A strategic shift from programme to mission mode could help India revitalize its government service delivery coupled with flexible funding options and measurable outcomes writes Narender Yadav
With National Mental Health Programme (NMHP) completing four decades of its existence, it makes India one of the earliest countries to have a comprehensive policy framework and an execution plan in place to address the challenge of mental health. Interestingly, India was the only country which strongly pushed and succeeded for the inclusion of mental health in the list of non-communicable diseases at the first Ministerial Conference on Healthy Lifestyles and Non-communicable Disease Control held in Moscow in 2011. However, despite such global accomplishments, a favourable policy environment and a national programme in place, Mental Health has not been accorded the urgency and importance it requires. Infact, Government of India’s “National Institution for Transforming India” (NITI) Aayog Health Index (NAHI), which was framed to meet the United Nation’s (UN) sustainable development goal (SDG)-3, has also neglected MH in its reporting and findings.
A critical analysis of the evolution of mental health programme under GoI and its functioning till now, makes a strong case to deliver India’s National Mental Health Programme in the ‘mission mode’.
NMHP: Hits and Misses
India was one of the major World Health Organization (WHO) member countries to launch its National Mental Health Programme (NMHP) in 1982 in accordance with WHO’s recommendations to deliver mental health services to the people under the framework of general health care system in the community. Over the years, NMHP underwent many strategic revisions and in 1996, District Mental Health Programme (DMHP), was launched in 27 districts, with the aim of extending mental health services to persons with mental illness (PWMI) in the district through the existing healthcare personnel and institutions. Subsequently, it was incorporated with the National Rural Health Mission (NRHM) to ensure better program implementation, regular budgetary allocation, and periodic monitoring.
Though the programme has been partly successful in terms of enhancing its reach among the community, improving service delivery, and getting increased budgetary allocation, however it has been continuously plagued by financial and human resource constraints, in addition to lack of community participation, ineffective training, poor stakeholder partnerships, and lack of a standard monitoring and evaluation (M&E) system. During the last two decades, the coverage and functioning of DMHP has remained non-uniform across the country. Various evaluations and reviews of the programme have highlighted that there has been a lack of leadership at all levels (central, state, and districts) and the success of the program remained heavily dependent on the commitment of the state nodal officers. Invariably, delay in fund allocation, lack of judicious fund utilization by the states, administrative bottleneck at the centre, and lack of enthusiasm of the PHC professionals (medical officer and the supporting staff) has led to the poor implementation of the program. Due to a weak M&E component, there is negligible data available for future planning, implementation and research, thus minimising any possibility of a meaningful review and evaluation.
A Mental Health Policy Group (MHPG) was appointed by the MOHFW in 2012 to prepare a draft of DMHP for 12th Five Year Plan (2012–2017). The group also emphasized many of the findings of previous evaluations performed on the program and came up with a draft for DMHP (under the 12th Five Year Plan). However, policy sluggishness and inertia resulted in very limited change in programme implementation.
COVID-19 has brought the focus on mental health. The Union Budget 2022 also found a mention of the declining mental health among Indians. The finance minister, Nirmala Sitharaman in the budget speech, acknowledged that, “the pandemic has accentuated mental health problems in people of all ages,” leading to the announcement of a ‘National Tele Mental Health Programme’, to “improve the access to quality mental health counselling and care services.” However, without addressing the fundamental problems in the NMHP framework, these piecemeal steps won’t make any significant difference. The programme requires broad based support from the central govt. and continuous monitoring; revamping of the training of the PHC personnel (content, curriculum, and methodology); development of an operational manual for effective implementation of DMHP; a review of the priority mental health conditions covered under DMHP; and incorporation of preventive and promotive mental health services should be part of any comprehensive exercise to revamp DMHP.
On a Mission Mode?
Incorporation of DMHP into the existing National Rural/Urban Health Mission (NRHM/NUHM) was expected to bring about significant change in the functioning of NMHP/DMHP in diverse ways. However, as no evaluation of the programme has been done by the government, it is difficult to understand what has been the impact on program delivery, though there have been some initial reports which highlighted lack of coordination between NMHP and NRHM, and at many places, as NRHM had not included mental health in their agenda. With GoI, including MH services under the umbrella of Ayushman Bharat, it needs to take steps to ensure fast-paced service delivery and seamless integration at the PHC and CHC level healthcare system, something which needs a ‘mission mode’ approach and not the usual programmatic attitude.
Effective service delivery through government health system can only be ensured if there are clearly defined objectives, scopes, implementation timelines, milestones, as well as measurable outcomes. It has been seen in the past that ‘missions’ enjoy considerable attention, within government functioning, and is often supported by designated task forces or focus groups responsible for execution. There is better funding flow and mission mode projects offer a greater degree of flexibility in funding. Generally, missions have a clear execution plan with programme management units, and committees at all levels – national state, district, block, and even gram panchayat/village – ensuring a deeper focus on implementation responsibilities across tiers.
The focus on providing decentralized and de-professionalized community mental health services under the existing general healthcare system is difficult yet an achievable goal. Government need to ensure the availability of and accessibility to mental health care for all. In addition, reducing stigma, promoting community participation, broad-basing mental health with other programs like TB, and reproductive & child health (RCH), building capacities of health professionals and workers, and establishing governance, and accountability mechanisms is a pre-requisite to ensure effective service delivery.
(Author is a senior journalist based in New Delhi and a Mental Health Advocate. Views are personal)