By Julia Robinson, Executive Editor, PLOS Global Public Health In early May 2023, I had the great pleasure of attending the World…
Mind Matters: India’s Mental Health Budget Crisis
By guest contributors Manisha Shastri and Sayali Mahashur
10.6% of India’s population lives with mental health conditions, yet 76-85% of those in need of mental health care do not receive any services or support. This treatment gap stems from lack of trained human resources for mental health, disproportionate concentration of services in urban areas, lack of community-based services, stigma and discrimination, and poor budgetary allocations for mental health.
Despite the provisions in the National Mental Health Policy, 2014 and the Mental Healthcare Act, 2017 to increase funding for mental health to address the treatment gap, it has remained a low governance priority. Less than 1% of the country’s total budget for health is allocated for mental health.
Since India has a federal structure of governance, the power and responsibility for decision-making and budgeting are shared by the union and state governments. Health, including mental health, is a concurrent subject, which means the union and state governments can both frame and pass laws and policies related to health, as well as allocate funds for the same.
Nationally, funds for mental health are primarily disbursed through the Ministry of Health and Family Welfare (MoHFW), the authority that oversees implementation of health-related laws, policies, and programmes in the country.
The National Mental Health Programme (NMHP), is one of the main mental health service delivery programmes under the purview of the MoHFW. It was introduced in 1982, with the objective of facilitating the integration of mental health care with primary healthcare services. Over the decades, the NMHP has seen several revisions; currently it comprises four components which are focused on (i) integrating mental health services into general healthcare services, through the District Mental Health Programme (DMHP), (ii) training of human resources for mental health care, (iii) establishing Centre’s of Excellence and (iv) tele-mental health services through the T-MANAS launched in 2022.
Historically, the NMHP has received low budgetary allocations under the Union Budget. This can be attributed to poor utilisation of funds by the states. Consequently, this has created a vicious cycle where the allocation has remained low due to underutilisation. This has resulted in decreased budgetary outlays for the programme, a proxy indicator of which is the consistently low budgetary allocation. In 2018-19 and 2019-20, 96% and 93% of the funds allocated for the NMHP in the budget remained unutilised, meaning they were returned by the states to the national government, on account of being unused. In the budget for 2023-24, the NMHP has been subsumed and is no longer a separate line-item. Instead, the T-MANAS component of the NMHP has been introduced as a new line-item, receiving 15% of the total funds allocated for mental health. This change is indicative of the governments focus on strengthening digital mental health services in the country, in the aftermath of the Covid-19 pandemic.
Prior to the introduction of T-MANAS the District Mental Health Programme (DMHP) was the main service delivery component under the NMHP. The objective of the DMHP is to integrate mental healthcare services with general healthcare services at the primary and community level and to make mental healthcare accessible within communities. However, owing to challenges like insufficient human resources, poor allocation and utilisation of funds due to administrative barriers and lack of political will, the DMHP has been confined to providing specialised psychiatric care services at the district level.
To implement the DMHP, 60% of the funds are provided by the union government, and the remaining 40% is financed by states. Funds for the DMHP are allocated by the MoHFW are largely directed towards costs for medication, training and awareness activities and human resources. The exact amount allocated for the DMHP is a hard to ascertain from the union budget, since funds to states are allocated based on the number of districts with a functioning DMHP. Between 2015-2021, out of the $6,500 million (₹ 52,225 crore) allocated by the union government to states/UTs for the implementation of the DMHP, only 38.11% ($2,480 million) of the funds were utilised. Among the 28 states in the country, 5 states utilised less than 15% of the funds allocated, while only 5 states utilised more than 50% of the allocated funds.
Previous evaluations of the DMHP have reported the cause of underutilisation as inconsistencies or delays in transfer of funds by the union government, along with lack of co-ordination between different directorates of the state health departments. In many parts of the country the DMHP is not fully functional, hence persons with mental illness rely on either private mental health services, which are expensive or travel distances to avail of services at the district or tertiary hospitals.
Just as funding for mental health has been a low governance priority nationally, among the states too, the situation is similar. Consistently low funding for mental health over the decades has led to a weakened public mental health system, increasing the treatment gap for mental health conditions. This has also contributed to the poor implementation of the existing policy, legislation, and programmatic framework for mental health in the country.
The Mental Healthcare Act, 2017 was enacted to protect, promote, and fulfil the rights of every citizen to access affordable, acceptable, equitable and quality mental healthcare. The MHCA’s recognition of access to mental health care as a right is significant since the right to health is yet to recognised as a fundamental right in India. The legislation places upon governments the obligation to ensure sufficient funds are allocated for ensuring mental health services are made available in adequate quantity to meet the needs of the population. However, in the absence of substantial budgetary allocations for primary and community-based mental health services, these provisions remain unfulfilled.
Suicide is a significant concern in India. In 2022, the country’s first National Suicide Prevention Strategy (NSPS) was announced. The NSPS adopts and advocates for an intersectoral approach to reduce incidence of suicide in the country. However, in the present budget, no funds have been ringfenced for meeting the objectives identified within the NSPS.
While India does have a robust policy and legislative framework for mental health and suicide prevention, its implementation remains a low governance priority, which is reflected in the low budgetary investment in the public mental health system in the country.
Manisha Shastri has a Master’s in Social Work in Disability Studies and Action and is currently a Research Associate at the Centre for Mental Health Law & Policy, ILS, Pune. Since 2014, her work has focused on policy research and advocacy, particularly with Members of Parliament on issues related to mental health, child rights, disability, public health and human rights. Manisha’s engagement with mental health results from her own lived experience as a primary caregiver, service-user and researcher; her other areas of interest include implementation research and children’s mental health. She tweets at @ManiFaa
Sayali Mahahsur is a Research Associate at the Keshav Desiraju Indian Mental Health Observatory, CMHLP. Sayali is working on understanding financial matters that deeply concern mental health like insurance for mental illness, cash-transfers and their impact on mental health and various budget allocations for mental health at the national & state level. Sayali tweets at @SMahashur.
Disclaimer: Views expressed by contributors are solely those of individual contributors, and not necessarily those of PLOS.