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Friday 25 April 2008

Investments,Cash Flows and mental healthcare in India

Less than 1% of our health budget is spent on mental health

By Soumitra Pathare

Mental health disorders account for nearly a sixth of all health-related disorders. Yet we have just 0.4 psychiatrists and 0.02 psychologists per 100,000 people, and 0.25 mental health beds per 10,000 population. If access to mental healthcare is to be improved, mental healthcare must be provided at the community and primary level

Mental disorders are grossly underestimated by the community and health system in India and across the world. It is estimated that in 2000, mental disorders accounted for 12.3% of disability adjusted life years (DALY) and 31% of years lived with disability. Projections suggest that the health burden due to mental disorders will increase to 15% of DALY by 2020 (Murray and Lopez 1996). Thus mental disorders account for nearly a sixth of all health-related disability.

Despite this, most countries devote 1% or less of their health budgets to mental health services. India spends just 0.83% of its total health budget on mental health (WHO 2001a).

India has a high rate of suicides -- 89,000 persons committed suicide in 1995, increasing to 96,000 in 1997 and 104,000 in 1998, which is a 25% increase over the previous year (WHO 2001b). Hidden in the data on mental health morbidity are two points of particular importance for India:

  • The burden of mental disorders is highest among young adults aged 15-44 years, which is the most economically productive section of the community.
  • It is projected that developing countries such as India will see the most substantial increases in the burden of mental disorders in the next two decades.

Many people are still unaware that there are effective treatments for many mental disorders. For example, nearly 50-60% of persons with depression will recover with treatment in three to eight months; with schizophrenia, a combination of regular medication, family education and support can reduce the relapse rate from 50% to 10%. There is also sufficient evidence to show that adequate prevention and treatment of mental disorders can reduce suicide rates whether such interventions are directed at individuals, families, schools or other sections of the general community (WHO 2001c).

In spite of the high burden of mental disorders and the fact that a significant portion of this burden can be reduced by primary and secondary prevention, most people in India do not have access to mental healthcare due to inadequate facilities and lack of human resources. India has 0.25 mental health beds per 10,000 population. Of these, the vast majority (0.20) are in mental hospitals and occupied by long-stay patients and therefore not really accessible to the general population. There is also a paucity of mental health professionals. India has 0.4 psychiatrists, 0.04 psychiatric nurses, 0.02 psychologists and 0.02 social workers per 100,000 population. To illustrate the level of under-provision, Indonesia , a low-income-group country from the Asian region, has 0.4 beds per 10,000 population and 0.21 psychiatrists, 0.9 psychiatric nurses, 0.3 psychologists and 1.5 social workers per 100,000 population (WHO 2001a).

India has a community mental health programme that consists of integrating basic mental healthcare into general healthcare services by training primary healthcare personnel in mental healthcare, providing adequate neuropsychiatric drugs in primary care settings, supervising primary healthcare staff and establishing a psychiatric unit at the district level. The programme is being implemented in 22 districts in the country and covers around 40 million people, which is approximately 5% of the population. This programme will be extended to 100 districts over the next five years but will still only cover 150 million people, or approximately 15% of the country's population.

Thus, the key priority for mental health in India is addressing the accessibility issue. Policy interventions are needed to increase the level of access of the entire population to appropriate and quality mental health services.

How can access be improved?

First it must be acknowledged that improving access requires additional financial resources. There is an absolute as well as relative (to other health sectors) under-provision of financial resources for mental health that needs to be urgently corrected. Within the health budget it is imperative that allocation to mental health be increased, taking into account the burden of mental health problems. As noted above, India spends only 0.83% of its total health budget on mental health.

It is difficult to know the exact break-up of spending, as India does not have a separate mental health budget. However, details of mental health spending are available for one Indian state, Gujarat . In Gujarat , the total allocation towards mental health works out to Rs 82 million out of a total health budget of Rs 8,562 million. Of this Rs 82 million, Rs 37 million is spent on mental hospitals, Rs 34 million on medical colleges (presumably departments of psychiatry in medical colleges) and Rs 5 million on district hospitals (Mission Report, 2003). It appears that Rs 2.15 million under 'central sponsored schemes' is the only outlay on a community programme. About 67% of the total expenditure is on salaries and 20% on medicines and supplies.

Many countries spend much more on mental healthcare as a percentage of total health spending. For example, Malaysia spends 1.5% of its total health budget, China 2.35%, South Africa 2.7%, Australia 6.5% and New Zealand 11% (WHO 2001a).

Integrating mental health with primary care

Integrating mental health services into primary care is the only viable strategy for quickly increasing access to mental healthcare. Services provided through primary care also have higher acceptability within the community. There is less stigma associated with seeking help from primary healthcare services because these services provide both physical and mental healthcare. Community-based primary care services are also less likely to result in human rights violations for persons with mental disorders. Most such violations have occurred in institutions.

For integration to succeed it is important that primary care staff have the appropriate training and skills in providing mental healthcare. Primary care staff are already overburdened with multiple healthcare programmes. If they are to take on additional mental health work, the number of primary healthcare staff will have to be increased. Adequate support and supervision of primary care staff by mental health professionals is essential if integration is to succeed.

Availability of psychotropic drugs at the primary level

Psychotropic drugs provide an essential first line of treatment for mental disorders as they can reduce symptoms, shorten the course of mental disorders and prevent relapses. Psychotropic drugs should be included in the essential drugs lists so as to improve their availability at the primary care level. Legislative and policy changes may be necessary because only psychiatrists are authorised to prescribe many psychotropic drugs. If primary care integration has to work, primary care health professionals should be allowed to prescribe and have access to psychotropic drugs.

The indicative costs of drug treatment for mental illness is quite low compared to many other chronic medical conditions. For example, the indicative drug cost of treatment for schizophrenia is Rs 1,380 for three years; for bipolar disorder it is Rs 6,000 for three years and for depression it is Rs 1,300 for one year. These costs are based on retail pricing of drugs -- bulk purchases by organisations are likely to cost at least 30% less. There are also many low-cost providers of psychotropic medications who can provide these medicines still cheaper.

There is unlikely to be a significant impact of WTO patent protections coming into play in 2005 in the short-term as most of the drugs are already available in the Indian market. In the long-term, as new drugs are discovered, there may be a cost impact or non-availability in the Indian market. At the moment it is difficult to estimate this cost impact.

Increasing the number of mental health professionals

Increasing the number of mental health professionals is another area that needs urgent attention. Along with an absolute increase in the number of mental health professionals, the ratios of various mental health professionals should be balanced. India has a top-heavy and skewed distribution of mental health professionals, with nearly 10 times as many psychiatrists as psychiatric nurses, and nearly 20 times as many psychiatrists as psychologists and social workers. In most countries the ratios are the reverse, with 10-15 times as many psychologists, psychiatric nurses and social workers as psychiatrists. Unfortunately, there is no professional body that has overall training responsibility for mental health professionals. Professional psychiatric training is controlled by agencies dealing with medical education and training such as the Medical Council of India, National Academy of Medical Sciences and the like, while nursing education and training is the responsibility of the Nursing Council, and psychology and social work training the responsibility of university departments of psychology and social work. Many psychologists and social workers do not get any hands-on clinical training, as their courses are almost entirely classroom-based. There is a need for closer collaboration and co-operation between the various agencies involved in training different mental health professionals. For example, psychologists and social workers need clinical training in working with patients with mental illness -- this can only be done in medical departments of psychiatry, which historically have only been involved in training medical professionals. It is important that university departments of clinical psychology and departments of psychiatry work together to train all mental health professionals.

Inter-sectoral collaboration

Inter-sectoral collaboration provides another opportunity for improving access to mental healthcare. Inter-sectoral collaboration includes collaboration within the health sector and outside the health sector, as well as collaboration between the private sector, NGO sector and public sector. For example, there are many general practitioners in the private sector who can provide community-based care, with adequate training and supervision. Psychiatry departments in public sector medical schools could collaborate with these general practitioners to provide training and supervision and thus exponentially increase access to mental healthcare.

Within the health sector, collaboration with other health programmes such as those addressing HIV/AIDS and maternal and child health provides the opportunity to improve access, especially to vulnerable sections of society. Many NGOs have community-based programmes, and effective collaboration between the mental health sector and the NGO sector could help improve access to mental healthcare. For example women's mental health issues, including depression, could become part of a wider programme addressing domestic violence. Masum, an NGO working with rural women in Maharashtra , has decided to integrate mental health issues in all its programmes. Its staff (120 of them) will be trained to detect clinical depression in the community and in basic listening and communication skills. All staff will be trained to assess the risk of suicide. A smaller proportion of the staff (approximately 20) will be trained in specific psychotherapeutic methods and a basic understanding of psychotropic drugs. This is backed by a general physician prescribing medicines if necessary. They also have access to a psychiatrist who is mainly involved in training and supervision and will see only the most seriously ill persons. This way, most of the clinical work is done by community-based staff within the community and the medical professionals are only utilised for serious problems where medication or admission to hospital may be necessary.

Community participation and awareness

It is essential to involve communities, families and users in developing and delivering mental health services. This leads to the development of services that address people's perceived needs and are therefore better utilised by them. Community participation also has the added advantage of tackling the stigma and discrimination associated with mental disorders.

Increasing public awareness about the burden of mental disorders and the availability of quality treatment is essential to reduce barriers to treatment due to inadequate knowledge about mental health services. The media can play a role in highlighting the availability of effective and safe treatments for mental illness. It can stop using negative language when referring to people with mental illness (for example the use of words such as "crazy, mad, lunatic") and also spread information on the symptoms of common mental disorders. Public health departments also have a responsibility to disseminate information on the identification of common mental disorders and the availability of help at the primary care level. Many people who are aware of their own mental illness will not seek help because they fear they will have to approach a mental hospital and also fear the stigma of having a mental illness. It is important to assure them confidentiality and availability of mental healthcare at the primary level.

Mental health policies

Finally, it is important that we develop mental health policies, programmes and legislation to increase access to mental healthcare and promote respect for the human rights of persons with mental disorders. India 's mental health law is very inadequate and in many instances acts as a barrier to accessing mental health services. We need a modern mental health law that gives priority to protecting the rights of persons with mental disorders, promotes development of community-based care and improves access to mental healthcare. The legislation in India does not promote community-based mental healthcare and widespread access to mental health services. There is no specific law requiring the creation of community-based services in the Mental Health Act, or incorporating mental healthcare into primary healthcare. There is no explicit legislation requiring the informed consent -- oral or written -- of a patient for medical treatment upon admission under voluntary or involuntary circumstances. There are no safeguards or review mechanisms for involuntary treatment of patients, regardless of how they were admitted into a psychiatric facility. And, lastly, Indian penal laws still regard attempted suicide as a criminal act. Thus patients who have attempted suicide are liable for prosecution. In reality, no one has yet been prosecuted for attempted suicide but this provision gives the police an opportunity to harass people who actually need help and treatment. There is enough anecdotal evidence that the police extract money from patients and their relatives, threatening them with prosecution and publicising the fact that they attempted suicide. Thus we have a peculiar situation here -- the state will not provide medical help for what is clearly an act arising out mental illness, but is eager to prosecute vulnerable people who need help.

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