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When Will We Prioritise Our Mental Health System?

When Will We Prioritise Our Mental Health System?

Union finance minister Nirmala Sitharaman speaking in Lok Sabha, March 14, 2022. Photo: PTI

  • Of the Rs 670 crore allocated for mental health, 94% has been allocated for just two centrally funded mental health institutions.
  • On the other hand, the expenditure budget allocated for tertiary level activities under the National Mental Health Programme is only Rs 40 crore – or 6% of the direct expenditure for mental health.
  • Such low allocation stems from a vicious cycle of poor utilisation of previously allocated funds, which can be attributed to several operational and administrative bottlenecks.

Entering 2022, India is still reeling from the psychological and socioeconomic consequences of the ongoing COVID-19 pandemic. There has been a significant rise in emotional distress due to unemployment, depleted savings and financial insecurity. Children were unable to access schools for almost two years, which for many has meant affected learning outcomes, social development and the loss of one nutritious daily meal.

Increases in the prevalence of domestic violence and other forms of social discrimination have become ubiquitous. The National Crime Records Bureau reported a 10% increase in suicides in 2020 over 2019.

The 2022 Union budget presented an opportunity to address these challenges head-on. Unfortunately, budgetary allocations for mental health and other social welfare and security schemes have remained a low priority.

A 2017 study estimated that 197 million people in India – one in seven – live with some form of a mental disorder. Yet there is a treatment gap of approximately 83%, where most persons with a mental health condition are unable to access good-quality mental healthcare.

However, an abysmal 0.78%, or Rs 670 crore, of the total direct expenditure budget allocated by the Union health ministry has been for mental health. This poor allocation exists despite the WHO estimating that the burden of mental health problems in India is 2,443 disability-adjusted life years per 100,000 population, and the economic loss due to mental health conditions, between 2012-2030, is expected to be Rs 75.84 lakh crore.

Delving deeper, of the Rs 670 crore allocated for mental health, 94% (Rs 630 crore) has been allocated for two centrally funded mental health institutions: the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, which received Rs 560 crore, and the Lokpriya Gopinath Bordoloi Regional Institute of Mental Health, Tezpur, which received Rs 70 crore.

On the other hand, the expenditure budget allocated for tertiary level activities under the National Mental Health Programme (NMHP) is only Rs 40 crore, which is 6% of the direct expenditure for mental health. These tertiary activities include the establishment of ‘centres of excellence’, upgrading existing departments of psychiatry and capacity-building through the appointment of psychiatrists, clinical psychologists, psychiatric nurses, etc. across the country.

The low allocation for NMHP’s tertiary activities stems from a vicious cycle of poor utilisation of previously allocated funds, which were as low as 4% in 2018-2019 (see table below). This sub-par utilisation can be attributed to several operational and administrative bottlenecks, including inadequate planning for NMHP activities and poor coordination between disbursing and implementing authorities.

Table: Budget estimate, actual expenditure and utilisation percentage for NMHP tertiary level activities for 2018-2019, 2019-2020 and 2021-2022.

While budgetary allocations for mental health establishments and human resources are important, to make mental healthcare services and treatment more accessible, we need to strengthen delivery of mental health services at the primary and community levels, through a “community-based model” of service delivery.

The District Mental Health Programme (DMHP) is the key service provision component under the NMHP, to integrate mental healthcare with general health services at the primary and district levels. The allocation for DMHP is under the “flexi-pool” mechanism for Non-Communicable Diseases, a scheme under the National Health Mission.

When answering a question raised in Parliament on February 4, 2022, the health minister stated that the ministry was providing up to Rs 83.2 lakh per district per year to the DMHP, in 704 districts.

On February 9, 2022, in response to another question in Parliament, the home ministry revealed that an alarming 25,000 people died by suicide due to unemployment, debt and bankruptcy in 2020. It mentioned the DMHP as an intervention to address this problem through its suicide prevention services. However, the budgetary allocation to the DMHP suggests the opposite, that it is not a priority for the government.

Such a large number of suicides due to social, economic and cultural factors highlights that mental health and wellbeing need to be understood in a broader, intersectoral context – affected by one’s employment status, gender, caste, religion and several other identity markers. Axiomatically, a robust and responsive mental health system recognises and addresses these crucial determinants of health and well-being.

In India, welfare and rights-based schemes such as the Mahatma Gandhi National Rural Employment Guarantee scheme, the PM Garib Kalyan Yojana, the PM POSHAN (midday meal scheme) and others are vital because they provide a crucial lifeline for several marginalised and vulnerable groups. Considering the negative impact of COVID-19 on social and financial safety, the overall budget outlay for social sector and social welfare schemes should have been higher, but has in fact experienced a decline in real terms.

Nevertheless, there have been some initiatives within the mental health sector in this year’s budget. First is the announcement of a National Tele-Mental Health programme. Under this programme, the health ministry is to launch 23 tele-mental-health centres under the authority of NIMHANS. The aim of these centres will be to improve access to mental healthcare services by scaling digital capabilities and tgus reach more people in need in remote areas.

Plans to operationalise the programme should consider and address the ’digital divide’ and problems around accessibility in low-resource settings, data privacy and ethics in maintaining patient confidentiality as well as the psychosocial needs of individuals beyond prescribing medicines. Currently, the exact outlay for this newly announced programme is unknown.

Another important announcement in the budget speech was a tax relief granted to parents or guardians of persons with disabilities. Earlier, a tax relief on the sum received on life insurance was provided after the demise of the subscribing parent or guardian of a person with disability. With the new announcement, the payment of annuity or a lump sum amount to the person with disability henceforth can be made available during the lifetime of the parents or guardians upon their attaining the age of 60. This change was made to allow persons with disability to collect the sum in the lifetime of their parents or guardian itself.

Even before the COVID-19 pandemic, mental healthcare had been neglected for a long time in India. According to the WHO, roughly 20% of India’s population is likely to experience some form of a mental illness, yet little has been done to ramp up efforts to strengthen mental health systems. Budgetary allocations for mental health services shouldn’t be restricted to a few institutions within urban centres. Instad, investments must be made within communities to ensure last-mile service delivery through programmes like the DMHP.

In addition, state and the Central governments must tackle utilisation-related bottlenecks to ensure better allocations in the future. Finally, mental healthcare financing should reflect the rights-based intersectoral principles and priorities of the National Mental Health Policy 2014 and the Mental Healthcare Act 2017, thus ensuring all-round well-being – psychological, social and economic – for everyone.

Sayali Mahashur and Tanya Nicole Fernandes are research associates with Centre for Mental Health Law & Policy, Indian Law Society, Pune.

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