Health Justice And Mental Health

Introduction

Discussions regarding health justice, or its lack thereof, have been on the rise in India since the COVID-19 pandemic began in 2020. The virus has claimed over 460,000 lives in India alone¹; A disaster of such rapidness and unprecedented proportions in modern history was witnessed by humanity. The pandemic highlighted severe cracks in the Indian healthcare system – the result of decades of underfunding, lack of proper education, and a lack of interest on the part of the stakeholders. 

At the height of the pandemic, millions were facing mental health issues, often with nowhere to seek help, which begs the question, what exactly is good health? What are its key components? And why is it important to provide healthcare to everyone?

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Key Definitions

According to the constitution of WHO, health is defined as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”² 

Health has three basic components, namely, wellness of body, wellness of mind, and relation with one’s community. This means that a healthy person is not one who is merely devoid of sickness, but one who is also physically capable of leading a productive life, can handle day-to-day emotional stresses, and has healthy social interactions. 

A key component to a person’s overall wellbeing is the state of their mental health. However, it is also the aspect that is most overlooked, owing to the same being largely misunderstood by the general population. A person of sound mind and mental health is not just devoid of mental health disorders, but is able to realise their potential and abilities, can cope with regular work and personal stress, and contribute to society.³

Until the 80s, India measured health in terms of physical well-being alone, and physical illnesses were treated as and when they appeared. No research was conducted or interest was shown in understanding equitable health, access to facilities, and quality of life.

Having access to and receiving healthcare is dependent on various sociological factors including but not limited to economic class, social class, caste, education, geographical location, and others. Health justice would, therefore, be a more progressive outlook on welfare as compared to the traditional models of healthcare. It shines a holistic light on all components that affect an individual’s and a society’s overall well-being. Similar to how treating a bullet wound with bandages is insufficient, it is impossible to treat inequality, especially unequal access to healthcare, without providing a solution for the conditions that led to this grim situation in the first place.

Health justice goes beyond providing for basic human survival, it:

1. 1. Addresses the structure that puts equitable and quality healthcare out of reach of the underprivileged,
2. 2. Seeks to provide restitution by not just solving current issues but by restoring equality and freedom, and providing economic assistance to those who were previously oppressed, and,
3. 3. Listens to and adopts scientifically proven healthcare practices from various communities without prejudice.⁴

There is a severe difference in accessibility and availability of health care between High Income Countries (HIC) and Low to Middle-Income Countries (LMIC). While the reasons for that are many, the budget allocation towards healthcare can show the lack of seriousness the Indian government shows towards providing holistic welfare and care. The global average percentage of GDP spent on healthcare is 9.9, as India stands at a meagre 1.15, roughly divided among 1.4 billion people⁵. 

Indian Model of Healthcare

A well-functioning health system should:

1. 1. Provide equitable, quality services to everyone,
2. 2. At all times and places,
3. 3. Uphold the ‘Right to Health’ for everyone, including people with physical, mental, neurological disorders, and more

In extension, a well-functioning health system should create awareness in the community about timely first response and treatment as well as provide rudimentary health training to laypersons.

India has a three-tiered healthcare system that was conceived in 1946⁶. The system focused solely on government health bodies providing for citizens through its numerous welfare schemes. This continued until 2002, after which private health providers were utilised under government schemes to make healthcare more accessible. The majority of Indians reside outside of urbanscapes⁷ – consisting of very minimal private health facilities – resulting in 65% of the Indian population seeking government aid in receiving medical and mental health support.

A brief description of India’s public health model is as follows⁸. 

The Indian healthcare system is divided into three broad sectors, namely primary, secondary and tertiary. Starting from the grassroots and going up, primary healthcare is the first point of contact between common persons and a health facility/facilitator. It includes any laypersons near the incident with knowledge of first-aid, who take any affected persons to Sub-Centres (SC). They provide basic maternal & child care, family welfare, and nutrition to around 3,000 people in sparsely packed regions, and 5,000 people in urban locations. A SC does not have a trained physician, instead, they refer patients to Primary Healthcare Centres (PHCs) which are the first point of contact between the community and a medical officer. PHCs handles preventive and promotive aspects of healthcare, and takes care of around 20,000 to 30,000 people.

Secondary Healthcare sectors consist of Community Health Centres (or CHCs) and Sub-District Hospitals. A CHC provides for anywhere between 80,000 and 100,000 people, and has facilities for obstetric care and specialist consultations.

At the highest level, the tertiary sector has district hospitals and medical colleges.

Mental Healthcare Policies in India

India has been late to introduce welfare policies specific to mental health. Although attempts have been made to create a mental health policy in India since the 1980s, they have been far from successful in achieving most of its goals. 

Efforts to address the rampant lack of mental health awareness and resources in India began in 1982 with the ‘National Mental Health Programme’. Iterations of the same were created in 1996 to include district wise care, further upgraded in 2003 to include two broad schemes (modernisation of hospitals, and upgradation of psychiatric wings), and a ‘Manpower Development Scheme’ was added in 2009 that aimed at creating over 1,700 new mental health practitioners annually²⁷. The National Mental Health Programme sought to integrate mental health under primary healthcare, and “eradicate stigmatization of mentally ill patients, and protect their rights through regulatory institutions like the Central Mental Health Authority and State Mental health Authority⁹.”

Additionally, a group was constituted in 2011 to frame newer mental health policies which resulted in the creation of the ‘National Mental Health Policy’ of 2014¹⁰. 

The main goals and objectives of this policy aimed at: 

1. 1. Reducing distress, disability, exclusion morbidity, and premature mortality associated with mental health problems.
2. 2. Enhancing the understanding of mental health in the country.
3. 3. Strengthening mental health care services at all levels.
4. 4. Increasing access to and providing equitable, universal mental health care. 
5. 5. Identifying and addressing social, biological, and psychological determinants of mental health problems and providing appropriate interventions.

The National Health Policy of 2017¹¹ also included promises of changes in policies that should result in a net positive impact for the massive Indian population still suffering from mental health issues. In terms of Acts for Mental Healthcare, the 1912 ‘Indian Lunacy Act’ was replaced with the Mental Healthcare Act (1987), which was replaced again with the ‘Mental Healthcare Act, 2017’¹².

Some efforts have also been made to include a ‘School Mental Health Program’ in a few areas.

Barriers to Health Justice for Mental Health in India

Achieving equitable healthcare requires monumental effort, dedication, resources, and funding. Unfortunately, many of the mental health and welfare policies passed consist of more unrealistic goals than achievable ones. Recent examples of the ‘Mental Healthcare Act’ and ‘National Health Policy’ of 2017 promise actions and rights that would be highly improbable to achieve with the scarce resources allocated for them. Some of the goals/promises include:

1. 1. The universal right to access mental healthcare
2. 2. The right to life with dignity and without discrimination 
3. 3. Ensuring the availability of mental healthcare services at every district
4. 4. Decriminalising suicide 
5. 5. Using technology to access areas where specialists are unable to reach
6. 6. Training grassroots communities to provide psychological and mental health support

India has around 1.4 billion citizens¹³, and ranks 179th out of 189 countries in prioritization accorded to health in its government budget¹⁴, with 2,23,846 crores allocated for health and welfare for the year 2020-21¹⁵. India is known to be spending less than 1% of its health budget on mental health¹⁶. Translation of this into per capita terms means that each citizen has been promised around 1,500 rupees of healthcare per year (which includes water and sanitation), and out of which only 15 rupees on average will be spent on mental healthcare. This amount is not enough to satisfy the aforementioned promises.

A higher budget is not enough to solve issues of health justice, but it is a good starting point. A workable budget allows authorities to create the necessary infrastructure, recruit the right persons, train and create enough human resources to expand the workforce, and provide the services it has promised. Unfortunately, the lack of budgetary allocation has resulted in unachievable universal healthcare, with universal mental healthcare being but a distant dream. This was further proven when an independent study estimated that the conservative annual cost to bring MHCA 2017 into reality is over 93 thousand crores¹⁷, or over 40 times the entire budget allocation for mental health.

The majority of India’s healthcare infrastructure is private sector owned¹⁹. Additionally, there is only one hospital bed per 2,000 persons in the country, including public and private healthcare institutions²⁰. The unavailability of public healthcare facilities for various management-related reasons has pushed Indians towards private institutions for decades now. To provide financial support to the economically weaker sections, the Indian government in 2002 included private health providers in health subsidies and insurance policies so that patients can be treated in private hospitals at government-set discounted rates.²¹. However, the households’ out-of-pocket payments constitute the single largest source of finance towards healthcare¹⁸ at 94.7%, with the other 5% including social health insurance from employees or voluntary prepayments from households. Additionally, it is important to note that most private hospitals are not included in the scheme or do not provide this function due to various enforcement issues. 

For the financially poorest of Indians, health accessibility rates are very low. Reasons for this include unaffordability, unavailability of facilities, and a reluctance to be hospitalized, to name a few. Avoidance of medical care and hospitals is widespread among economically lower classes due to a lack of education, unpleasant and unkept facilities, lack of transparency in treatment in part of the hospitals, and fear of authorities. The Mental Healthcare Act of 2017 promises financial punishments against those not upholding the ‘Right to live life with dignity and without discrimination’, but despite the act being passed in 2018, many states and union territories are yet to draft and establish these rules, resulting in discrimination continuing in these places without any legal remedy.

Mental ill-health harms society as a whole. The WHO estimates that the economic loss due to mental health conditions between 2012-2030 is 1.03 trillion USD²³ (averaging around 57 billion per year). But before one receives treatment, one needs to know that they are unwell. A 2020 study²² found that around 1/3rd of the Indian youth lacks knowledge about mental health, its causes and symptoms, and associated it with negative connotations. The mentally ill were perceived to be dangerous, and it was generally believed that recovery for them was impossible. Access to mental healthcare is even harder in these conditions, as not only is one battling the abysmal practitioner to population ratio of 0.75 ~ 2.8 mental health professionals per 100,000²⁴ people, but they are also fighting the social stigma around mental health due to generational trauma from family, neighbours, and peers alike.

It is an unfortunate reality that during times of acute shortage of resource persons and facilities, only the upper class can afford life-saving treatment. Access to mental healthcare is a luxury in India, as only the destigmatized and wealthy can afford expensive therapy and psychiatric treatments without much backlash from society. The COVID-19 pandemic saw an uptick in discussions relating to mental health. Many online workshops, therapy sessions, and more were conducted. Although this immensely helped alleviate the anxiety and stress of many, many more were left without care as they did not have access to gadgets and internet connectivity.

This situation also worsens when widely followed and trusted political and ideological leaders make ignorant remarks, effectively harming the mental health of several already struggling individuals. In recent times, a popular political leader criticised the Prime Minister by calling his party “schizophrenic”, a few political adversaries’ feuds involved asking each other to go to a ‘mental hospital’, and the Prime Minister of India himself was caught mocking dyslexia at a public event²⁵. Besides being insensitive, these incidents highlight the deep seated ignorance within a population that has, for generations,  misunderstood, marginalised, and ill-treated people affected by mental health issues. 

Despite being faced with unfavourable odds such as these, India has been witnessing positive growth in awareness and acceptance of mental health as a legitimate factor affecting a person’s overall health. Taking it a step further, India is also recording an increase in mental health practitioners and practices.

The ‘School Mental Health Programme’ (SMHP) has been recognized as a key to helping and supporting children and adolescents in a time where they are most vulnerable to stress and other mental health issues. Unfortunately in India, the SMHP is badly neglected.

The Way Forward

Health Justice is more than just promises; it is action. Resolving surface-level issues by simply providing access to healthcare cannot create a permanent solution to deep-rooted societal issues that caused the rift between the haves and have-nots in terms of healthcare. Ensuring the right to life with dignity in terms of mental health and health justice means the right of a patient to live in a clean environment, be provided with decent meals, be respected and taken care of, have the right to make their own decisions regarding their treatment, and have legal protection in case these rights are violated. No citizen should be put in any position, because of pre-existing socio-political conditions, that would negatively affect their mental health. This includes discrimination in terms of their sexual orientation, gender preference, caste, religion, economic status, and other factors.

Enforcement of welfare policies is best achieved when the population understands its necessity (much like the polio eradication and HIV/AIDS prevention programs). The ‘School Mental Health Program’ is a good idea on paper, but it has not been properly implemented. This program will help students and teachers receive the necessary help, get destigmatized to, and be properly educated on stress, anxiety, and other mental illnesses that can harm an individual’s quality of life. Educating students on matters of mental health early on may also encourage more students to undertake fields in mental health, thereby increasing the psychiatric and psycho-therapy practising workforce in India. Additionally, proper education can help eradicate inequality between communities. 

The ‘Emerging mental health systems in LMICs’ (Emerald) programme ran from 2012- 2017. It aims to improve outcomes of people with mental, neurological, and substance use disorders in six LMICs (Ethiopia, India, Nepal, Nigeria, South Africa, and Uganda) by generating evidence and capacity to enhance health system performance in delivering mental health care²⁶. The Emerald programme had a progressive outlook, applied the results of evidence-based research to provide mental health care, improved goal-attainment in outputs, and addressed stigma and discrimination to improve the delivery of mental health services. 

Providing equitable healthcare through fostering health justice is a difficult, yet much-needed task, especially during the present climate as the already stark divide between the haves and the have-nots only increases. To provide equitable mental healthcare, governments need to first provide financial equity, accessibility to healthcare, and apt education about mental health. Budget allocation will not solve all issues, but it is always advantageous to have more resources. Although the budget allocation for health may seem large, it is by no means enough to provide universal, equitable healthcare to 1.4 billion Indians. 

Additionally, the acts and policies need to be enacted speedily, with facilities to redress and amend them as and when required. Improvements can be seen only when policies are implemented with the same seriousness with which they are drafted.

 

Prepared by Suhasini Srinivasaragavan

Research And Analysis 

              Hibiscus Foundation

 

References