A National Mental Health Survey conducted by the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, estimated that approximately 150 million people in India experience one or the other mental health condition. Typically, care access points are limited to clinics, psychiatrists or therapists, all serving essential and distinct purposes. However, concerted attacks on inequality through innovative social interventions that build social capital and decrease the experience of relative poverty and discrimination could influence trajectories of well-being and mental ill health, especially among families living in poverty (India is home to 30% of all poor children globally). These in conjunction with effective health systems, marked by early identification and appropriate care paradigms, could yield ideal results.
A challenging nexus
The gender-poverty-caste nexus opens up a Pandora’s box in an unquiet ecosystem that underestimates the impact of structural barriers on mental ill health. Poverty is feminised in an uninterrupted, ceaseless cycle; characterised by malnourished women and girl children who drop out of school to care for their male siblings or because they are unable to manage their menstruation in schools without toilets or water. The last to access health care when unwell and the first to play caregiver, girls are married off before the legal age even today, often subject to brutality perpetrated by a patriarchal society, ills of dowry and intimate partner violence. We fare poorly (130/150) on the gender inequality index, measured by indicators including workforce participation, access to secondary education and control over reproductive rights.
In this context, it is no surprise that depression and anxiety are twice as prevalent among women than men, and inordinately high among the poor. This cannot be viewed exclusively in medically hegemonic frameworks of a depressive illness. Sociological and philosophical attributes reflective of one’s disempowered status and impoverished internal locus of control are just as relevant.
Poor budgetary allocations
Yet, in the 2017 Union Budget, growth in health and disability budgets remains marginal. Particularly disappointing is the negligible focus on mental health, especially considering India’s suicide rates rank among the highest globally. Unimaginative allocations primarily assigned towards upgradation of premium institutes leave scarce resources to address challenges in mental hospitals, leave alone grappling with issues around long-term care in inclusive community spaces or constructing a robust social care component within the District Mental Health Programme.
Taking into cognisance health and non-health pathways to achieve mental health gains, what if we applied unorthodox and creative options, such as unconditional cash transfers (UCTs), as a stress-reducing, equity-promoting intervention for those among the 150 million in need of financial recourse? Evidence from a rigorous randomised control trial conducted in Kenya by social scientists Johannes Haushofer and Jeremy Shapiro from Princeton University indicates that UCTs resulted in an increase in earnings and other assets, greater nutritional spend, decrease in domestic violence and increase in mental health gains, qualified by an increase in levels of happiness and life satisfaction, and reduction in stress and depression. There was no adverse impact on alcohol or tobacco spend, crime or inflation. Economist Esther Duflo in another study observed that the gains were not unitary — i.e. the person who received the transfer also seemed to influence outcomes, so if the woman received the transfer, better outcomes for girl children seemed possible. Closer home, a survey of the Banyan’s service users’ disability allowance of Rs. 3,600 per annum for over 11 years again indicated enhanced social mobility and sustained engagement with the mental health system.
It is time to discern whether our fiscal climate would allow this. Professor Pranab Bardhan from the University of California, Berkeley seems to think it could, especially since direct bank transfers would eliminate middlemen, corruption, subsidy leakages and related administrative costs. However, UCTs cannot operate independent of, or as a substitute for public goods, namely health and education.
The bi-directional influence between mental ill health and poverty is clear as is the need to make meaningful investments and pursue inclusive development. Experience of autonomy, one’s agency and choice — the allied, yet pivotal benefits of UCTs — are imperative to social change.
Vandana Gopikumar is co-founder, Banyan and BALM, and Professor, School of Social Work, TISS