Vol.3, No.12, 757-761 (2011)
opyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Mental health services in rural India: challenges and
Anant Kumar
Department of Rural Management, Xavier Institute of Social Service, Dr. Camil Bulcke Path, Ranchi, India;
Received 18 August 2011; revised 11 October 2011; accepted 10 November 2011.
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
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.
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
Copyright © 2011 SciRes. Openly accessible at http:// www.scirp.org/journal/HEALTH/
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].
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.
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.
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
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.
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
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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
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.
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.
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
Copyright © 2011 SciRes. Openly accessible at http:// www.scirp.org/journal/HEALTH/
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.
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.
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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