What do Ulysses S. Grant, Abraham Lincoln, Mahatma Gandhi, Winston Churchill, Martin Luther King Jr. and John F Kennedy have in common? Besides being striking personalities, all of them were afflicted by some or the other form of mental illness. Imagine the loss to humanity had the depressive, alcoholic or suicidal struggles of these extraordinary men who have shaped historygot the better of them.
Still taboo
Mental illness has always remained taboo in both public and private discourse. In India, it is a relatively neglected subject even in the eyes of the government. The National Mental Health Policy of India 2014 and the Mental Healthcare Act, 2017 heralded a change in the right direction. The Act is revolutionary in many ways, mainly because of its patient-centric and progressive approach, along with carefully-drafted provisions for transparency and professionalism in service delivery and governance. While the Act is forward-thinking, there is a genuine fear that it will remain a paper tiger like so many other government laws and policies.
Health care costs money. In India, this burden is borne mainly by the patient. Out-of-pocket expenditure constitutes more than 60% of all health expenses. This expense and lost productivity due to mental illness are significant factors that contribute towards poverty. Treatment and care are further compromised when families give up on persons with mental illness because of the social stigma and the financial costs. The mentally ill are often abandoned or institutionalised and left to the mercy of the government to address their medical needs and put them on the path to recovery. Unfortunately, the public health system has also failed this vulnerable group of society.
Scant spending
Historically, India has not invested sufficiently in the health-care sector. In 1950-51 the government had spent 0.22% of GDP on health (Economic Survey, 2016-17). Today, this has number risen to a little over 1% and is well below the world average of 5.99% (World Bank, 2014). The 2015 draft health policy proposes raising public health expenditure to a conservative 2.5% of GDP. However, this is to be seen to be believed as spending on health decreased from 1.4% in 2009-10 to 1.2% and 1.3% in 2013-14 and 2014-15, respectively. Spending further dropped to 1.15% in 2015-16 and is shown at 1.18% (BE) for 2016-17.
Despite the overall gloomy picture of health care, Union Minister of Health and Family Welfare J.P. Nadda’s promise that “budget will never be an issue” should provide a ray of hope for providing access to quality health-care services for all persons with mental illness.
At a multistakeholder roundtable discussion organised by the Observer Research Foundation (ORF) Mumbai and the Centre for Mental Health Law and Policy (CMHLP) Pune with representatives from the Union and State governments, academia and non-governmental organisations, participants shared that usage of funds provided by the Centre was a challenge at the State-level — understandably so. Apart from Gujarat and Kerala, few States have a stand alone mental health policy.
Lack of plans
The National Mental Health Survey (NMHS) 2015-16 says states that the total budget for mental health was less than 1% in most States. Out of this, few States use funds in totality due to a lack of clear mechanisms and guidelines. Mental health financing needs to be streamlined and only Gujarat and Kerala have a separate budget head for mental health. Budgetary support for mental health suffers from a lack of State-level action plans that identify and define specific activities for implementation, budget availability, time lines, responsible agencies and indicators for monitoring outcomes (NMHS, 2015-16).
“Much of the budget allocated to mental health is spent on staff salaries and procurement of medicines.” Despite this, there is a dismal lack of psychiatrists working in rural settings. The ability to hire and retain mental health professionals by the government remains poor. There are 4,000 psychiatrists working in the country and 70% of them practise in the private sector. Mental health programmes are covered under the flexi pool for non-communicable diseases (NCDs) of the National Health Mission. The amount allocated for the flexi pool for NCDs has nearly tripled over the past two years. In 2016-17 it was ₹555 crore and this year it is ₹955 crore. States can use this centrally-sponsored scheme to pay for specialists and more. This resource base has remained relatively untapped by most States.
Financing is critical in the realisation of an effective mental health system. Unless there is clarity, cooperation and shared responsibility between the Centre and the States for allocation and usage of funds, mental health-care reforms will not be achievable.
Shaheeda Kirtane is an Associate Fellow at the Observer Research Foundation (ORF), where she works on public health and policy issues like diabetes, innovation in medical technology, mental illness and hearing impairment