Implementation of National Mental Health Programme for India

Article

NIMHANS Journal

Implementation of National Mental Health Programme for India
Paper presented at the Symposium on 'National Mental Health Programme for India' at the Annual Conference of Indian Psychiatric Society, January 3-5, 1985, Jaipur, Rajasthan, India

Volume: 04 Issue: 02
G N Narayana Reddy

July 1986 Page: 77-84

Director, National Institute of Mental Health & Neuro Sciences, Bangalore
, -DNr.aStioMnaClhIannstniatubtaesaovf aMnnenatal Health & Neuro Sciences, Bangalore 560 029, India

Department of Psychiatry
&, -RNSartiinoinvaasl aInMstuitruthteyof Mental Health & Neuro Sciences, Bangalore 560 029, India

Department of Psychiatry
, - National Institute of Mental Health & Neuro Sciences, Bangalore 560 029, India

Abstract
The National Mental Health Programme (NMHP) for India was the result of efforts to develop non-institutional models of mental health care. The NMHP envisages integration of mental health care with general health care and welfare activities. Since 1982, a number of steps to involve the professionals, health planners and strengthen the manpower needed have been undertaken. A result of all these efforts is its implementation in about 10 States / Union territories and financial support for the programme in the Seventh Five Year Plan.
Key words Primary health care, Community mental health, NMHP Primary health care, community mental health, NMHP
Organisation of mental health care in the country has been the subject of professional concern from the time of Independence. This is being discussed since the formation of the Indian Psychiatric Society for the past forty years. A number of suggestions have been made by the professionals in the various conferences, seminars and working groups to consider non-institutional approaches to mental health care. These recommendations received concrete shape in 1975-76, when major community mental health care experiments were launched at Chandigarh and Bangalore to integrate mental health care with general health services [1], [2], [3], [4].

It is significant to note that the last decade has shown an increased emphasis on the primary health care as the approach to provide total health care including mental health and other components. The result of the professional aspirations and the research effort was the formulation of the National Mental Health Programme (NMHP) for India [5].
The present paper highlights the approaches adopted to implement the NMHP. It considers the various steps undertaken, the recent developments in the area of community mental health, the activities initiated at different levels of health care and outlines the future areas of work.
The National Mental Health Programme for India (1982)
Following the experiences of different centres in providing community care for the mentally ill, the professionals and planners formulated a programme for mental health at the National level in 1982. The objectives of the programme are : (i) To ensure availability and accessibility of minimum mental health care for all, in the foreseeable
future, particularly to the most vulnerable and under privileged sections of population. (ii) To encourage application of mental health knowledge in general health care and in social
development. (iii) To promote community participation in the mental health services development and to stimulate
efforts towards self help in the community.
The specific approaches suggested for implementation of the NMHP are : 1. Diffusion of mental health skills to the periphery of the health service system. 2. Appropriate appointment of tasks in mental health care. 3. Equitable and balanced territorial distribution of resources. 4. Integration of basic mental health care into general health services and 5. Linkage to community development.
The Central Council for Health and Family Welfare in its meeting held from 18-20, August 1982 recommended that : (i) Mental health must form an integral part of the total health programme and as such should be
included in all National Policies and Programmes in the field of health education and social welfare. (ii) Realising the importance of mental health in the course curriculae for various levels of health
professionals, suitable action should be taken in consultation with the appropriate authorities to strengthen the mental health education components. The planned approach is to integrate mental health services with existing general health services.
The NMHP outlined a set of time-bound targets to be achieved at the Central level as well as at the State level. It would be appropriate to review these prior to consideration of the steps undertaken in the last four years. The targets outlined in NMHP are : 1. Adoption of programme (NMHP) by all states. 2. Formation of National Mental Health Advisory Body as focal point. 3. Coordination cell at DGHS. 4. Formulation of curriculum for health personnel of different levels. 5. Organisation of mental health training programmes for Primary health care (PHC) personnel at state
levels. 6. Provision of psychiatrists at District level.

7. Provision of programming officers for mental health at state level. 8. Enhancing mental health training in undergraduate medical education. 9. Formation of a task force on psychotropic drugs. 10. Development of linkages with other developmental programmes like Integrated Child
Development Services Scheme (ICDS) and, 11. Improvement of mental hospitals and teaching psychiatric units.
Developments since 1982
Mental health care programme at primary care:
At the first workshop on NMHP in July 1981 only few centres had attempted to integrate mental health care in primary health care. Since 1981, about a dozen centres have taken up this work in different parts of the country from Jaipur in the North, Calcutta in the East, Baroda in the West and Bangalore in the South. Current programmes are operational at Lucknow, Vellore, Madras, Hyderabad, Hamirpur, Poona, Ratnagiri, Thane, Pondicherry and Nagpur. The states of Punjab and Haryana have initiated work in early 1986. These experiences have shown the willingness of PHC personnel to take up mental health care.
Training for PHC personnel:
At Bangalore Centre, since April 1982, regular monthly training programmes for health workers and medical officers have been in progress. These institution based training involving nearly 300 health workers and 150 medical officers has resulted in (i) development of manuals of mental health for doctors and health workers (ii) clarity of the training approaches, (iii) development of evaluation instruments and (iv) record system for mental health care at primary health care [6], [7], [8].
Follow up visit to Primary Health Centres:
An often asked question is the ability of the PHC personnel to undertake mental health care following training programmes. Two systematic attempts were made to visit all the trained PHC personnel, about six months to two years following the training by the NIMHANS team. The aim was to understand the process of implementing the mental health programme at grassroot level and the need for administrative support. More than 30 Primary Health Centres and sub-units were visited and evaluated. These primary health centre staff had received training of one to two weeks at NIMHANS, Bangalore. During the visit each of the trained person was seen in a one-to-one situation. During the interview the information relating to the various mental health care activities undertaken by the person, the problems in implementing the programme, the availability of drugs and records and the practicability of carrying out mental health care were obtained. A pleasant surprise was that of PHC personnel did not consider mental health care as an additional work. However, the following administrative and supervisory needs were considered essential, namely (i) regular monitoring at District level (ii) provision of simple records for care and reporting (iii) provision of psychotropic drugs on a regular basis

(iv) provision of health education material for public education (v) organisation of camps to improve public understanding and acceptance of PHC as places of
treatment (vi) refresher courses for all health personnel following initial training, and (vii) need to train all members of primary health care team.
Following this a number of activities were initiated at the state level (Karnataka) like periodic meetings with District Officers and sensitisation of Director of Health and Family Welfare. This led to the appointment of a programme officer at state level and the formation of State Mental Health Advisory Committee for Karnataka.
District Mental Health Programme:
The community mental health projects reviewed earlier have involved population units of 40,000 to 1,00,000. This meant that the mental health programme was implemented in one of the 8-10 blocks in a district. Discussions with planners and administrators pointed to the need to develop a model involving the district as the planning unit. This meant that the population covered had to increase from 1 lakh to 1.5 million to 2 million. This led to the development of district mental health programme, at Bellary district which is 320 kms away from Bangalore. The essential features of this project started in 1985 are (i) coverage of a population of 1.5 million (ii) appointment of a programme officer from state services (iii) decentralised training to all the health personnel and medical officers at the district headquarters
and primary health centres (iv) development of a simple records system (v) ensuring availability of drugs constantly, and (vi) monthly monitoring at district level.
The important features of this project is the combined effort of three agencies - Director of Health and Family Welfare, Karnataka, District Commissioner, Bellary and NIMHANS. An officer of DHO team is posted as a full time coordinator. The District Commissioner, Bellary has provided Rs. 50,000 annually for drugs and records. The outcome of this project should provide a probable model to plan the mental health programme at a district level.
Steps taken in implementing the NMHP
Training of trainers:
Implementation of the NMHP requires the mental health professionals to play a more active role in addition to clinical care. This specifically relates to (i) understanding of the health and welfare infrastructure in the country, (ii) aspects of mental health planning like choice of support and supervisory work.
Training and orientation to these aspects has not been part of regular post-graduate training. Even now, only about 25% of the post-graduate centres of psychiatry have facilities for this area of training.

It was recognised that mental health professionals should be provided short courses of training in this area. The first was organised by ICMR, New Delhi in July-August 1981. Since 1982, a number of 3-4 weeks training for trainers courses have been organised at NIMHANS, Bangalore, CIP, Ranchi, AIIMS, New Delhi and PGIMER, Chandigarh. It is gratifying to find that many of the trainees have initiated PHC level activities in their own centres. The training has been multi-disciplinary and has involved different categories of mental health professionals. Currently, support for this training is available from WHO country funds as well as from ICMR, New Delhi, through its Advanced Centre for Research on Community Mental Health at NIMHANS, Bangalore.
The trainers often could not start any training programme without the support of the administrators and planners of their states. The feed back from many of these trained professionals brought home the necessity to sensitise the planners and administrators about NMHP and demonstrate the working of the community mental health services. This resulted in the organisation of the next level of activity.
Workshop for state level planners:
In most of the states mental health is not identified as part of the basic health care. Attempts to provide mental health care through existing health infrastructure requires an active involvement, and support of the planners for the provision of essential drugs and reorganisation of the work pattern of mental health programmes.
Against this background workshops were organised for state planners (Health Secretary, Director of Health and Family Welfare, DME, and Senior psychiatrist) with the objectives to : 1. Review mental health services in participating states 2. Review the development of community mental health care approaches in the country and the
formulation of NMHP 3. Develop mechanisms to implement NMHP in their states.
The first workshop (February 13-14, 1984) included planners from Andhra Pradesh, Madhya Pradesh, Rajasthan and Uttar Pradesh. The participants of a second workshop were from Haryana, Himachal Pradesh, Maharashtra, and Pondicherry (U. T.) (August 16-17, 1985). The third workshop involved the state planners of Kerala, Jammu and Kashmir, Gujarat, Punjab, Tamil Nadu and Goa (U. T) (February 13-14, 1986).
The first day of each workshop was devoted to the review of current mental health activities and constraints in functioning. Next the National Mental Health Programme was discussed and different approaches to Community Mental Health were reviewed. Following this, on the second day, the state level teams met with resource personnel to develop specific plans to implement the National Mental Health Programme in the respective states. It is salient to note that these are the first attempts to examine the operational aspects of NMHP. The recommendations of the workshop are as follows: 1. Recognition of mental health as part of PHC. 2. Approval of approaches in NMHP as the basic method to provide mental health care. 3. Recommendation for state level representation in central mental health advisory body by rotation. 4. Formation of mental health advisory bodies in the state as part of PHC Advisory Bodies. 5. Provision of programme officer at state level. 6. Strengthening of departments of psychiatry in medical colleges. 7. Acceptance of provision of essential psychotropic drugs at all health facilities. 8. Creation of psychiatric posts at District Hospitals and 9. Need for central support for finances and professional / technical support from National Institutes.

Workshops on NMHP for MH professionals:
As noted above, the NMHP outlines the broad approaches to be adopted to provide mental health care. The different states and union territories of the country have striking differences in the development of health services in general and mental health services in particular. It is this recognition that calls for development of state level plans with the active involvement of the professionals. To achieve this goal, two levels of activities have been initiated. One is state level workshops for psychiatrists. Secondly, workshops for clinical psychologists, psychiatric social workers and psychiatric nurses.
State level workshops for psychiatrists have been organised in Andhra Pradesh (October 4, 1985), Karnataka (November 22, 1985), Himachal Pradesh (November 30, 1985), Maharashtra (January 11, 1986), Punjab (February 1, 1986), Rajasthan (April 9, 1986), Haryana (April 10, 1986), Tamil Nadu, April 21, 1986), Kerala (May 3, 1986) and Gujarat (June 13, 1986).
The aims of the workshop were to : (i) Review the existing mental health care facilities in the state and constraints in functioning, (ii) Review the background to community mental health approach and development of NMHP. (iii) Develop recommendations to integrate mental health with primary health care in the state.
There has been a consistent appreciation and willingness of all the psychiatrists for implementation of the NMHP. There has been an uniform view that development of state level plans is important and timely. The workshops have also provided an opportunity to develop the services in a coordinated manner. The possibility of intra-state cooperation in future work is another development. The major recommendations of the workshops conducted so far are: 1. Strengthening of psychiatric departments (staff, beds, full team, drugs, transport). 2. To organise training for psychiatrists in community mental health. 3. Develop linkages with ROME Programme 4. Organisation of Extension services with available resources. 5. Regular training for the PHC staff at 2-3 centres to begin with in every state. 6. Appointment of a Programme Officer at State Health Directorate. 7. Formation of the state MH Advisory Committee. 8. Better coordination of district surgeon and district health officers and 9. Organisation of periodic review workshops for monitoring of the mental health programme in the
states.
Training for PHC personnel at state level:
Following the training of trainers and workshops for planners a number of states have taken up regular training for medical officers. Currently, such programmes have been organised in Andhra Pradesh, Uttar Pradesh, Maharashtra, Rajasthan, Himachal Pradesh, Pondicherry, Punjab and Haryana. This development of state level training is a positive one. It can be expected that such training programmes will be organised in greater number of centres in the near future. Similarly, the Central Institute of Psychiatry, Ranchi, for Northern and North Eastern states is organising a number of programmes.
Involvement of the community:
One of the three important objectives of National Mental Health Programme is to involve the community in the implementation of the programme. This can be in the fields of (a) creating awareness to eradicate the misconceptions (b) act as a pressure group to develop facilities and

(c) to provide support by way of financial, material and organisational help.
Limited experiences in our extension services, and organisation of mental health camps in rural areas, has confirmed the utility and importance of active community involvement [10].
Mental health in 7th five year plan:
A happy development since the formulation of NMHP in 1982 has been the consideration of MH care as part of health planning for the 7th Five Year Plan. For the first time a working group on Non-Communicable Disease (NCD) was formed with a subgroup on mental health. The mental health group was led by Prof. N N Wig of New Delhi. This group considered the activities to be taken up in the 7th Five Year Plan. The subgroup recommended training programme for PHC personnel, strengthening of facilities in the mental hospitals and provision of essential psychotropic drugs. It is gratifying to note that in spite of resource constraints, mental health has received support and has been included in the budget of the 7th Five Year Plan with a tentative budget of Rs. 1 crore [11].
ICMR advanced centre for research on community mental health:
The ICMR, New Delhi identified the Community Mental Health Unit of NIMHANS, Bangalore, to set up the above centre. The Centre was inaugurated in September 1984. The aims of the centre is to carry out systematic long range research in the areas of (i) developing models of mental health care (ii) development of culturally relevant research tools for CMH work, (iii) preparation of health education material (iv) dissemination of mental health information and (v) organisation of training programmes on CMH for mental health professionals.
The centre has brought out a research protocol on MH in PHC and manual of MPWs. A news letter on CMH has been started. In October 1985 all the professionals who have worked in this area participated in a workshop to review the decade's (1975-1985) work in this area. The functioning of the centre can be seen as a reflection of the recognition of the needs in this area as well as the professional commitment to support this field of work.
Future Plans
There are three major components of the implementation of the National Mental Health Programme, namely; (i) Sensitising the states to the mental health needs, (ii) Creating mental health programme infrastructure and (iii) Phased implementation of the programme.
State level plans:
The importance of the development of state level strategies has been already emphasised. The efforts carried out have been beneficial to develop operational details of NMHP. It will be necessary to carry out reviews in these states on a periodic basis. The possibility of formation of Regional committees involving the states of the region, along the lines of regional health committees needs consideration. This will lead to cooperation and coordination among the neighbouring states.

Mental health programme infrastructure:
It is essential to identify a programme officer at the level of Joint Director in every state, to implement NMHP and regular monitoring of the activities. State level committee should be part of Primary Health Care committee. This committee should coordinate all the activities at the Primary Health Care and ensure adequate supervision, supply and support to provide total health care. There are many levels of programme infrastructure between mental health advisor at the centre and the PHC personnel in the periphery. The already identified mechanism to plan and monitor i.e. the National Advisory Group on Mental Health (NAGMH) should be set up at the earliest. The NAGMH should have the following aims: (i) To assess priorities in mental health as part of general health services and welfare programmes. (ii) To provide the know-how for the mental health programmes. (iii) To allocate resources to deal with priority problems. (iv) To ensure continuous mental health input in national plans of health and social policy.
The integration of mental health with general health at primary health care should be supported by good back up from specialists at the district level, medical colleges and mental hospitals or other institutions. While the training of personnel at primary care is to be pursued more vigorously, it is essential to ensure that full time psychiatrists are available to manage difficult cases and to supervise and support the activities in the district. The two way referral systems from primary health care, district specialists, medical colleges and mental hospitals should be developed. In spite of recommendations by Indian Medical Council, sufficient attention is still not given for mental health at undergraduate level. Many medical colleges do not have the departments of psychiatry. The mental health skills, needed even in general health care, are not adequately taught and the students are not exposed to mental health problems. This requires urgent attention.
Phased implementation of the programme:
The limited financial outlay and other manpower constraints would necessitate that the programme be implemented in phases. It would be desirable that minimum aspects of the NMHP are implemented in each of the states / UTs including a geographically defined catchment area. Such an approach will also provide for modifications depending upon the difficulties and bottlenecks encountered by the various implementing agencies, corrective measures can be evolved / adopted for the smooth and result-oriented functioning of the mental health programme as envisaged in NMHP.
Conclusions
Though it is only three years since the formulation of the National Mental Health Programme for India (1982), it is gratifying to note that the approaches and the outline of the programme has been taken up in a number of centres all over the country. The professionals, planners and administrators have been involved in a positive manner. The awareness in the community is steadily increasing. With greater commitment and support by the mental health professionals, the National Mental Health Programme can become a reality.

Acknowledgement
The various activities relating to the NMHP at NIMHANS has been the collective effort of the Departments of Psychiatry, Clinical Psychology, Psychiatric Social Work and Psychiatric Nursing and other staff members of the Institute.
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