The Erwadi fire in August 2001 brought to the fore the tragic circumstances facing millions of people with mental illness, rousing India's consciousness. Yet, many years later, nothing seems to have changed; only one in 10 people receives appropriate treatment. Mental illness remains neglected and invisible, associated with shame and stigma. Millions suffer in silence without access to basic medicines and health care.
The World Health Organisation (WHO) spearheaded the crusade to incorporate mental health into primary health care in low and middle-income countries in the 1970s. The WHO expert committee reports, their multinational collaborative community care projects, and the Alma Ata Declaration of “Health for all by 2000” formed the platform for launching national mental health programmes. India accepted the need for community care and proposed the National Mental Health Programme in 1982. The programme aimed at ensuring the availability and accessibility of minimum mental health care. The shortage of mental health professionals demanded that its principal strategy be to integrate and deliver mental health care through the primary health care system. Despite good intentions, the programme failed to deliver. The complete lack of estimates of cost and the absence of a provision of budgetary support were important contributors to its failure.
The Bellary project attempted to scale the scheme to the district level and formed the basis of the District Mental Health Programme (DMHP). This demonstration of scalability resulted in the rolling out of the programme across many districts in the country. The DMHP aimed at establishing nodal training centres in each district, training local health professionals for early detection and management, and providing out-patient clinical services and facilities for in-patient treatment. It aimed at erasing stigma through mass education and providing data for future planning. Today, the DMHP operates in over 122 districts.
The Supreme Court was the catalyst for the process, with its interventions on the state of government mental institutions after the Erwadi fire. It focussed the government's efforts on increasing the priority and funding for mental health. The national programme was restructured in 2003, with clearly specified budgetary allocations. The funding increased from Rs.28 crore during the Ninth Plan to over Rs.400 crore in the Eleventh Plan. However, only a small fraction of the monies allocated in the Five-Year Plans has been utilised.
Failures on the ground
The national programme remained on paper while the district programme, after the initial fanfare, remains dysfunctional in many districts. Most experts agree that integration with primary care is non-existent. The lack of in-patient facilities at the district level, non-empowerment of physicians, and the failure of the out-patient clinics to move out of district hospitals make its reach minimal. While the programme has ensured wider availability of essential psychotropic medication, the failure to integrate mental health care delivery into primary care has resulted in limited impact on patient services.
Mental health Gap Action Program
The WHO's new mental health Gap Action Program (mhGAP) is the latest in a series of repackaged solutions to bridge the huge gap between the burden of mental illness and the delivery of mental health care. The core strategies identified by the programme are information, policy and service development, advocacy, and research. Small-scale research projects, which work well in ideal Third World settings, are projected as solutions for national programmes in poor countries. Governments are again being exhorted to implement the integration of mental health care into the primary care delivery system. The different national and physical health priorities, limited funding, lack of general health infrastructure, scarcity of trained health and mental health professionals, and the overburdened health care systems are rarely factored in as is the magnitude of the scaling-up required.
Flawed assumptions
The programmes had fundamental flaws, which ensured their failure. Their Achilles' heel is particularly visible with our 20/20 hindsight, although the flaws were obvious to the more discerning even earlier.
Poor infrastructure, overburdened systems : The primary health care delivery system in the public sector is poor even in managing physical health problems. This is particularly true at the primary health centre, sub-centre and the community level. Although the National Rural Health Mission has increased the infrastructure, physical resources and personnel, decades of neglect, the overburdened system and the poor discipline and morale of the health professionals make the inclusion of mental health care provision in primary care difficult. Such integration is possible only in well-established, functional and efficient systems.
Vertical programmes : Specific programmes, with their limited aims, are often successful when employed in project mode but fail to produce results when rolled out on a larger scale. The political and administrative leadership, financial commitments, the increased human resource, supervision and monitoring, which ensured the success of the pilot projects, are missing in the national and expanded district programmes. While such national programmes are certainly better than no programme, they have not moved out of district hospitals, even in districts where the national programme is operational, and into the community and primary health centres for increasing patient access.
Inappropriate training : The complete lack of training to manage common psychiatric conditions seen in general medical settings is a major lacuna in curriculum. It has spawned many short courses, which transfer knowledge, rather than skill and confidence, to physicians. In addition, most of the courses are set in specialist facilities and employ complex psychiatric perspectives, making it difficult for physicians to translate their knowledge into primary care practice.
Medical education : The global emphasis on specialisation has resulted in a transmission of knowledge without proficiency and confidence during basic medical training. It results in a lack of acquisition of skills required for independent practice. The movement towards specialisation has also eroded the standing of general and family practice.
Professional apathy : It is no secret that the majority of psychiatrists and their professional associations are indifferent to empowering general physicians. The community psychiatry movement always had a second-class status within the discipline. Psychiatrists prefer the safety of specialist institutions to moving out into the community. They favour referrals and consultations rather than transferring expertise to primary care professionals.
Institutional leadership : The community psychiatry movement was led in the 1970s and 1980s by many national institutes and centres of excellence. However, the very ideas of decentralisation and empowerment gradually lost ground and are all but abandoned by these centres, resulting in a leadership vacuum.
Advocacy and technical inputs : Attempts to revive community psychiatry programmes at the national and international levels are more about mental health advocacy and less about technical inputs and guidance. The technology to translate psychiatric research evidence into primary care practice does not exist in poor countries. The idealism of the original primary health care movement, without technical contribution for scaling-up, meant that implementation at the national level was problematic, patchy and unproductive.
The way forward
The repeated failure of such programmes begs the question: “Why do national and international leaders and agencies regularly repackage and reintroduce failed programmes?” The answers seem to suggest that they mistake activity for accomplishment and advocacy for technical leadership and solutions.
The goal of mental health for all, a socialistic ideal struggling in today's capitalistic world, demands a reappraisal of past programmes. Medical education needs to be skill-based to produce competent practitioners. The strengthening of the general health infrastructure, to improve primary health care delivery, is mandatory for the effective integration of mental health into primary care practice. Leadership from politicians, administrators, health and mental health professionals is crucial. The changed reality in India demands new technical inputs, including the use of the private sector. Educating the population about mental illness using the mass media will erase stigma and increase the demand for services.
The availability of effective and affordable treatments and improved national finances have not closed the gap between mental health need and services. A “HIV/AIDS model” of activism, where users, families, interest groups, health professionals and scientists come together with the single aim of service provision, is required for transformation. Slick documents, scintillating launches, stirring speeches and shallow programmes, which repackage failed strategies, are no substitute for hard technical inputs for translating research evidence into primary care practice.
(K.S. Jacob is Professor of Psychiatry at the Christian Medical College, Vellore.)
