry paper, the Committee said the nation needed 27,000 more psychiatrists to achieve the desirable number of 3 psychiatrists per 1,00,000 population. It, therefore, asked the government to continue the Manpower Development Scheme beyond 2024 (when it is scheduled to end).
Commenting on the issue of discontinuation of MPhil programmes as per the New Education Policy and its impact on MPhil Clinical Psychology courses, the Committee made the following recommendation:
“The Committee further recommends the Ministry to expedite the solution of the problem which has emanated due to the discontinuation of the M. Phil courses as per the New Education Policy. The Committee believes that Clinical Psychologist is an essential mental health resource and thus suggests that the Ministry may explore re-naming the course or any other alternative and thus relieve the candidates who have already joined for the course.”
Awareness Generation Programmes regarding Mental Health
Under the DMHP, the Union Government provides up to Rs. 4 lakh per year to each district for mental health awareness generation activities. The Committee recommended to “rope in popular personalities who have battled mental issues to spread awareness amongst the masses and encourage people to come out and seek help and treatment.” It also asked the Government to run campaigns on social media to reach adolescents and youth.
But it did not ask how those Rs 4 lakh per year were spent by the districts so far, or if they were spent at all.
Budgetary Allocation for Mental Health
Needless to say, the funding for mental healthcare in India is far from adequate. Neither the Union government nor state governments have ever prioritised budget allocations for mental health. As per the Committee, the scarcity of funds has perpetuated a stark disparity between the magnitude of the problem and the available support systems. Further, it wrote:
“The Committee, after analysing the budget numbers, is of the consensus that the budgetary allocation falls woefully short of meeting the escalating demand for mental health care, and it hinders the improvement of the existing infrastructure. Therefore, the Committee strongly recommends the Ministry of Health and Family Welfare to conduct an in-depth assessment of the current mental health infrastructure, identifying the gaps and deficiencies that need urgent attention. The Committee recommends the Government to allocate funds to establish and enhance regional mental health centres, ensuring accessibility and adequate services in remote areas.”
The Committee has also compared the budget of NIMHANS, Bengaluru with the United States’ National Institute of Mental Health (NIMH). The budget of NIMH for financial year 2023 was about 2.3 billion dollars, while that of NIMHANS was about 85 million dollars only! The NIMH’s budget is about 27 times of NIMHANS’s! The Committee asked the government to increase NIMHANS’s funding substantially so that it can “reach a broader population and invest in advanced research endeavours.”
For National Tele Mental Health Programme (T-MANAS), the budget allocation for current fiscal year is Rs 134 crore. The Committee appreciated the scheme as a “valuable initiative”, but asked the government to take “adequate measures to address the concerns regarding the security, privacy, and management of personal and sensitive data, considering the absence of robust data privacy regulatory frameworks in the country.”
It also cautioned that the scheme “cannot be viewed as a comprehensive solution for long-term mental health improvement, nor should it be the sole focus of the Government's efforts.”
Finally, the Committee asked the Government to include mental health parameters in the Sustainable Development Goals India Index to “track [India’s] progress in this area and identify areas where more work needs to be done.”
Summary of the Review
In this part, I first summarise the findings and recommendations of the Committee and then my critical analysis of its omissions and commissions.
The aim of the Committee, in its own words, was to “examine the landscape of mental healthcare in India, regulatory structure, the status of mental health infrastructure, causes behind the high prevalence of mental health issues and the rising cases of suicides in the country.” As far as I know, it was for the first time that a Parliamentary Committee, outside of demand for grants and bills, took up the topic of mental health for examination.
Findings and Recommendations of the Committee
Relying on the National Mental Health Survey 2015-16 (NMHS 2015-16), the Committee noted that “about 150 million Indians are affected by some type of mental illness” and the lifetime prevalence was 13.7%. It highlighted the huge treatment gap that ranged between 70 to 92% for different disorders.
It pointed out that most of the issues highlighted by the NMHS 2015-16 remained almost the same even in 2023. It flagged the “lack of mental health professionals, weak mental healthcare infrastructure, inadequate and inequitable access to mental health services, stigma and discrimination” as the reasons for huge treatment gap.
The Committee underlined the impact of the COVID-19 pandemic on the people’s psychosocial well-being due to “fear and uncertainty surrounding the virus”, isolation and limited social interactions because of the lockdowns, economics hardships such as loss of employment and financial instability, and lifestyle changes such as blurring of boundaries between personal and professional life resulting from work from home policy.
To assess the impact of the COVID-19 pandemic on mental health, the Committee expressed the need of a new survey and recommended that the National Mental Health Survey - 2, scheduled to be completed in 2025, should be expedited. [NHMS-2 is being conducted in two phases: Phase 1 during October 2022 - Mar 2024 in 18 States/UTs and Phase 2 during April 2024 - March 2025 covering the remaining 18 states.]
As per the NMHS 2015-16, 7.3% of children aged 13-17 years lived with a mental disorder, but the prevalence almost doubled to 13.5% in the cities. The Committee recommended the government to
work with employers and schools to implement workplace wellness programs and mental health education for students, respectively;
add provisions in the second National Mental Health Survey (NMHS 2) to collect data on “mental health and psycho-social well-being of children, adolescents, youth and caregivers”;
train mental health professionals specifically to address mental health concerns of children and youth; and
develop “a dedicated cadre of school counsellors in all schools under the "Manodarpan" initiative”.
Suicides: To reduce the number of suicide attempts by the students, the Committee recommended the establishment of a 24x7 helpline to counsel students who could not qualify for competitive examinations. It asked the government “to strengthen surveillance mechanisms to track factors causing suicides and trends and thus devise mitigation strategies.”
It also underlined that despite Section 115 of the Mental Healthcare Act, 2017 (the MHCA 2017) decriminalising the suicide attempt, the police personnel were largely unaware of this provision and continued to file cases under section 309 of the Indian Penal Code.
National Mental Health Policy 2014: The Committee said that “despite almost a decade since its introduction, the policy's progress has been limited” and “only a few states have embraced and implemented” its recommendations. For the proper implementation of the NMHP 2014 recommendations, the Committee recommended “formulating national and state-level action plan (s)”.
Central Mental Health Authority (CMHA): The Committee noted the CMHA was largely absent from public arena even after five years of existence and did not even have a website. Along with recommending the Government to develop its dedicated website, it asked the “the authority to release its annual report comprising of its vision, objectives, programmes implemented, achievements etc.”
State Mental Health Authorities (SMHA): Their public presence and performance are also similar to those of the CMHA. Although many states have established these bodies, the Committee noted, “efforts related to the appointment of ex-officio and non-official, appointment of CEOs, officers and other staff, development of mechanisms for complaints redressal and establishment of SMHA funds need further push in most of the States.”
The Committee recommended the development of a tracker “to track the implementation status of the establishment of SMHAs, MHRBs [Mental Health Review Boards] and other determinants governing the development of mental health infrastructure and human resources.”
Prisoners with Mental Illness: The Committee noted that as per the NCRB, 1.7% of total prisoners were living with mental illnesses as on December 31, 2021.
It recommended the Government to
(a) provide adequate training to the prison staff regarding mental healthcare;
(b) ensure that adequate mental healthcare staff is stationed in the prisons to address the needs of the inmates; and
(c) conduct periodic training programs for police, judiciary and general health practitioners to sensitise them about their responsibilities and provisions of the MHCA 2017.
Mental Health Insurance: The Committee asked the Government to
(a) “develop a mechanism for monitoring the insurance delivery for mental health issues”;
(b) collect “data on policies covering mental health issues, total claims received for mental issues, total claims cleared, rejection of policies and reasons for rejection.”; and
(c) discourage the insurance companies from excluding outpatient services (such as counselling sessions) and treatment for suicide attempt from their policies.
Rights of Persons with Mental Illness (PMIs): The Committee recommended the government to
(a) expedite the establishment of half way homes and to ensure that the treated patients who “don’t require to stay in mental health establishments are not redesignated to old age or beggar homes”;
(b) establish vocational training centres in all districts and special employment exchange for PMIs; and
(c) develop “a portal for real-time display of half-way homes established in all states and UTs, their capacity and occupancy, the facilities provided and the mental healthcare professionals available.”
Infrastructure: The Committee noted the statement of the National Human Rights Commission that all 46 government run mental healthcare institutions across the country “are in deplorable conditions and depict a very pathetic handling by the different stakeholders.”
It asked the Union government to “put concerted efforts to strengthen the infrastructure, capacity, and facilities and upgrade these institutions to generate more human resources” and make them “centres of academic research”.
National Mental Health Programme (NMHP): The Committee said the funds allocated for the primary and secondary mental health facilities under the NMHP and the District Mental Health Programme (DMHP) were far lower than required. It stated that the expenditure (public and out-of-pocket) for treating mental illnesses was comparatively lower if mental issues could be screened early at the primary health centre and community health centre levels.
It asked the government to allocate more funds to mental healthcare schemes and “develop improved monitoring systems to oversee the functioning of the DMHP and to generate reliable data on the functioning of the DMHP.” It also recommended focusing on community-based care along with bio-medical approach.
To increase the number of mental health professionals in the country, the Committee asked the government to continue the Manpower Development Scheme beyond 2024 (when it is scheduled to end). It also recommended to solve the problem of MPhil Clinical Psychology that arose due to the discontinuation of the M. Phil courses as per the New Education Policy.
To generate awareness regarding mental health issues among the masses, the Committee recommended to “rope in popular personalities who have battled mental issues to spread awareness amongst the masses and encourage people to come out and seek help and treatment.” It also asked the Government to run campaigns on social media to reach adolescents and youth.
The Committee recommended to increase the budget allocations for mental healthcare substantially and asked to “allocate funds to establish and enhance regional mental health centres, ensuring accessibility and adequate services in remote areas.”
The Committee appreciated the National Tele Mental Health Programme (T-MANAS) scheme as a “valuable initiative”, but asked the government to take “adequate measures to address the concerns regarding the security, privacy, and management of personal and sensitive data, considering the absence of robust data privacy regulatory frameworks in the country.” It also cautioned that the scheme “cannot be viewed as a comprehensive solution for long-term mental health improvement, nor should it be the sole focus of the Government's efforts.”
The Committee asked the Government to include mental health parameters in the Sustainable Development Goals India Index to “track [India’s] progress in this area and identify areas where more work needs to be done.”
Criticism of the Report
Perhaps the most significant criticism of this Report is that it adds nothing new to our understanding of mental healthcare frameworks, infrastructure, and funding in the country.
The Committee appears to have seen only what the government showed. It reported only those omissions and commissions which the government acknowledged. From the Report, it appears that the members did not ask relevant and difficult questions to hold the government accountable. In some cases, even basic information was not provided to the Committee. By not pressing for data, the Members of Parliament let the Government escape its responsibility easily.
Citing the NMHS 2015-16, the Committee wrote that “despite years of research and a continued focus on improving health systems, changes seen in the mental health field are few and limited.” My question: where are the “years of research and a continued focus on improving health systems”? Forget continued focus, other than spilling ink on paper in the form of a few laws and policies, I have not seen a single attempt on ground by the Union Government to improve mental health systems.
On government response to mental health issues during the COVID-19 pandemic, the Committee simply accepted its submissions without asking if the reported initiatives — a helpline and a few guidelines — were sufficient. The Committee did not demand data about, for instance, the number of people who called the helpline, their issues, and if they were solved. It did not ask if the guidelines were effective. Most importantly, it did not ask that during a once-in-a-century pandemic, was issuing guidelines and launching a telephone helpline the most a government could do for the mental health of 140 crore Indians?
On the National Mental Health Survey - 2, the Committee wrote: “[it] is of the firm opinion that the findings from the Survey will serve as crucial evidence for policymakers to take informed decisions related to mental health funding, infrastructure development, and evidence-based interventions.”
My question: did the first Survey compelled the policymakers to take informed decisions related to mental health funding, infrastructure development, and evidence-based interventions? If the past is the best predictor of the government’s performance, then who can deny that the second Survey will also not be worth the paper it will be printed on?
Some of the mistakes in the Report seem to show that none of the Committee members read the draft before signing it. For instance, the Committee stated that the “The [the MHCA Act 2017] does not explicitly address the issue of periodic review and updating of advance directives.” But the Section 8(1) of the Act provides for it:
“An advance directive made under section 6 may be revoked, amended or cancelled by the person who made it at any time.”
On page 16 of the Report, there are mistakes in even copying and pasting sentences from the note supplied by the Ministry of Health and Family Welfare.
The figures 9 and 10 on page 34 seek to compare the budgets of the NIMHANS, Bengaluru and the National Institute of Mental Health, USA. But the both figures are identical and provide incorrect information.
In several cases, the Committee did not ask the government sufficient questions about the steps taken for the implementation of legal provisions and schemes it mentioned. For example, the mental health of children and youth after the NMHS 2015-16, the National Mental Health Policy, the rights of the prisoners with mental illness, implementation of mental health insurance, the National Mental Health Programme, the District Mental Health Programme, the National Suicide Prevention Strategy etc. Consequently, it let the government get away without even need to say ‘No Data Available’.
The Committee did not raise the fact that none of the states/UTs fully spent funds allocated to them under the DMHP in at least last ten years. Between 2014 and 2020, only five states had spent over 50% of the allocated funds. Delhi government’s performance was the worst and its expenditure stood at 0.000079% of the budget. The MPs did ask why even the minuscule allocations were not used by the governments.
The Committee did not ask why even after repeated recommendations in its previous reports (especially those pertaining to the demand for grants), the government had not enhanced budget allocations for mental healthcare. It was perhaps the most important question, but the Report neither raises it nor answers it.
The Committee held meetings with NGOs like Manas Foundation, New Delhi and Ashadeep, Guwahati. It claims to have received written submissions from various organisations and associations. Either the inputs provided by these stakeholders were not used or they were not of adequate quality, but their views are not a part of the Report.
Finally, the Parliamentary Standing Committee on Health and Family Welfare had a historic opportunity as, like I stated before, it was for the first time that a Parliamentary Committee, outside of demand for grants and bills, took up the topic of mental health for review. This Report could have resulted in a definitive document assessing the developments and deficiencies in mental healthcare sector in the last decade. Unfortunately, by not attempting to hold the government accountable, the Parliament has squandered away this historic opportunity.