A Critique of the National Mental Health Policy of India 2014 ‘New Pathways, New Hope’

Mani Kalliath, Executive Director, Basic Needs India

An Inspirational Document
The National Mental Health Policy 2014 is an inspiring document. The quote from the Executive Summary captures this inspiration “ This policy does not reduce mental health interventions to merely disease and disability prevention and it takes into account the need for all stakeholders to work synergistically and achieve common policy goals”. The Policy document has attempted to broad-base the perspectives on mental health – the variety of determinants, the needs of diverse vulnerable populations, the requirements for a variety of care models to respond to these needs and the particular lacunae present in the public health system, in the context of a system level response required. Sincere effort is apparent at grasping the complexities, within the present experience and knowledge base. It acknowledges the various social and psychological contexts, leaving their imprint as mental health problems. This is a very welcome direction, opening up a chink in the rigid compartmentalization of the mainstream discourse and a great improvement over earlier documents (especially the Mental Health Act 1987) which have adopted a narrow disease perspective of mental health.  

The basic positioning of the document is located in the medical perspective, as is made clear in the Preamble. Hence the complexities of the mental health sector are attempted to be grasped from this intrinsic position, and they are perceived as ‘cross cutting issues’. This the writer interprets as an early stage of knowledge base development in this sector.

The long term Vision and Goals of this policy document are : - promoting quality of life of the mentally ill persons (PWMI) and carers – towards a sensitized society, respectful of the dignity and personhood of the PWMIs – access to quality, equitable and affordable mental health services – interventions towards prevention of mental illness and their disabilities and promotion of positive mental health – strengthening professionals capacities – strengthening people’s roles in mental health. The policy paper have segments/sections on a) ‘Values and Principles’, underlying b)  ‘Cross cutting issues’, analyzing the broad determinants of mental ill-health and their imprint on the  problem situation c) the ‘Systemic deficits’, of the governmental responses presently d) ‘Strategic Directions’,  the priority areas for strengthening e) ‘Research’ a recognition of the paucity of worked out models and solutions and the need for ongoing research.

This is a realistic analysis of the deficits in the existing responses at the health system level. The ‘Values and Principles’ enshrined are broad based and development sector oriented, respecting the personhood of the mentally ill persons as well as the rights of the affected persons and their ‘carers’.  There is an acceptance of the roles of the various stakeholders, including the community stakeholders and inviting of their participation. The ‘Cross cutting issues’ section sensitively identifies, the various social contexts of marginalization and the mental distress component invariably associated. It acknowledges that  there is grossly inadequate information presently available on these aspects and the need for evidence based strategies. The ‘health system’ based analysis stresses on issues such as, compartmentalization versus need for inter-sectoral collaboration, gaps in the referral systems, neglect of health promotive interventions and importantly the priority for investing adequate funds.

The Policy recommendations are in ‘Strategic Direction’ section and emphasizes development of care services reaching out to the various social vulnerabilities identified-through preventive, curative, rehabilitative and promotive services. The need for diverse care models to suit the diversity in the mental health needs context is emphasized. Innovative ideas are brought in on such interventions, especially those within institutional settings, such as reaching out to the various age groups in the Educational and ICDS institutions. Towards universal access to care, a continuum of care services are advised, both institution based and community based. Integration of such service models at each of the levels of the public health system could be problematic, though. Perhaps as a symptom of the current lack of worked out models and experiences, especially regarding the community level rehabilitative and promotive services, the recommendations in these areas are a bit vague. Under development of human resources, need for sensitization and competence building of the various cadres of care providers are emphasised. Importantly the policy acknowledges “persons affected by mental health problems and their caregivers are an important mental health human resource”. Participation of affected groups are explored in the existing social sectoral programs and in the ‘community governance forums’ being created in the major Public Health Programs.
Having the benefit of access to subsequent documents on implementation strategies, i.e. the 12th Plan Guidelines on District Mental Health Program (DMHP), it is seen that the progressive positioning of the Policy document is maintained. The 12th Plan Guidelines preserves the broader value positions, the health system level perspectives, the immense requirements of human resources development (especially from a non stigmatizing and respecting of the rights of the affected individuals) and the need for building spaces for the involvement of primary stakeholders and community groups. The enhanced funding for DMHP (increased to almost Rs. One  crore per district annually) and generous supports to development of ‘centres of excellence’ at the state, regional and national levels and to psychiatry departments of medical colleges, are indications of the policy commitment. This is a welcome change experienced by the mental health groups (civil society), who have faced obstacles in past efforts at lobbying for a progressive Mental Health Act.

The Concerns
Having painted a positive picture of the processes envisaged in the policy document, it is necessary to state the strong barriers existing, which is unlikely to permit the success of the policy directions. Though there are hints in the policy document recognizing barriers, the reality is far worse (as per the writer’s limited knowledge of the health system). Karnataka is one of the few progressive states, which has implemented the State Mental Health Authority, a requirement of the Mental Health Act 1987. The situation of DMHP in Karnataka, one understands is worse than pathetic. Funding for the existing 4 DMHP programs had been held up (recently released) for several years and they must have been dysfunctional, regardless of whatever reports coming from them claim. Eight new DMHP districts have been sanctioned in Karnataka and Central funds apparently have reached the Karnataka state since over 8 months, yet the funds have remained with the state level authorities and nothing has started at the ground level in these districts. This is by no means an isolated event in one state, as shown up by the fact that half the allocations for DMHP for the whole country, in the 11th Plan were subsequently taken away unspent.  The writer (who does not have direct insights into the functioning of the public health system) recognizes these realities as symptomatic of the strong systemic barriers that will not permit progress, in the spirit of the document.

Two dimensions in the policy environment have not been factored in adequately into the policy document, which could be lethal to the spirit of the document. One is the existing overall policy environment of Privatization and ‘withdrawal of the State’ from direct responsibility taking in social sectors. The large Corporate players have established a strong negative impact on the functioning as well as undermines the efforts at strengthening of the Public Health System and hence, of access of the marginalized segments to quality care and supports. Surely such private players are waiting at the wings of the mental health sector, awaiting the opportune moment. What distortions maybe brought in by such players, in the access of quality care for the most vulnerable segments of mentally ill persons?

Another aspect insufficiently recognized by the Policy document, relates to the reality that there is no mobilization or ‘voice’ presently of the affected people-namely the poor mentally ill persons and their carers, regarding their needs and rights. The issue based mass movements of marginalized people, have not yet come to recognize the significance of mental health to their issues. Even in the ‘People’s Health Movement’ Mental Health (from the people’s perspective) is yet to find a place. It is unlikely that such a ‘voice’ will emerge in the near future. Hence without the ‘balancing’ influence of this stakeholder segment, what will be the distorting pulls and pressures on this emerging mental health policy scenario?