Healthcare

GLOBAL INVESTOR 2.12 — 43
Photos: Steffen Thalemann | Anthony Jeong
practices have been assessed to be effective in low-income settings
such as India’s. These include counseling and psychotherapy (e.g.,
for depression and other behavioral disorders) and pharmaceutical
interventions (e.g., for schizophrenia, dementia and depression).
Evidence, mostly from developed countries, suggests that various
forms of community and family support along with provision of drugs
can also address behavioral problems associated with mental illness
among children. Better population and healthcare provider awareness
of mental illness at the primary care level can help identify cases and
allow timely interventions. Provision of coordinated health services
for mental health and physical health at the primary care stage is
also desirable given the co-occurrence of both sets of conditions in
many patients. Mental health experts largely agree that managing
patients at the level of the community, including ambulatory care
received at primary health centers, is likely to yield high returns in
terms of health gains relative to cost.
Resource constraints complicate the way forward
India lags in the effective implementation of many of these interventions,
in part because mental health has remained a neglected cousin
of the government’s health policy agenda. Available estimates suggest
that mental health attracts no more than 2% of India’s government
health expenditures, considerably less than the health burden it imposes
on the population. Despite the National Mental Health Programme
and a commitment to a community-based mental healthcare
model that dates to 1982, even this limited spending favored hospitalbased
spending. No doubt hospital-based specialized care can contribute
to treating patients with severe mental health conditions. However,
there is a cost to doing so. Hospital-based care isolates patients
and does little to end the stigma attached to mental health. It is also
diffi cult to access, since hospitals tend to be located in urban areas.
A natural solution lies in better integrating mental services at the
primary care level with hospital services, so that only the severe
cases are referred to hospitals. A limited supply of psychiatrists and
healthcare providers with training in mental health, however, adds
an additional layer of difficulty when considering options to expand
community-based mental health services to rural areas. This shortage
is compounded by a reticence on the part of Indian governments to
engage with a rapidly growing private sector, which also happens to
dominate the provision of ambulatory care services as well as “alternative”
or “traditional” therapies. Additional inertia results from healthcare
provision being primarily a responsibility of provincial governments
that tend to be resource-constrained.
India’s policy makers are beginning to recognize the challenge
posed by mental health. For close to two decades, the central government
has left the centerpiece of its community-based approach – the
District Mental Health Programme – essentially adrift. India’s central
Ministry of Health is planning to support a renewed exercise to scale
up this program to cover all districts in the country over the next five
years. A mental health policy group, comprising many experts from
outside the government, is helping to shape this new exercise, after
close consultation with civil society organizations and local and provincial
governments. However, implementation remains a challenge.
And the new strategy offers little in the way of addressing major human
resource shortages, or engaging the private sector. By way of comparison,
one could argue that there is a paradox in which wealthy countries
face a large burden of mental illness despite their wealth. Consequently,
even in such materially developed countries, new approaches and ideas
Ajay Mahal is the Finkel Chair of Global Health
at Monash University. He received his
M.A. from the University of Delhi (1986) and
his Ph.D. from Columbia University (1995).
Until August 2010, he was Associate
Professor at the Harvard School of Public
Health and before that a senior researcher at
the National Council of Applied Economic
Research in New Delhi.