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*population in 2020，GNI and life expectancy in 2019 are updated based on UN's data. *Medical information is based on WHO’s report of 2017Mental Health Atlas-country profile |
I. Overview |
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India is located in the Indian subcontinent of South Asia, the seventh largest area (effective control of 328.7 square kilometers) in the world and the largest country in South Asia. It situated therein with Myanmar in the east and Pakistan at the west, and share the borderline with China, Bhutan and Nepal at the north, however, the land of Bangladesh is enclosed by that of India at the northeast side with a most complicated borderline in between. The population in 2020 is estimated to reach 1.36 billion, second only to China’s 1.412 billion. According to data from the World Bank in 2019, its gross national income per capita is only US$2,120 and to be considered as a low- or middle- income country, however, it ranks fifth of the world economy, which is next only to USA, China, Japan and Germany, and its economic development has attracted the worldwide attention. India is a federal constitutional republic consisting of 28 states and 8 union territories. The capital Delhi was upgraded as National Capital Territory in 1991 and is considered as one of the states, Each state, Delhi and two of the union territories have the legislative and democratic parliaments and local governments, while the other five union territories are governed by the appointed administrators from the federal government. There are huge differences between states, from population distribution to industrial development, and GDP per capita. There are more than 100 ethnic groups in the country, the largest is Indo-Aryan (72%), the main religious beliefs include 79.8% Hinduism, 14.2% Muslim and other minorities. The main official languages are Hindi and English, and there are other 22 officially recognized languages in circulation in the whole nation. In 2011, it was estimated that 43.6% of the population speaking with Hindi. According to statistics in 2020, the urban inhabitants account for about 34.9%, while there are approximately 70% of the population live in the countryside. The core of the population is located in the north along the Ganges River, and the other river basins and southern coastal areas in which are also very concentrated. The population density is high in most parts of the country, with the exception of the Northwest Desert (including the Thar Desert) and the edge of the northern mountainous area. The Ministry of Health and Family Welfare (hereinafter called MoHFW) is the federal government agency responsible for health policy. Currently, the main four types of health insurance implemented in India include the employee insurance plan, the federal government health system, the national health insurance only for people living below the poverty line, and the elderly health insurance. However, in 2016, the coverage rate in India was less than 15%. At present, medical expenditure only accounts for 1.3% of the overall GDP, and the public by out-of-pocket medical expenditure is as high as 86%. In addition, about 70% of medical institutions are concentrated in 20 metropolitan areas. The medical standards vary greatly between urban and rural areas. The main gap of professional medical manpower lies in rural areas. |
II. Mental health policy and system |
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The 2017 Mental Health Act replaced the old one that has been implemented since 1987. In order to deal with the heavy burden caused by mental illness and the severely inadequate mental health care, it started a national mental health plan since 1982 and joined the regional plan in 1996. In 2003, the modernization of state hospitals and the upgrading of psychiatric wards of universities or general hospitals were included, and in 2009, the human resources development plan were added in. India launched the District Mental Health Program (DMHP) in 1996, increase access to mental health care by training general practitioners and health care workers at the district level to solve the problems of the shortage of mental health specialists in small towns and villages. It also promoted the National Mental Health Policy of India (NMHPI) in 2014 with the aim of narrowing the gap in mental health care. The policy seeks to promote mental health, prevent mental illness, destigmatize and desegregate, and ensure socioeconomic inclusion of persons with mental illness by providing accessible, affordable and quality health and social care through their lifespan, which is within a rights-based framework. It calls for enhanced understanding of mental health and strengthening of leadership in the mental health sector at all levels to achieve universal access to mental health care. It also clearly stipulates the roles and functions to be played by the federal and state governments, local agencies, and civil society organizations in the policy to implement as the first step. DMHP will have to be expanded from the present 182 to all 648 districts, to ensure delivery of low-cost psychosocial interventions by appropriately trained and supervised community-based workers, increase availability of acute inpatient beds at district hospitals, and to reach out to the most vulnerable. The Parliament approves for the Mental Health Act is also necessary to ensure the rights of people with mental illness and to decriminalize the law of suicide prevention. Longeval India Premier's People's Health, also known as Ayushman Bharat National Health Protection Scheme (NHPS), it is a national health insurance plan of the Indian government. It aims to provide free medical care services for low-income people in the country and launched by MoHFW in September 2018, and later established the National Health Service as the official organization to manage the plan. This is a federally funded program, co-funded by the federal and the state government, and serves 500 million people. It is so far the world's largest government-funded health care program. |
III. Human Resources |
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Although India is the fifth largest economy in the world, in the past few years, it has spent only 0.05% of its health budget on mental health, which is even much lower than the average expenditure in some low-income countries that accounts for an average 0.5% of their health budget. There are 9,000 psychiatrists and 700 psychiatrist graduates, and calculated to 0.29 for every 100,000 people in India. This is far below the recommended level which should have at least 3 out of 100,000 people, and it means that India lacks 18,000 mental health physicians. The standard introductory degree in modern medicine in India is the Bachelor of Medicine and Bachelor of Surgery (MBBS), which is a certificate to be obtained after completing five and a half years of undergraduate courses. The courses are divided into one year of general science and preclinical research, and three and a half years of clinical research, and then followed by one year of clinical practice. Before starting the internship, students need to pass several exams and the last exam is divided into two parts. Postgraduate education in medicine usually requires another three years after the MBBS and ends with a master's degree in surgery or a doctorate in medicine (MD). After completing the two-year training courses, a postgraduate diploma in medicine can also be awarded. Since any core skill in psychiatry is not a compulsory course for completing a medicine education in school, the Medical Council of India (MCI) has developed a set of core competencies for medical graduates to cultivate more contacts with the psychiatry at the period of graduation in India. |
IV. Mental health system and promotion |
India's health care services are mainly operated independently through the public and private medical systems. The public medical systems are financed by the federal or local government, and normally collect lower fees because they have the goal of "all citizens should enjoy basic and equal medical services", therefore, the public hospitals are understandably crowded. Private medical systems are mostly operated by large enterprises or individuals, which are profit-oriented and costly, however, their overall service quality are considerably better. The medical system adopts a three-tier referral system according to the size of the population. The primary level is also a medical network, such as the Sub-Centers (SC) and Primary Health Centers (PHC), while the second level covers the Community Health Centers (CHC) and Sub-divisional Hospital which play the role of connecting in between the three levels. At the third level, there are District Hospitals, large general hospitals and hospitals affiliated to the medical schools. The first and second levels are mainly public hospitals established by the government, while most of the third level are privately funded. The private medical systems control the medical resources accounting for 74% of the overall expenditure and about 49% of the country’s hospital beds, and furthermore, 80% of physicians, 26% of nurses, and 78% of ambulance services.
Part of the 2015-2016 National Mental Health Survey was conducted in 48 districts of the Madhya Pradesh state, and to provide an overview of the conditions of the mental health system in India.
The most important problem facing Indian medical care is the severe uneven distribution of medical resources. Most medical service resources are concentrated in urban cities. Rural areas have nearly 70% of the population in India, but they only have about 2% of medical service resources.
For the mental health services, there are only 0.03 of government core hospitals which provide the mental health facilities per 100,000 population. About 1.18 beds can be provided for mental health inpatient services out of 100,000 people. Approximately 11.8% of district/general hospitals (third level) and 3.03% of community health centers (CHC, second level) are involved in providing mental health services. Please see Table 1 for reference.
As for the Mental health facility, only two mental hospitals (0.003 per 100,000 people) and 14 medical schools with psychiatric departments (0.019 per 100,000 people) provide mental health services. Six general hospitals have designated psychiatric departments (0.008 per 100,000 people). There are no mobile mental health units, half-way accommodation centers, long-term psychiatric nursing homes, and sheltered workshops. See Table 2 for more details.
The are 148 trained health professionals/personnel working for mental health, but only 37 psychiatrists and 5 clinical psychologists and counsellors are in the services, and the calculated figures per 100, 000 population is 0.2, 0.05 and 0.01, respectively. There are also 99 trained mental health/nurses with DPN qualification in the past three years and 7 psychiatric social workers, who have the ratio of 0.14 and 0.01 out of 100,000 population. Rehabilitation workers, special education teachers and professional/paraprofessional psychosocial counsellors are almost non-existent. See Table 3 is for the reference.
In terms of health promotion, Action for Mental Illness India (ACMI) was established by a non-profit charitable trust fund in 2003 to serve the rights and needs of patients with mental illness. ACMI is also an advocacy forum, trying to bring about changes at a macro level for the rights and needs of people with mental illness and their families. Advocacy and action have become the hallmarks of ACMI, affecting 60 to 70 million Indians with mental illness and mental disorders, most of whom have not yet received treatment.
ACMI is committed to India's advocacy of policies, laws and services related to mental illness. It is different from non-governmental organizations that provide services, through the 3E (Empowerment, Enablement and Enlightenment) model, ACMI has carried out many innovative projects, from advocating emergency outpatient services, establishing nursing centers for people who cannot afford medical expenses, and supporting families suffering from mental illness. ACMI recently launched a national forum called the "Families Alliance on Mental Illness" (FAMI), which provides a platform for families to build awareness, advocate and take action.
V. Major issues, challenge, and opportunities |
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WHO estimates that about 7.5% of Indians suffer from mental illness, and predicted that by the end of 2019, there might be about 20% of Indians who would suffer from mental illnesses. The data shows that 56 million Indians suffer from depression, and another 38 million Indians are tortured by the anxiety. From 2015 to 2016, MoHFW conducted an annual nationwide mental health survey for the population over 18 years of age, in addition, in some areas, a survey for the group of age between 13-18 adolescents was also carried out. The goal was to estimate the prevalence of mental illness, the rate of treatment, the utilization of the health care system, disability, and related impacts and assess the current state of mental health services and systems. The results of the survey found that the prevalence rate of mental illness excluding smoking in India was 10.6% and the lifetime prevalence rate was 13.7%, and the high risk of suicide was 0.9%. Besides, the prevalence of schizophrenia disorders(0.64%), emotional disorders (5,6%) and mental related stress (6.93%) in the metropolitan cities is two to three times higher than that of the rural areas, it is noticeable because of the quick pace, complicated life style, out of the original support system and the unstable economy conditions. Some of the common mental disorders (CMDs), like depression, anxiety, substance abuse, et., affect 10% of the population according to the research report. The prevalence and lifetime prevalence rate of depression are 2.7% and 5.2%, respectively, while the women with age 40-49 who live in the urban areas and the elderly will have the higher possibility of depression. There also have a higher suicidal death rate due to the depression at many of the developed states in the south India, especially the prevalence for the elderly with depression disorders, which is an indication of the aging problems. There are more women who suffer from depression, anxiety and eating disorders, while lots of men are tormented by autism and ADHD. The eating disorders are a worldwide tendency of body images anyhow. The 2016 National Mental Health Survey found that nearly 14% of the Indian population need active mental health interventions. Approximately 2% of people have severe mental disorders, and there are still a large number of people with mental illnesses that have not been diagnosed, and furthermore, among those diagnosed, few of them receive proper treatment. Lack of mental health awareness and the shortage of mental health experts have hindered thousands of patients from obtaining medical help. This situation is more pronounced in small towns and rural countryside of India. Additionally, WHO's data shows that 15% of the population of the elderly in the world suffer from mental disorders, and it takes a high rate of 21.9% in India, which is more than the global average. |
VI. Potential exchange issues |
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The main issues of mental health in India include high suicide mortality, insufficient professional mental manpower, inadequate mental health training for primary medical staff, and lack of mental health services at all levels of medical care. The main items of future exchanges shall cover suicide prevention, mental health staff members' training and development, primary medical care, community mental rehabilitation models, etc. |