India’s Mental Health Care Act is one of the most progressive legislations on mental health globally, and should be read as a bill of rights for people with mental disorders. Fundamentally, the Act enshrines equality for mentally ill people with those who have physical health problems in all matters related to health care. Conceptually, it transforms the focus of mental health legislations from supposedly protecting society and families by relegating people with mental disorders to second-class citizens, to emphasising the provision of affordable care, aligned with the preferences and needs of the affected person, financed by the government, through the primary care system.
Involuntary treatment and confinement in mental hospitals, which have historically been associated with profound depravity and abuse of human rights and which have been robustly contested by the Convention for the Rights of Persons with Disabilities, has been greatly reined in with stringent procedures to ensure that these are restricted to the rarest of circumstances with systemic supports to enable the right of the person to make his/ her own decision.
However, it is hard to imagine these visionary ideals finding their way into the grim realities of the lived experiences of the tens of millions of Indians living with a mental disorder and the countless more of their family members and friends who are also affected. The National Mental Health Survey of India (2016), the largest exercise to count the numbers of people affected by mental disorders, reported that one of every ten adults experiences a clinically significant condition. Nearly 90% of these people have received no care at all in the past year.
The recent observation that some of the victims of the horrific series of lynchings in our country were people with mental disorders is a tragic reminder of their vulnerability. Indeed, no other health condition in this country has such astonishing levels of unmet needs for care. Scarcity is the mother of invention, and this is so true of health care innovations in India, a country where the majority of people get too little of the care that they desperately need, while a few get as much care, never mind if it is actually needed, that they can pay for. And the care that many receive, whether too little or too much, is often not aligned with scientific evidence. In the case of mental disorders, for example, only a tiny fraction of the population will have access to brief psychosocial interventions, one of the most effective classes of treatments in medicine.
As with so many other formidable challenges facing our people, the community has been at the heart of innovative solutions. A variety of community actions have illustrated paths to mental health care which is affordable, evidence based, empowering and equitable. Prominent amongst these are the use of community based workers to deliver mental health care.
The community health worker, including cadre such as the ASHA worker and the Auxiliary Nurse Midwife, are the foundation of our public health care system. Indeed, they have played a central role in the success of our public health programmes which substantially reduced maternal and child mortality. Even as they are slowly, but surely, winning these age-old battles, they present a unique human resource to be deployed to helping people with mental disorders to recovery.
Over the past decade, some national health care programmes (such as for adolescent health) and NGOs have begun to task community-based workers to provide low intensity psychosocial interventions. Sangath, an NGO I co-founded in Goa in 1996, has pioneered the design of an entire suite of psycho social interventions for delivery by persons from the local community with no prior professional training in mental health. These interventions have targeted a range of conditions, from autism in childhood, emotional and behavioural problems in adolescents, depression, drinking problems and psychosis in adults, to dementia in older people. Through rigorous public health trials, we have demonstrated, time and again, that such interventions are not only effective but, importantly, highly desired by people who are affected by these disorders. There is no longer any doubt about whether community health workers can be trained and supervised to deliver clinically effective psychosocial interventions. The challenge before us now is how to go beyond pilots and research studies and scale these innovations up in routine health care.
Sangath is currently embarking on a series of projects seeking to achieve these goals, by embedding its proven interventions for delivery through existing community health workers and counsellors of the public system, in partnership with state governments. In New Delhi, we will train ASHA workers to deliver parent-mediated interventions for children with autism. In Madhya Pradesh, we will design digital interventions to train and support ASHA workers to deliver brief psychological therapies for depression. In Goa, we will train primary care based counsellors and community based workers to reduce the burden of depression in the population. Each of these models for scaling up could offer opportunities for wider adoption across the country.
No NGO can ever match the mandate, reach and resources of the state for taking health care to India’s vast and diverse population. For this to happen, we will need a structural rethink in how we plan and implement mental health care. The doctor and hospital-centric approach which dominates must be balanced with a robust investment in community based care, as was done with such great results for maternal and child health.
The recent decision to rebrand the primary health care sub-centre as a Health and Wellness centre, with a mid-level provider trained in community health, offers a major new opportunity. Coordination between mental health professionals, primary care providers and community workers is essential to address the longterm nature of many mental disorders and the need for integrating clinical and social care. Only then will the creativity and science, which harnesses civil society’s talent and instinct to care, be able to play its rightful role in realising the vision of the National Mental Health Care Act.
The author is the Pershing Square Professor of Global Health at Harvard Medical School and is affiliated with the Public Health Foundation of India and Sangath.