Mental health services in rural India: challenges and prospects

doi:10.4236/health.2011.312126

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Vol.3, No.12, 757-761 (2011)

doi:10.4236/health.2011.312126

Health

Mental health services in rural India: challenges and

prospects

Anant Kumar

Department of Rural Management, Xavier Institute of Social Service, Dr. Camil Bulcke Path, Ranchi, India;

pandeyanant@hotmail.com

Received 18 August 2011; revised 11 October 2011; accepted 10 November 2011.

ABSTRACT

Mental health services in India are neglected

area which needs immediate attention from the

government, policymakers, and civil society or-

ganizations. Despite, National Mental Health Pro-

gramme since 1982 and National Rural Health

Mission, there has been a very little effort so far

to provide mental health services in rural areas.

With increase in population, changing life-style,

unemployment, lack of social support and in-

creasing insecurity, it is predicted that there

would be a substantial increase in the number

of people suffering from mental illness in rural

areas. Considering the mental health needs of

the rural community and the treatment gap, the

paper is an attempt to remind and advocate for

rural mental health services and suggest a

model to reduce the trea tment gap.

Keywords: Mental Health; Policy; Rural; India;

Services; Treatment Gap; NMHP; DMHP ; NRHM

1. INTRODUCTION

Health is “a state of complete physical, social, and

mental well being and not merely the absence of disease

or infirmity” [1,2]. Nevertheless, our health system is

pre-occupied with curative health care services and dis-

ease prevention, with little attention on social and mental

well being. Among these, mental health and well being

is the most neglected one [3,4], particularly in rural areas

[5,6]. Silence on mental health services in rural India [7]

in the National Rural Health Mission (NRHM) [8] is a

serious matter of concern. The omission of mental health

in the NRHM mission document becomes even more

serious in the backdrop of the uneven performance of the

National Mental Health Program (NMHP, 1982) [9-11]

and District Mental Health Programme (DMHP) [12]

which is operational in only 125 districts out of 626 dis-

tricts of India. With various flaws and implementation

constraints in the NMHP and DMHP [13,14], there has

been a very little effort so far to improve the rural mental

health services.

2. ISSUES AND CONCERNS

Mental illness constitutes nearly one sixth of all

health-related disorders [15]. With the population in-

crease, changing values, life-style, frequent disruptions

in income, crop failure [16], natural calamity (drought

and flood), economic crisis [17], unemployment, lack of

social support and increasing insecurity, it is fearfully

expected that there would be a substantial increase [18,

19] in the number of people suffering from mental ill-

ness in rural areas. Among priority non-communicable

diseases in India, mental illness constitutes 26 percent

share in the burden of disease and available data suggest

that there would be a sharp increase in this in coming

years [20-22]. Projections suggest that the health burden

due to mental disorders will increase to 15% of DALY

by 2020 [23]. The study by the National Commission on

Macroeconomics and Health (NCMH) shows that at

least 6.5% of the Indian population has some form of

serious mental disorders, with no discernible rural–urban

differences [24]. Epidemiological studies done in last

two decades shows that the prevalence of mental disor-

ders range from 18 to 207 per 1000 population with the

median 65.4 per 1000 at any given time. Most of these

patients live in rural areas, far away from any modern

mental health facilities [25]. The overall individual bur-

den for rural areas cannot be estimated with the available

studies. Nevertheless, considering the fact that 72.2 per-

cent of population lives in rural areas, with only about

25 percent of the health infrastructure, medical man-

power and other health resources, it may be surmised

that the number of people affected with any mental and

behavioural disorder would be higher in rural areas [26].

Despite NRHM initiatives and improvements, general

health services in rural areas are not adequate and are

struggling with infrastructural, human resources and

A. Kumar / Health 3 (2011) 757-761

758

other problems. Only 31.9 percent of all government

hospital beds are available in rural areas as compared to

68.1 percent for the urban population. At the national

level the current bed-population ratio for Government

hospital beds for urban areas (1.1 beds/1000 population)

is almost five times the ratio in rural areas (0.2 beds/

1000 population) [27-29]. There is a shortfall of 8% of

doctors in Primary Health Centres (PHC), 65% of spe-

cialist at Community Health Centres (CHC), 55.3% of

male health workers, and 12.6% of female health work-

ers [30].

3. CHALLENGES

The epidemiological situation and available health

service system shows that providing mental health ser-

vices in rural areas is a challenging task, which needs

infrastructural, architectural, and programmatic correc-

tion in the existing National Mental Health programme

and District Mental Health programme. Lack of trained

human resource for mental health care and treatment is

another challenge [31], considering few institutions avai-

lable for mental health professional training. Besides

these, major challenge is lack of political commitment

and realization that mental health is an important aspect

of our health system which has far reaching implication

for the development of the country.

4. NEEDS AND THE TREATMENT GAP

Considering the limited or no service availability; the

treatment gap is huge in rural areas. According to one

estimate, even if all 3000 psychiatrists available in the

country are involved in face to face patient contact and

treatment for 8 hours a day, five days a week, and see a

single patient for a total of 15 - 30 minutes over a 12

month period, they would altogether provide care for

about 10% - 20% of the total burden of serious mental

disorders. Surprisingly, it is almost similar to the esti-

mated ‘treatment gap’ of ninety percent.

5. BARRIERS IN SEEKING HELP

Barriers in seeking help in rural area are many. Major

barriers in seeking help are unavailability of mental

health services, low literacy, socio-cultural barriers, tra-

ditional and religious beliefs, and stigma [32] and

discrimination associated with mental illness. Unavaila-

bility of mental health services and lack of resources,

particularly in terms of human resources, financial cons-

traints, and infrastructure are one of major barriers

which makes access to mental health services in rural

areas more difficult. The services available in urban

areas are far and costly; and difficult to utilize and

access due to various reasons. Lack of awareness and

recognition of CMD (common mental diseases) with

prevailing stigma and discrimination is an important

issue and barrier which is closely associated with low

literacy in rural areas.

Other barriers are low political will of Central and

state governments and unclear plan of action and policy.

Another barrier is resistance to decentralization [33], and

resistance by mental health professionals and workers,

whose interests are served by large hospitals. Above all,

major barrier is difficulties in integrating mental health

in Primary Health Care. Primary health care workers are

overburdened with lack of supervision and specialist

support. Other barrier is that medical students and psy-

chiatric residents are often trained only in mental hospital

settings with inadequate training of general health work-

force and lack of infrastructure for supervision in the

community.

Another important barrier is mental health leadership

of the country which often lacks public health skills.

Those who are in leadership positions are psychiatrists,

trained in clinical management, without formal Public

health training. Besides, the major barrier and challenge

is resistance by psychiatrists to accept others as leaders.

6. HUMAN RESOURCES AND

INFRASTRUCTURE GAP

The people in rural areas are unable to access the ser-

vices of the qualified doctors and other mental health

professionals, where just 0.2 psychiatrists, 0.05 psychi-

atric nurses, 0.03 psychologists per 100,000 people (see

Ta bl e 1 ), and 0.26 mental health beds per 10,000 popu-

lations, 0.2 in mental hospital and 0.05 in general hospi-

tals (see Tab le 2 ) [34] are available for the whole coun-

Table 1. Professional per 100,000 populations.

2001* 2005**

Number of psychiatrists 0.4 0.2

Number of neurosurgeons 0.06 0.06

Number of psychiatric nurses 0.04 0.05

Number of neurologists 0.05 0.05

Number of psychologists 0.02 0.03

Number of social workers 0.02 0.03

Source: *Atlas, Country Profile, 2001. World Health Organization. **Mental

Health Atlas, 2005. World Health Organization.

Table 2. Psychiatric beds per 10,000 populations.

2001* 2005**

Total psychiatric beds 0.26 0.26

Psychiatric beds in mental hospitals 0.2 0.2

Psychiatric beds in general hospitals 0.05 0.05

Psychiatric beds in other settings 0.01 0.01

Source: *Atlas, Country Profile, 2001. World Health Organization. **Mental

Health Atlas, 2005. World Health Organization.

A. Kumar / Health 3 (2011) 757-761

759759

try. Interestingly, the number of availability of psychia-

trist has gone down during 2001 and 2005. To make the

resources equitable, India needs about 140,000 psychia-

trists whereas we have about 3000 psychiatrists and 75%

of them are working in urban areas where less than 28%

of the population lives. The government expenditure on

mental health is another concern where it spends just

0.83 percent of its total health budget on mental health

[35].

7. INNOVATIONS ATTEMPTED SO FAR

NGOs and civil society groups are involved in pro-

viding mental health service delivery and community

mental health and have done commendable job [36].

Many of them have set up day care centres, half-way

homes, long-stay homes, counselling centres, suicide

prevention centres, school mental health programmes,

disaster mental health care, and community based pro-

grammes for the mentally ill. Nevertheless, most of their

services are “extension clinics” concentrated in urban

areas with little attention on rural areas. Some of NGOs

who are doing commendable jobs are Medico-Pastoral

Association, Bangalore; Paripurnata, Kolkata; SCARF

and The Banyan, Chennai; Richmond Fellowship Soci-

ety (Bangalore, Lucknow, and Delhi); Cadabams, Ban-

galore; and Ashadeep in Guwahati. Interestingly most of

these efforts are concentrated in Southern states and in

urban areas. Nav Bharat Jagriti Kendra (NBJK), Hazari-

bagh is one of few organizations working in rural areas

in partnership with 23 NGOs in 14 districts of Bihar and

Jharkhand [37]. Some of other organisations working on

mental health in rural areas are Shant Manas Trust in

Madurai [38], and the Richmond Fellowship Society in

Bangalore [39].

Though various NGOs are doing commendable job in

their areas, their geographical and service reach is very

limited and dependent on donor support. Secondly, their

initiatives have been isolated to pockets with limited

funds and have not been supported by the government,

both at the Centre and state level [40]. Thirdly, the con-

tinuance and the quality of services is a serious concern

where the staffs lack professional training and skills.

Fourthly, we have failed to recognize, learn from their

experiences and extend these efforts in rural areas. It

emerges that these NGOs can supplement in providing

mental health services but they cannot be an alternative

to provide mental health care services in rural areas con-

sidering the need and treatment gap.

8. FUTURE PROSPECTS

Proposed decentralization and synchronization of Na-

tional Mental Health Programme (under 11th Five Year

Plan, 2007-2012) with National Rural Health Mission is

a good opportunity and has a wider prospect [41]. We

can hope that this will ensure Primary Health Centre

(PHC) based mental health services to the rural popula-

tion. Involving and training village level Accredited So-

cial Health Activists (ASHA) is another opportunity.

Adding a module on community mental health and train-

ing ASHAs will definitely help in early detection, treat-

ment, and rehabilitation of patients in the community in

the rural areas. Presently, most of the rural people ap-

proach traditional healers (religious saints, tantriks (black

magicians), unregistered medical practitioners, and quacks)

for treating mental health problems. Considering peo-

ple’s faith in them and lack of trained professional,

training these traditional healers could help in alleviating

mental illness in rural areas. Developing short-term spe-

cial curriculum based training for medical officers is

another prospect which will help in providing clinical

services at block level.

9. SUGGESTIONS

Presently, the Government of India is providing men-

tal health services in 125 districts through District Men-

tal Health Programme under NMHP. There is need to

integrate NMHP and DMHP with NRHM Programme to

provide mental health care, services and support to each

and every individual in rural areas.

The Table 3 suggests a model to provide mental health

services in rural areas. Some of the suggestions through

Table 3. Model of mental health care and service in rural areas.

Institution Personnel Level Role

Mental Health Institution Specialist institutional care and servicesState level Treatment of severe mental health disorders

District Health Society Civil surgeon District level Planning, implementation, and service delivery

Community Health Centre Psychiatrist On one lakh population Treatment for common mental health disorder

Primary Health Centre Medical officer in charge Block (on 30,000 population)Counselling/identification/ referral

Community Care ASHA Village/Community Care, support, education, acceptance, and in

addressing stigma and discrimination

Self Care/Family Care Family/Community members Family Care

A. Kumar / Health 3 (2011) 757-761

760

which mental health care and services can be strength-

ened in rural areas are increasing the availability of re-

sources, improving equity in their distribution, and en-

hancing efficiency in their utilization. Besides, there is

also a need to emphasize the role of specialists in filling

the treatment gap. Building capacity of other health

workers, particularly ASHA under the NRHM pro-

gramme may help in demand generation as well as re-

ferral. Following suggestions or strategies in combina-

tion can be used for strengthening the rural mental health

care services:

1) Convergence of National Mental Health Programme/

District Mental Health Programme under National Rural

Health Mission Programme and using existing PHCs and

sub centres to provide mental health services;

2) Capacity building of Rural/registered Medical Prac-

titioners/Primary Health care doctors/ASHA workers/

teachers/Aanganwadi workers on tailor made modules;

3) Advocacy through community, social and other

bodies and involvement of religious leaders, teachers,

local community leaders with key stakeholders;

4) Targeted awareness programme using available ru-

ral media;

5) Provisioning social security to the mentally ill pa-

tients; and

6) Training for caregivers and relatives.

10. CONCLUSIONS

The rural mental health services are neglected area

which needs immediate attention considering the burden

of disease and treatment gap. District Mental Health

Programme needs restructuring and convergence within

the NRHM. The “extension clinic” approach needs to be

replaced with integration of mental health services with

general health services, particularly under NRHM. In-

volving ASHAs under NRHM is an opportunity to pro-

vide mental health services at door steps in rural areas.

Lastly, ensuring bottom up approach and community

ownership are must to achieve universal mental health

services, care and support in rural areas.

11. ACKNOWLEDGEMENTS

I am thankful to Prof R. Srinivasa Murthy, Prof Doncho M. Donev

and Dr. Amit Ranjan Basu for their comments on the paper.

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