Addressing healthcare challenges in a country as diverse and vast as India is a difficult feat as it is, leaving aside the stigma, and social and structural barriers that prevent people experiencing mental health problems from seeking care. The National Mental Health Survey (2015-16) estimated that close to 150 million Indians require mental health interventions and there exists a treatment gap of 70 to 92%. Considering that the overall impact is not just on the person, but also on those around them (hidden burden), the actual affected population may be much higher. This burden has been aggravated by the Covid-19 pandemic due to the rise in uncertainty and anxiety, and is now becoming increasingly critical to address.
India has only 0.75 psychiatrists per lakh population largely concentrated in urban areas even though nearly 70% of the country’s population resides in rural areas, against the desirable 3 per lakh population- a deficit that would take at least 42 years to meet given the current pace of psychiatric education in the country. Despite this reality, most conversations on mental health either look at breaking the stigma (which will increase the demand for services) or improving quality service delivery through psychiatrists (who are in limited numbers). This article therefore looks at bridging the care gap with the use of psychosocial interventions, through community-led models, to leverage non-formal caregivers and para-professionals, rather than relying only on qualified mental health professionals.
This paradigm shift would cultivate a rights-based approach to mental healthcare which is accessible, affordable, inclusive, and fosters help-seeking behavior at the community level. As a community comes together to address the unique stressors they experience, in conjunction with linkages and referrals to public health and welfare systems – these provide context based, accessible care. This may prevent deterioration of the individual’s mental wellbeing thereby reducing the medical intervention required. Community based care would enable early screening for mental health issues, along with better uptake of a range of services. Being from the same community, having the cultural understanding a more contextual intervention can also be undertaken by community volunteers, to address the specific needs of different individuals. These may include trauma resulting from gender-based violence or caste-based discrimination, anxiety and substance dependency faced by adolescents, particularly due to the pandemic and social media.
Following the ‘Look-Listen-Link’ (3L) Model, this care community could undertake need-based interventions that allow non-formal, trained community workers to look into the particular mental health challenges of the community. The trained workers could listen to what they say, identify if they have symptoms of any common medical disorders (‘CMD’) such as depression, anxiety and suicide ideation — that can be addressed at the community level, provide basic counselling and link them to referral institutes where necessary.
An efficient and robust community-integrated model will have the ability to build a response system of cadres of community volunteers and leaders to create ‘safe spaces’. They would build upon locally established peer support networks such as Self-Help Groups (‘SHGs’), activity-based groups, and civil society organizations to provide care. It is important that any community-based mental health program provides access to institutional social care benefits by building strategic partnerships with the local governments, panchayats, educational institutions and other stakeholders to enable referrals and access to existing social benefit schemes.
The success of the ‘Atmiyata Project’ run by the Centre for Mental Health Law and Policy in Mehsana, Gujarat and funded by the Mariwala Health Initiative (‘MHI’) is noteworthy in this regard. The program is led by community volunteers who identify persons in distress, and who can benefit from informal care. The volunteers provide them with counseling sessions. It also addresses barriers of language, age and disability, by making use of videos to generate awareness about mental health. Two other partner organisations of MHI must also be mentioned in this regard. The ‘Janamanas’ program run by Anjali, a NGO based in Kolkata, focuses specifically on addressing the differential mental health concerns of women, by creating safe community spaces for other women, in the community to come, assess and discuss their issues. Likewise, the SEHER program by Bapu Trust works in the urban bastis in Pune, and initiates conversations on mental health at street corners.
The triumph of community participation in other public health challenges such as tuberculosis where ‘TB Champions’ who are survivors of the disease as well as ‘ASHAs’ who assist in the last mile connectivity of maternal and child health in the country, must also be paid heed. These programs reduced the stigma associated with seeking help, enabled access at the village level, and established outreach and support chains that are functioning even in the midst of the pandemic.
To conclude, a diverse collaboration with the community can humanize the existing public health institutions by reducing hesitancy and building awareness about mental health. It also allows for early screening, assistance mechanisms and preventive measures to be built and decentralize the delivery of mental health services to make way for personalized solutions that are contextual thereby bridging the healthcare gap and making a significant contribution towards the amelioration of mental health.
(Dr Dalbir Singh, President, Global Coalition Against TB and Policymaker’s Forum for Mental Health); (Dr Virander Singh Chauhan, Emeritus Professor, ICGEB and Founder ETI); (Priti Sridhar, CEO, Mariwala Health Initiative)