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The COVID-19 pandemic and the associated uncertainties, such as economic insecurity, loneliness and fear, have exacerbated a mental health crisis alongside the threat of infection. However, mental health practitioners and researchers argue our world was already in the middle of a growing mental health crisis.
According to the National Mental Health Survey 2016, over 10% of Indian adults, approximately 150 million people, live with a mental health disorder and are in need of support services. Moreover, the survey estimates that between 70% and 92% of persons in need of mental healthcare are unable to access quality services. This highlights a huge gap in psychological and social support. Lack of access to quality mental health services, while a public health crisis, needs to also be recognised as an issue of human rights.
The legislative and policy landscape around mental health has evolved in recent years. In the past five years, we have seen the enactment of the Rights for Persons with Disabilities Act (RPDA), 2016 and the Mental Healthcare Act (MHCA), 2017. Both laws provide a robust set of principles that recognise the rights of people with mental illness and psychosocial disabilities. Further, existing policy initiatives and programs, such as the District Mental Health Programme (DMHP) and Ayushman Bharat, are continuing to work to provide mental health services integrated with primary health services.
Access to mental health services
However, the implementation of the DMHP is not uniform and various provisions of the MHCA and RPDA have not been fully implemented yet. Thus, accessing care and treatment is still largely impeded by procedural and financial hurdles. Government sponsored mental healthcare is free or subsidised. However, availing it requires regular visits to government healthcare facilities as the medications are frequently unavailable or only dispensed in small doses. There are time and transportation costs to obtain medication refills for patients with chronic mental illness.
These multiple costs add to the psychological and financial burden already borne by individuals and their families. Few who can afford it, turn to more expensive private healthcare as an alternative option. While the MHCA does mandate insurers to provide coverage for mental illness on par with physical illness, its implementation has been delayed. Financial protections are crucial in a country where out-of-pocket expenditures on healthcare is exorbitant. High recurring expenses cause financial shocks that force families into a vicious cycle of poverty and indebtedness, further exacerbating mental illness.
Beyond economic hardship, multiple layers of discrimination based on gender, sexuality, caste, religion and ethnicity can lead to further marginalisation. Bias and discrimination based on social identity pushes people into a perpetual cycle of exclusion and unequal opportunities, further compounding vulnerabilities and affecting well-being. Unfortunately, many of these biases are reflected in the medical health systems too.
A recent study by Sobin George titled “Reconciliations of Caste and Medical Power in Rural Public Health Services” published in 2019 illustrates caste discrimination in healthcare services in India. The study found discrimination occurs both at the level of infrastructure and treatment where there is insidious, and almost normalized, discrimination in medical interactions. Almost all healthcare providers in the system were from non SC/ST communities, implying a lack of representation and inclusion. The health facilities, used based on identity, had notable differences in infrastructure and provisions in the facility used exclusively by members of the dalit community. And finally, within medical interactions, the respondents reported experiencing differential treatment by higher-caste health workers. Limited touch, an attitude of avoidance and apathy, and insufficient time for consultation would lead the respondents having to make “several visits for the right diagnoses”. All these factors shed light on the myriad ways discrimination takes place within health systems.
In contrast, a few innovative intervention models with a multi-sectoral approach for mental healthcare do exist. One example is Home Again, a housing intervention with support services for homeless women with mental health illness in Tamil Nadu. Another is Swasthya Labh Sadhan, an initiative to involve individuals with lived experiences to co-create their own treatment plans in Uttarakhand. Both have been tested and have reported positive results in parts of India. While such initiatives are promising, until they are prioritized and scaled-up uniformly, the existing systems leave much to be desired.
Limits of the mental health services model and way forward
It is unrealistic, ultimately, to expect the mental health system alone to address the underlying social, political and economic inequities. Accessibility of health services is determined by people’s perceptions of whether mental health services can be a solution to their problem. Very often, the cause of distress is social rather than a ‘disorder’ or ‘disease.’ This is a sharp reminder of the limits of the mental health services. It compels us to recognise that mental health issues are deeply embedded in and intertwined with the unequal world we live in. Social determinants of mental health, such as financial insecurity, unemployment and violence against women, often stand at the root of the problem. Addressing this, through continued intersectoral action and coordination with different government departments and ministries, is crucial.
The ongoing pandemic and the global and national response have left millions more vulnerable than before. And those living with disability or mental illness are further impacted due to pandemic-induced disruptions in mental health services. This global crisis has brought to the forefront the glaring gaps in our health and social systems.
Human Rights Day, December 10, is an opportunity to acknowledge and reflect on how mental health and access to services are deeply intertwined with human rights. There is a need to create and implement policy frameworks and programmes that take a strong intersectoral approach. And to address social, political and economic factors that contribute to poor mental health and act as barriers to the accessibility of mental health services. Advancing human rights and creating favourable living conditions is an important humanitarian goal in itself, and further, is a goal that directly benefits mental health.
Amiti Varma and Tanya Fernandes are research associates working with the India Mental Health Observatory, at the Centre for Mental Health Law and Policy, Pune.