The Context

BALM - Mental Health
Mental health problems are amongst the most important contributors to the global burden of disease and disability. Mental and neurological conditions account for 12.3% of disability adjusted years lost globally and 31% of all years lived with disability at all ages and in both sexes. In a sharp contrast to the magnitude of the issue, less than quarter of the people requiring mental health care receive necessary services in both Low and Medium Income Countries (LMICs) and High Income Countries (HICs), and mental health receives only 1% of funding from national health budgets around the world. The intersection between mental ill health and poverty is pronounced in the Indian context; the World Bank estimates 400 million persons living below the poverty line, and 841 million living below US $2.00 per day with inadequate access to basic needs such as housing, nutrition, education and employment- all critical to one’s well- being. In India, about 65-70 million people appear to be in need of mental health care. Besides the availability and access to appropriate services, stigma and community resistance affect help seeking behaviour.

According to the WHO persons with disabilities in poverty are among the poorest and most marginalised communities. The evidence of social determinants affecting mental health exists in plenty – social phenomena such as homelessness, poverty and insufficient social support systems expose individuals to adverse experiences that can trigger mental health issues and also determine the extent of success in management of recovery. Work participation, quality of familial relationships and community linkages, discrimination on the basis of gender, age, caste and poverty affect the quality of mental health outcomes. Hence there is a critical need to cultivate multi-dimensional and multi-pronged approaches to address these issues simultaneously at the individual, family and community levels. In India and other Low and Middle Income Countries (LMICs), there is no organised approach to comprehensively address mental health care issues in a sustainable and cost effective manner.

Several barriers persist in the context of countries such as India in reaching these intended targets to reduce burden of mental disorders. Deficiencies in public health and social care infrastructure hinder the scale up of community based interventions. The District Mental Health Programme (DMHP) in India has therefore remained largely on paper and implemented in the form of overburdened and isolated camps dispensing medication. Further, less than 1% of the budget in India is allocated for mental health, with an overwhelming bias towards state tertiary care services that more often than not carry the legacy of asylums from the colonial era. This paucity in availability, affordability and quality of services, is further conflated by stigma, incongruence of services with prevailing sociocultural norms and socio-economic structural barriers may be persistent deterrents to addressing mental health. Structural barriers of poverty and marginalisation are particularly relevant to note in the context of mental health - association with mental ill-health for those at the margins higher than the general population and recovery process is substantially linked to addressing these intractable barriers.

Substantial deficits are present in the quantum of human resources available to offer mental health services - as per data from a 2002 nationwide survey, India has only 2 psychiatrists, 1.5 clinical psychologists and 2 psychiatric social workers per 100,000 population. Educated in largely didactic paradigm that relies heavily on a biomedical construct of mental health, in the context of a population with complex social realities that are intertwined with their mental health narratives, such human resources often fall short of necessary knowledge and skills.

Thus the urgent need to view mental ill health within broader frameworks of care that focus on promotion of wellbeing, social justice, equity and rights – the development paradigm. Development as a concept has evolved from almost exclusive focus on national income increments to more contemporary notions of promoting people’s capabilities in order to achieve the kind of lives they have reason to value, encompassing a broad range of well-being goals such as social justice, education, housing and health. 2015 marks the year the world, as organized around the United Nations, reexamine its goals for a new era of development. National and international organisations taking cognisance of this urgent need to initiate and reform mental health systems have strongly advocated for the integration of mental health into the Sustainable Development Goals 2020 (SDGs), reiterating its importance in the health and development discourse. The World Health Organisation (WHO) has underlined the need to focus on human resource development as a key strategy in pursuing this larger vision.

In this context, three critical issues need to be addressed for sectoral change in mental health:

Development of human resources and capacities that are congruent with an ethos of personal recovery, justice and wellness
Development of evidence to inform policy on unique cultural ecology of marginalised populations and justice oriented initiatives to address their mental health priorities
Diffusion of locally relevant, culturally sensitive and pragmatic approaches to care, and re-orientation of existing human resources and services to focus on addressing structural barriers and enabling personal recovery