The Union Budget 2021-22, that came out on February 1, proposed a corpus of Rs 71,269 crore for Ministry of Health and Family Welfare. This also includes the budget for mental healthcare – a total of Rs 597 crore. One would expect that a good chunk of this would be for the National Mental Health Programme, which is a national government scheme, as it is applicable and accessible – at least in theory – countrywide.
However, only seven percent of the mental health budget has been allocated for the NMHP; while a majority of it has been set aside for two institutions: Rs 500 crore for Bengaluru based National Institute of Mental Health and Sciences (NIMHANS) and Rs 57 crore for Lokpriya Gopinath Bordoloi Regional Institute of Mental Health in Tezpur. . Overall, the budget for the NMHP has remained the same as last year – Rs 40 crore.
For FY22, Finance Minister Nirmala Sitharaman said that health and wellbeing are one of the key pillars of an Atmanirbhar Bharat (self-sufficient India). However, experts say that proposing only Rs 40 crore for NMHP will leave India unprepared and unable to deal with the requirements of the population, especially with the added mental health impact and fallouts of the COVID-19 pandemic.
Dr Edmond Fernandes, a physician and CEO of the CHD Group, a public health organization, said that while “giving majority funds to selected institutions will definitely strengthen the institutional capacity, it will paralyse resilience building with diversity.”
“In a post COVID-19 world, mental health is the next pandemic with increasing social isolation, work from home, and a stronger e-presence over ‘e-motional’ presence that drives our lives. The budget should be inspired to combat the next pandemic - mental health. In this context, the approach to mental health needs to assume a preventive role and not a curative positioning alone. Mental health financing is one thing, but mental health management is entirely different,” he says.
Paras Sharma, a psychologist and founder of The Alternative Story, an organisation that also offers therapy services with a sliding pay scale, points out that prioritising national mental health institutes over the NMHP impacts diverse approaches to mental health. “This ensures that only mental health practitioners (MHP) who subscribe to certain models have an advantage because they are from these big institutions that are regulated by the state.”
Experts also say that it is less likely that MHPs from big institutes will go to PHC level or community level programmes, and are more likely to set up private practices in cities, which adds to inaccessibility of mental healthcare.
Paras points out that there has always been a trend of allocating big funds for big institutions rather than looking at mental health at the block level and the Public Health Centre (PHC) level.
“The problem is that whatever little budget does come at the state level for PHCs for mental health, because there isn’t enough awareness, push, and there is scarcity of MHP. There is just one general practitioner at the PHC, who may, in some cases, ask a patient to go to a district level hospital for mental health concerns because there isn’t an MHP at the local level. But the dropout rate becomes high when one is asked to go from the PHC to the district hospital. Hence, the government thinks there is no demand because there is little caseload, and so, it does not allocate money in the next budget,” he explains.
A majority of the funds being given to centrally controlled institutes like NIMHANS also adds to the lack of decentralisation of mental healthcare. “Because places like NIMHANS keep coming up with one ambitious programme after the other, utilisation is there to show. This leads other states to want to set up the same model – set up one big multispeciality, flashy institute to get the funds. But this is a cost-heavy model; it will be far more effective and accessible and to set up mental healthcare infrastructure at PHC level,” Paras says.
Even the existing NMHP needs to engage further with the private as well as the non-governmental sector to improve accessibility, says Dr Edmond. “Above all, we must build a dedicated cadre of community health physicians and public health professionals skilled in mental health to address it with a multi-pronged approach.”
Dr Edmond adds that it is not merely enough to increase budgets, unless it is accompanied by engagement with grass-root level mental healthcare. “Setting up of counselling centers, driving aggressive promotional health campaigns where people are encouraged to consult with psychiatrists and psychologists in a traditional society that thinks otherwise; investing in community health physicians and public health professionals to strengthen mental health epidemiology as well and engagement in preventive care are crucial.”
It has been pointed out several times before that India’s mental healthcare system had several lacunae even before the pandemic, and the situation has been exacerbated by the pandemic. One of the issues is that mental health is still seen as a ‘non-communicable disease’ by the Indian government, and not as the public health crisis that it is, states Paras. This, experts say, is reflected in the Union Budget as well.
A senior official with the state Mental Health Authority in Karnataka, set up under the Mental Health Act, also admits that more funding is needed in mental healthcare. He argues that while funding institutes like NIMHANS is important to promote robust research and utilise the resources that it has, the government should remember that “good mental health is needed to improve the health of the entire population.” He adds, “While the focus on it has been more of late, more funding is required, even to the states. The authorities also need to remember that implementation of the Mental Health Act also requires money for disbursing salaries.”
Further, the Centre for Mental Health Law and Policy pointed out that the lack of change in the budget for NMHP for the FY 2021-22 “indicates that increased training and capacity building for mental health professionals and upgrading centres of excellence are low priority.” Manisha Shastri, Tanya Fernandes, and Amiti Varma, Research Associates with the India Mental Health Observatory who responded from the Centre, say that it appears that a major portion of this fund will go towards sustaining existing mental health services. The Mental Healthcare Act, (MHCA) 2017 and National Mental, rather than expansion. “The National Mental Health Policy (NMHP), 2014 emphasises that universal access to mental health care and protection of all rights of people who are mentally ill. The present budgetary allocation does not appear to do justice to these commitments.”
The Centre also pointed out that there is a treatment gap of 83% treatment gap in India, which is an obvious impact of continued low allocations for mental healthcare services at the community level. Further, given that mental healthcare requirements are going to become more acute due to the pandemic, “a stagnated budget for the NMHP limits the state’s ability to meet this need.”
“Beyond budgetary allocation for mental health services, other overlapping and related sectors experienced either a reduction in funding or received no funding, such as social welfare schemes (e.g., one stop centres for survivors of Domestic Violence, NREGA, scheme for the welfare of persons with disabilities), the outcomes of which impact the wellbeing of individuals with mental health problems,” the Centre said.
Paras asserts that it would help if the state government revamps who it considers an MHP. As of now, only the Rehabilitation Council of India, a statutory body, can license clinical psychologists and rehabilitation psychologists. “In a resource poor country like India, if a person has a masters in psychology, they will not necessarily be recognised by the government. One needs to be a minimum of an M Phil holder for an institute such as NIMHANS to be certified. Unless we start recognising and including psychiatrists and practicing psychologists as MHPs in the countries and open up positions in districts to them, our needs will not be met.”
Practitioners also say that the government urgently needs to set up bodies that recognise NGOs and community level organisations working in the mental health space and perhaps look at funding them so that they can continue their work. Mass awareness programmes – such as the equivalent of pulse polio awareness – also need to be undertaken.
(Note: This story has been edited after it was first published.)