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Published on Jul 23, 2020
Improving India’s Mental Healthcare: A Case Study of Kerala

COVID-19 has revealed  the importance of having a robust and well-funded public healthcare system. Research suggests that the subsequent health crisis faced by India will likely be related to mental health — characterised by increased anxiety, depression, substance abuse, and suicides. Hence, it has never been more necessary to integrate mental health into our understanding of public healthcare. The Government of India attempted to do this through measures like the National Mental Health Policy in 2014 and the Mental Healthcare Act (MHCA) in 2017. Although these are significant steps in the right direction, the fundamental problem is with the execution of these policies. In fact, most states don’t even have state-level policies or action plans to ensure implementation. Kerala is one of the few states that has a mental health policy and is also ahead in terms of funding, awareness, adolescent care, and the number of available professionals in most districts. Therefore, it might be helpful for other states to understand the successes and limitations of the Kerala model — so that they can tailor their own state-specific systems. 

What Kerala has done right

Kerala is pioneering mental health integration in schools. If mental illnesses in children are not accurately diagnosed and treated, there is an increase in the probability of health issues in adulthood. The state administered UNARV, a model for adolescent mental health in schools at a district level in 2007. Students with behavioural and academic problems from Class 8 to 12 were counselled by their teachers, who were trained in adolescent developmental psychology, and mental health disorders. If their problems persisted, they were given cognitive behavioural therapy, problem solving skill therapy, and anger management skills at a clinic. If there were family problems at home such as alcoholism or domestic violence, their parents were also given family therapy.

Kerala is pioneering mental health integration in schools. If mental illnesses in children are not accurately diagnosed and treated, there is an increase in the probability of health issues in adulthood

This innovative programme ensured that students who might have been suspended or dismissed from school were now treated for their issues. Within this sample, 95 percent of the students returned back to school. The fact that this was done by integrating school teachers curtailing possible social stigma and developing a model that can be implemented in areas with resource constraints, by any district-level administration. The state has many other mental health programmes at the school-level such as ‘Thalir’, a scheme that focuses on eliminating similar psychological issues in all districts. 

Kerala also has one of the highest budgetary allocation for mental health - 1.16% of its total health budget. Most other states do not even allocate separate funds for mental healthcare. In fact, India as a country spends only approximately 0.05% of its total health budget (around Rs. 345 crores) on mental health. To put this in perspective, a cautious estimate of the cost of executing the 2017 MHCA is around INR 94,073 crores. Funding, is one of the most significant hurdles when it comes to implementation. Further, a lack of investment is likely to cause a larger financial burden on the government — around 6.5 times more than actually implementing these policies would.

Kerala also has one of the highest budgetary allocation for mental health - 1.16% of its total health budget. Most other states do not even allocate separate funds for mental healthcare

Additionally, Kerala is the only state that meets the requirement of at least one psychiatrist per lakh population and also has the greatest number of clinical psychologists (0.6 per lakh population). In the 12 states that were surveyed in the 2019 National Mental Health Survey, the availability of psychiatrists per a population of one lakh was found to be 0.05 in Madhya Pradesh. In an attempt to bridge this gap, the District Mental Health Programme was created to ensure the availability of minimum mental healthcare by encouraging community participation and self-help. However, Kerala, alone has fully implemented this programme in all their districts. The core idea of involving the community in the process of mental health first aid is absolutely necessary for India, where most patients look for help in temples, dargahs, or from traditional healers rather than a mental health expert. Hence, it is necessary to also train social workers, community healers, and religious persons in basic mental healthcare and create job opportunities in this field to incentivise more young people to pursue it.

Out of the total states, Kerala and Gujarat are the only states wherein several districts routinely conduct Information Education and Communication (IEC) campaigns to spread awareness on mental health issues. India’s low mental health literacy, high levels of stigma, and large treatment gaps illustrate the need for such efforts. In all other states, mental health education is “isolated, sporadic and invisible in nature and lacks focus and direction”. When state-specific policies and action plans are drafted, it is necessary to include robust mechanisms for IEC activities as well. 

How the Kerala model can be improved 

A significant issue that even Kerala is facing is related to the lack of coordination between different sectors. There are several sections within the Ministry of Health and Family Welfare (MoHFW) as well as departments in other ministries that are involved in mental healthcare. On both national and state level, these sectors do not function in a uniform nor coordinated manner. They all have varying sources of funding, nodal agency, and staff patterns. They often do similar work, which drains resources without creating significant change. Closely related to this is a lack of monitoring of the implementation of these policies in every state. This is the most neglected section of mental health in India — evaluation has either been completely absent or done at a minimal level. There should be state-level advisory and monitoring committee to ensure transparency, accountability, and coordination with other department linkages.

Further, although Kerala does have a separate mental health budget, only 0.18% of the budget was utilised in 2019. A large portion of existing funds aren’t fully utilised due to an absence of clarity and muddled responsibilities between the central and state governments in terms of activity designation, well-timed allocation, and human resource constraints. Kerala also has a significant treatment gap (around 84 percent) — which is lower than most states but is still high. It also has an extremely high suicide rate -around 23.9 per 1,00,000 population, and high levels substance abuse disorders.

Although Kerala is ahead of most Indian states in several avenues, there are significant ways in which its mental healthcare can also improve. This is likely because there is still a certain level of stigma regarding mental health interventions. The restructuring of mental health hospitals and an increased focus on easy access to this facility could help mitigate this. It is also necessary to look deeper into the principles that guide these policies, so that mental health is not just viewed as a health issue but as a social problem that requires collective engagement, community intervention, and a preventive focus. Another essential undertaking is to evaluate specific mental health issues like suicide, substance abuse, and any other disorders to carefully track the circumstances and triggers for affected individuals. This will ensure that intervention strategies can be context-specific and hence more effective. In tandem, as illustrated above, there is a nation-wide necessity for state-specific policies and action plans, adequate and streamlined funding, robust mental health research, awareness building, mental health interventions in schools, and strong monitoring mechanisms.

The author is a Research Intern in ORF, Mumbai
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