National Mental Health Programme: Time for reappraisal

Mohan Isaac
Professor of Psychiatry
School of Psychiatry and Clinical Neurosciences
The University of Western Australia, Perth, Australia
(Formerly, Professor and Head, Department of Psychiatry, NIMHANS, Bangalore)

(Chapter from Kulhara P et al Themes and Issues in Contemporary Indian

Psychiatry New Delhi, Indian Psychiatric Society, 2011)

Level 6, W Block, Fremantle Hospital, Fremantle, WA 6160, Australia

Tel: ++ 61 8 9431 3467, 9431 3474, Fax: ++ 61 8 9431 3407
E-mail: Mohan.Isaac@uwa.edu.au

National Mental Health Programme: Time for reappraisal

Introduction
India was one of the first countries in the developing world to formulate a national
mental health programme. As early as 1982, the highest policy making body in the
field of health in the country, the Central Council of Health and Family Welfare
(CCHFW) adopted and recommended for implementation, a National Mental Health
Programme for India (NMHP)1. More than 35 years have passed since this historic
adoption and much has changed in the fields of health care delivery as well as
population mental health in India. It is worthwhile to review the progress of
implementation of the programme and consider how relevant the initial formulations
are in the context of current scenario of mental health in India. This paper will provide
a historical perspective of the genesis and evolution of NMHP, describe its current
status, critically appraise the existing situation, the progress, successes and failures in
this area and then discuss where we go from here i.e. what further needs to be done
and future direction for sustainable growth and development of this area.

Genesis and evolution of the National Mental Health Programme for

India
By the 1970s, community surveys of mental disorders carried out in different parts of
the country had shown that all types of mental disorders were widely prevalent in
India.2 Comprehensive and authoritative reviews of the situation of psychiatric
disorders in developing countries including India by Neki and Carstairs highlighted
the gross neglect of mental disorders in developing countries due to a variety of
reasons which included pervasive stigma, widespread misconceptions, grossly
inadequate budgets for health care including mental health and acute shortage of
trained mental health personnel. It was pointed out that in developing countries; basic
mental health care should be decentralized and integrated with the existing system of
general health services. 3, 4
There are at least five important factors which contributed to the drafting of the
national mental health programme for India during the early 1980s.
1. The organization of mental health services in developing countries a set of
recommendations by an expert committee of the World Health Organization. 5
The strategy of integrating mental health into primary care services was strongly
endorsed by an Expert Committee set up by the World Health Organization to make
recommendations about ways and means of delivering mental health services in
developing countries which had acute shortage of trained mental health professionals.
Some of these recommendations made during the mid 1970s are very relevant even
today and have been repeated and reemphasized by numerous expert groups and
international organizations, subsequently... For example, the expert committee
recommended that:
Basic mental health care should be integrated with general health services and be
provided by non-specialized health workers, at all levels.

. countries should, in the first instance carry out one or more pilot programmes to
test the practicability of including basic mental health care in an already established
programme of health care in a defined rural or urban population.
. training programmes, including simple manuals of instructions for training of
health workers should be devised and evaluated
2. Starting of a specially designated Community Mental Health Unit at the
National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore
1975 6
Mental health needs assessment and situation analysis in over 200 villages situated
around the rural mental health centre at Sakalwara in Bangalore rural district covering
a population of about 100,000 (average population covered by a primary health centre
in most states of India during the 1970s) were carried out by the community mental
health unit of NIMHANS. Simple methods of identification and management of
persons with mentally illness, mental retardation and epilepsy in the rural community
by primary care personnel were developed.7 Pilot training programmes in basic
mental health care for primary health care (PHC) personnel were conducted in various
primary health centres such as Anekal, Malur and Solur in Bangalore, rural, Kolar and
Tumkur districts in Karnataka state.8 Draft manuals of instructions in mental health
care for PHC personnel were written and pilot tested.9,10 Simple mental health
educational materials which could be used by multipurpose health workers in rural
areas were also developed. A variety of methods for evaluating the training in mental
health provided to PHC personnel were developed and tested. 11,12,13,14 Based on the
pilot experiences from its rural mental health centre, the community mental health
unit at NIMHANS developed a strategy for taking mental health care to the rural areas
through the existing primary health care network.15
3. World Health Organization (WHO) Multi-country project: Strategies for
extending mental health services into the community (1976-1981)
The propose model of integrating mental health with general health services and
providing basic mental health care by trained health workers and doctors as an
integral part of primary health care received substantial support from a multi-country
collaborative project initiated by the WHO and carried out in 7 geographically defined
areas in 7 developing countries, Brazil, Colombia, Egypt, India, Philippines, Senegal
and Sudan. The department of psychiatry at the post graduate institute of medical
education and research in Chandigarh was the centre in India and the model was
developed in the Raipur Rani block in Haryana state.16, 17, 18
4. The Declaration of Alma Ata- to achieve Health for All by 2000 by universal
provision of primary health care (1978)
The emergence of the concept of primary health care during the 1970s provided a
radically new way of formulating health care policy particularly in developing
countries of Africa, Asia and Latin America. A major international conference on
primary health care organized in 1978 by the WHO and UNICEF in Alma-Ata in the
then Soviet Union (now Almaty, capital of Kazakhstan) urged all governments, health

and development agencies, and the world community to protect and promote the
health of all the people of the world. The famous Health for All by 2000 slogan
was born and primary health care was declared the bedrock of health care provision
globally. According to the Alma-Ata declaration, primary health care is "essential
health care based on practical, scientifically sound and socially acceptable methods and
technology made universally accessible to individuals and families in the community through
their full participation and at a cost that the community and the country can afford to maintain
at every stage of their development in the spirit of self-determination" (Declaration of AlmaAta 1978).19 Primary health care was essentially an approach to the provision of basic health
services.

5. Indian Council of Medical Research Department of Science and Technology

(ICMR-DST) Collaborative project on Severe Mental Morbidity
During the late 1970s and the early 1980s, the Indian Council of Medical research
(ICMR) and the Department of science and Technology (DST) of Government of
India funded a 4 centre collaborative study to evaluate the feasibility of training PHC
staff to provide mental health care as part of their routine work. This evaluation of a
mental health intervention strategy involving primary care personnel was carried out
for one year covering a population of 40, 000 in a primary health centre at four
centres, one each from the South, North, East and West of the country, Bangalore,
Patiala, Calcutta and Baroda. At the end of one year period about 20% of the actual
cases were identified and managed by the PHC personnel under the overall
supervision of the centre staff. 20, 21, 22
The above factors contributed in no small measure to the drafting of the NMHP. The
draft of the NMHP, written by an expert drafting committee which consisted of some
of the leading, senior psychiatrists in India then was reviewed and revised in two
national workshops attended by a large number of mental health professionals and
other stakeholders during 1981-82, before its final adoption by the Central Council of
Health and Family Welfare (CCHFW) in August 1982. The objectives of NMHP
were: (a) to ensure the availability and accessibility of minimum mental healthcare for
all in the foreseeable future, particularly to the most vulnerable and underprivileged
sections of the population; (b) to encourage the application of mental health
knowledge in general healthcare and in social development; and (c) to promote
community participation in the mental health service development and to stimulate
efforts towards self-help in the community. The approach to achieve these objectives
was diffusion of mental health skills to the periphery of the health service system and
integration of basic mental health care into general health services. Towards achieving
the objectives, a set of actions as well as several ambitious targets with specific
timelines were proposed.

What happened after NMHP 1982?

While the adoption of the national mental health programme document in 1982 by the
CCHFW (and recommendation of its implementation) was a great achievement, there
were numerous issues which were left unclear. Most importantly, no budgetary
estimates or provisions were made for the implementation of the programme. There
was lack of clarity regarding who should fund the programme the federal
government of India or the state governments who perpetually had inadequate funds

for health care. Although the draft of the programme was discussed in great detail by
the mental health profession and revised before its final adoption by the CCHFW,
there was a very lukewarm response and in some instances, almost rejection of the
programme by psychiatrists. Great doubts were expressed about the feasibility of
implementing the programme in larger populations and in real world settings as
almost all the pilots and feasibility projects were carried out by only research and
training institutes and in smaller populations of up to 40, 000. Important concerns
such as, can results obtained by highly motivated personnel in a small population be
replicated in ordinary health care settings, are experiences from 40,000 population
translatable to the total population (15 to 20 lakhs) of the administrative unit of a
district, were raised by many. The need for planning the implementation of the
programme at a district level was highlighted.
The progress of implementation of NMHP during the past 28 years (from 1982 to
2010) can be considered under the following five specific periods when various
significant developments occurred.
1) 1982-1990 Development of the pilot district mental health programmea at
Bellary district in Karnataka
Realizing that the NMHP was not likely to be implemented on a larger scale without
demonstration of its feasibility in larger populations, the National Institute of Mental
Health and Neuro Sciences developed a programme to operationalize and implement
the NMHP in a district. Bellary district with a population of about 20 lakhs, located
about 350 kms away from Bangalore was chosen for the pilot development of a
district level mental health programme. This project was undertaken with the active
support of the directorate of health and family welfare services, government of
Karnataka and the Bellary district administration.
Medical officers and health workers from all the primary health centres in the district
were trained in mental health care in a staggered and decentralized manner.23. They
were also supported, supervised and provided with additional on-the-job training.
Besides training for all primary care staff, the other components of the district mental
health programme at Bellary were: provision of 6 essential psychotropic and anti
epileptic drugs (chlorpromazine, amitryptaline, trihexyphenidyl, injection
fluphenazine deaconate, phenobarbitone and diphenyl hydantoin) at all primary health
centres and sub centres, a system of simple mental heath case records, a system of
monthly reporting, regular monitoring and feed back from the district level mental
health team. At the district head quarters, the mental health team consisted of a
psychiatrist, clinical psychologist, a psychiatric social worker and a statistical clerk.
The psychiatrist ran a mental health clinic at the district hospital to review patients
referred from the primary health centres. The psychiatrist could admit up to 10
patients at the district hospital for brief in patient treatment, if and when necessary.
The mental health programme was reviewed every month at the district level by the
district health officer during the monthly meeting of primary health centre medical
officers. During the period 1985 1990, the feasibility of delivering basic mental
health care at the district, taluk and primary health centre levels by trained primary
health centre workers was demonstrated in whole district of Bellary in Karnataka
State. 24, 25, 26, 27.

2) From the late eighties to 1996 Training of trainers and sensitization

workshops
Despite showing that, with appropriate support from the state health department,
primary health centre workers can be trained and supervised to identify and manage
certain types of mental disorders and epilepsy along with their routine work at the
primary health centres, the climate in the country amongst senior health planners and
administrators as well as public health and mental health experts were not ripe wider
implementation of the NMHP. Most mental health professionals were disinterested in
public health aspects of mental health. The country office of the WHO supported a
programme of training mental health professionals to become trainers of primary care
staff and programme mangers of NMHP. Funding was also made available for holding
nation wide sensitization programmes for senior health administrators.28
State level health administrators, planners and mental health professionals from all the
States and Union Territories were sensitized to implement the national mental health
programme in their respective states, through series of workshops. It was suggested
that modest and viable mental health care programmes be developed in each state and
union territory. However, states and union territories themselves were unable to
initiate any meaningful programmes due to various constraints, most notably, paucity
of funds.
A national workshop organized by NIMHANS, in collaboration with Ministry of
Health and Family Welfare, Govt. of India involving the health departments all the
states and union territories in February 1996, strongly recommended that National
Mental Health Programme should be activated by sanction of adequate funds from
Central Government (Plan funds). The workshop further recommended that District
Mental Health Programmes should be implemented in each state/union territory and
the Bellary programme as developed by NIMHANS could serve as a prototype.
The emphasis should be in involving the families in looking after the mentally ill and
special emphasis should be given to poor, weaker and underprivileged sections of the
society. The workshop also suggested various requirements and components such as
human resources, equipments, beds etc for such a District Mental Health Programme.
The Ministry of Health and Family Welfare, Govt. of India formulated District Mental
Health Programme (under National Mental Health Programme) as a fully centrally
funded 5 year pilot scheme with a total outlay of 115.9 lakhs of rupees for five years
(28.5, 21.5, 20.7, 21 and 24 lakhs of rupees during the 1 st, 2nd, 3rd, 4th and 5th years of
the scheme respectively) in 1996-97. The programme was to be implemented in two
phases, the Phase I was to be taken up during 1996-97, and the Phase II was to be a
continuation of the programme during the IX Five Year Plan period (1997-2002).
Thus, a budget line for implementation of the DMHP as a major component of the
NMHP was created in 1996; 14 years after CCHFW approved the NMHP. DMHP was
to be implemented as a fully centrally supported project

3) 1996-97 to 2002 (IX Five Year Plan) Wider implementation of the District
Mental Health Programme
The District Mental Health Programme was launched during 1996-97 in four districts
one district each in Andhra Pradesh, Assam, Rajasthan and Tamil Nadu. The
programme was extended to 7 more states during 1997-98 the states of Arunachal
Pradesh, Haryana, Himachal Pradesh, Punjab, Madhya Pradesh, Maharashtra and
Uttar Pradesh. The programme was subsequently expanded to one district each in the
States of Kerala, West Bengal, Gujarat and Goa and the union territory of Daman &
Diu during 1998-99, Mizoram, Manipur, Delhi and union territory of Chandigarh
during 1999-2000, and Tripura and Sikkim during 2000-2001. Kerala and Assam
started the programme in a second district during 1999-2000, Andhra Pradesh took up
their second district and Tamil Nadu started the programme in 2 more additional
districts during 2000-2001. The district mental health programme was initiated in 27
districts spread all across the country, situated in 20 states and 2 union territories. The
total budget allocation for the implementation of NMHP during the IX plan period
was rupees 28 crores.
The objectives of the fully centrally funded District Mental Health Programme (under
National Mental Health Programme) scheme were as follows: i) To provide
sustainable mental health services to the community and to integrate these services
with other services, ii) Early detection and treatment of patients within the community
itself, iii) To see that patients and their relatives do not have to travel long distances to
go to hospitals or nursing homes in cities, iv) To take pressure off mental hospitals, v)
To reduce the stigma attached towards mental illness through change of attitude and
public education, and vi) To treat and rehabilitate mentally ill patients discharged
from the mental hospital within the community.
The steady expansion of the district mental programme all across the country during
the IX plan period was also facilitated by a variety of other factors such as:
i)

ii)
iii)

Further recommendations and resolutions by the CCHFW. For example,

the sixth meeting of the CCHFW held in April 1999 made the following
observations and resolutions: a) The central council notes with concern
that mental health problems are on the increase and that this has been a
neglected area so far. As mental health and physical health are both
integral parts of health, mental health should be integrated with physical
health b) More states and UTs should actively participate in the district
mental health programme initiated by the centre c) At least one district
in each state and in the larger states, one additional district for every ten
districts should ideally be covered under this programme in a phased
manner d) To achieve this objective, the council recommends that higher
budget allocation may be made for this programme
The publication of an influential report by the National Human Rights
Commission of India (NHRC) on Quality assurance in mental health29
The wide media publicity, public out cry and intervention by the Supreme
Court of India following the Erwadi tragedy wherein 26 chained mentally
ill persons were accidentally killed in a fire accident that took place in
Erwadi Dargah in Ramanathapuram district of Tamil Nadu state in August
2001.30

4) 2002 to 2007 - X Five Year Plan period

While the DMHP implementation grew from a few districts to 27 during the period
1996-2002, this coverage represented less than 5% of the districts in the country.
Therefore, the Ministry of Health and Family Welfare, Government of India reviewed
the NMHP implementation through a series of meetings with mental health
professionals involved in DMHP and various other stake holders. One of the thrust
areas identified for increasing access to mental health care during the X Five Year
Plan period (2002-2007) was the expansion of DMHP to 100 more districts. The need
to restrategize the NMHP from a single pronged to a multi-pronged programme and to
strengthen facilities and services at secondary and tertiary levels of mental health care
provision to support the growing DMHP was also recognized.31
The Planning Commission of India approved a budget of 190 crores during the X Five
Year Plan for a five pronged strategy to continue implementation of NMHP. The five
strategies adopted were: i) Expand the DMHP to 100 districts ii) Upgrade and
strengthen the departments of psychiatry in government medical colleges / general
hospitals attached to medical colleges to improve treatment and training facilities.
Better mental health care facilities at general hospital and medical college hospital
settings was expected to bring down the load on mental hospitals iii) Modernize and
transform mental hospitals to improve patient care and reduce / prevent long stay iv)
Stronger emphasis and funding for activities providing mental health information,
education and communication (IEC activities) to communities and v) Support
research and training on issues related to the implementation of NMHP. Support to
Central and State mental health authorities to effectively fulfill their role of
monitoring mental health care and implementing the Mental Health Act 1987 and
funding for an independent mid-course evaluation of the DMHP scheme were also
provided for during the X Plan period.
An audit of DMHP carried out by NIMHANS in 2003 32 in the 27 districts where the
programme was started during 1996-2002 showed that there were numerous problems
and bottlenecks in the actual implementation of DMHP. The efficiency and the
effectiveness of the programme varied widely between districts and states / union
territories. A variety of factors such as the motivation and commitment of the nodal
officer and the programme staff, interest and administrative support of the state health
authorities (which include senior officers of Directorate of Health Services,
Directorate of Medical Education, Principal of Medical College, Head of the District
Hospital etc.) and absence of an effective Central Support and Monitoring mechanism
at the Government of India level could be attributed to the differential effectiveness.
District mental health clinics and inpatient facilities for the mentally ill were
established only in 15 of the 27 districts. In districts where the programme was
functioning adequately, mental health services were decentralized to the district level,
if not to the PHC level with partial integration of these services with general health
services. Mental health services were started in a lot of places where none existed.
While adequacy of funds was never a constraint, accessing the available funds posed
enormous administrative and bureaucratic problems. The audit highlighted the need to
i) develop an operational manual for the DMHP ii) review the content, curriculum and
method of training the PHC personnel iii) provide continued support, supervision and
on-the-job training for PHC personnel after the initial training iv) review the priority
conditions covered by the DMHP and make necessary amendments to include

common mental disorders v) enhance IEC activities vi) monitor the programme
regularly and develop time bound targets vii) incorporate aspects prevention and
promotion of mental health such as life skills training and counseling in schools
During the X Plan period, grants were provided for up gradation of psychiatry
departments of 75 government medical colleges /general hospital psychiatry wings
and 26 mental hospitals. DMHP was under implementation in 123 districts throughout
the country. One of the major hindrances to the effective implementation of DMHP
was the non-availability of trained, motivated mental health professionals such as
psychiatrists, clinical psychologists, psychiatric social workers and psychiatric nurses.
The numbers of these professionals trained annually in the country is limited
contributing to the acute shortage of trained human resources in mental health.
5) 2007 onwards - IX Five Year Plan, The current phase
Dealing with the acute shortage of trained human resources in mental health is the
main thrust of the current (XI) Plan. A major chunk of the approved total budget
outlay for mental health of Rupees 408 crores, more than threefold increase from the
previous X Plan, is for setting up 10 Centres of Excellence in the field of Mental
Health in different parts of the country. These centres are being established by
upgrading and strengthening identified mental health institutes, mental hospitals and
departments of psychiatry. The centres will focus on training psychiatrists, clinical
psychologists, psychiatric social workers and psychiatric nurses. 33 Government
medical colleges would also be supported for starting post graduate courses or
increasing the intake capacity for post graduate training in mental health. The existing
districts where the DMHP is under implementation will continue to be supported as
also the other programmes initiated during the X Plan namely modernization of state
run mental hospitals, up gradation of psychiatric wings of government medical
colleges/general hospitals, IEC activities and research on issues relevant to the
NMHP.

Appraisal of the existing situation

As the implementation of NMHP and in particular, the DMHP, its community mental
health programme aimed at enhancing access to basic mental health care in rural
areas, expanded steadily across the country during the past two Five Year Plan
periods, several questions were often raised: Isnt it time for a reappraisal of the
NMHP? Is the main approach of the NMHP namely integration of mental health with
primary care still the right approach, appropriate to the current situation of mental
health in the country? How effective is the DMHP component of NMHP? What
evidence is available for the usefulness of DMHP? Is the DMHP cost-effective? Has
there been any independent evaluation of the DMHP? While answers for all the
questions are not readily available, there are numerous published papers and various
types of reports which provide some of the answers.
1) Is the main approach of the NMHP namely integration of mental health
with primary care still the right approach?
During the past two decades, several international organizations including the World
Health Organization and many expert committees recommendations have repeatedly
9

emphasized the soundness of the approach to integrate mental health with primary
health care as a major relevant strategy for mental health care delivery in developing
countries. An evaluation of this strategy in low and middle income (LAMI) countries
by the WHO in 2001 pointed out that while it was difficult to assess the success of
existing primary care mental health programmes, such integration was the only
realistic option, due to continuing resource constraints in LAMI countries. 34 The
World Health Report in 2001 which was specifically devoted to mental health,
highlighted the need to integrate mental health into primary care especially in low and
middle income countries.35 More recently in 2008, a joint WHO and WONCA report
reaffirmed the urgent importance and advantages of integrating mental health into
primary care systems around the world. 36
This report shows that integration is
achievable in all countries and provides detailed case studies of best practices from
across the world which includes the DMHP in Thiruvananthapuram District of Kerala
State, India. The theme of the most recent World Federation of Mental Health - World
Mental Health day on 10 October 2009 was Mental health in primary health care:
enhancing treatment and promoting mental health. In 2008, thirty years after the
Health for All by 2000 AD Declaration of Alma Ata in 1978, WHO again reiterated
the significance of Primary Health Care in strengthening health systems in LAMI
countries.
An extensive and authoritative review of the situation of mental health care across the
globe in 2007 - the Lancet Global Mental Health series, unequivocally recommends
that .. mental health should be recognized as an integral component of primary and
secondary general health care, particularly in low and middle income countries37.
Several other influential international reports such as the Institute of Medicine, USA,
report on Neurological, Psychiatric & Developmental Disorders - Meeting the
Challenges in the developing world in 2001 and the Disease control in developing
countries Mental health project report have recommended the strengthening of
existing systems of primary care services in developing countries to provide services
for persons with mental disorders.38,39 A recent programme launched by the WHO in
response to the Lancets Call for Action, with the objective to scale up care for
mental, neurological and substance abuse disorders in low and middle income
countries, the mhGAP (mental health Gap Action Programme) has developed
evidence based guidelines of interventions for a number of mental and behavioural
disorders to be used by the primary health care personnel of LAMI countries.
2) How effective is the implementation of NMHP?
There have been several publications and reports which have looked at different
specific aspects of the implementation of NMHP. Most reports suggest that the
implementation is far from optimal and the reasons are numerous. Widespread
misconceptions about the causation and management of mental disorders continue to
be rampant in most parts of the country. Stigma towards mental disorders is rife and
may contribute to underutilization of mental health services where they are provided.
Utilization of public health service especially from primary health centres is generally
low in India. Integration of mental health adds another set of chores to the already
overwhelmed primary care clinicians and other personnel. Time available to assess
and counsel patients is very limited in primary health centres Doing more takes
time and dispensing pills is simply not enough. Patients routinely seen in primary
care settings are patients with co morbidity, sub threshold disorders and multiple

10

somatic complaints, many of whom are chronic. Depression often presents as chronic
pain, chronic fatigue. PHC doctors need to acquire new skills through practical
guidance, in addition to gaining new knowledge through didactic teaching. Most
doctors need help in managing medically unexplained somatic symptoms, which their
mental health training may not have provided.40Although there was gain in
knowledge, doctors were unable to manage patients with mental disorders on their
own. There was need for greater liaison with the district team.41
A variety of lacunae in the current implementation of NMHP have been reported.
These include: i) absence of full time programme officer for NMHP in many states ii)
inadequacies in the training for PHC personnel iii) inadequate record maintenance iv)
non-availability of basic information about patients undergoing treatment at various
centres (regularity of treatment, outcome of treatment, drop-out rates etc) v)
difficulties in recruitment and retention of mental health professionals in the DMHP
vi) non-involvement of the non-governmental organizations (NGO) and the private
sector vii) inadequate mental health educational and community awareness activities
viii) absence of programme outcome indicators and monitoring ix) inadequate
technical support from mental health experts.42 As the NMHP primarily focuses on
rural areas, the need for decentralized mental health care in urban areas has been
highlighted. Drawing data from an 18 month clinical ethnographic study of the
Kanpur DMHP in Uthar Pradesh, Jain and Jadhav observe that the programme relies
heavily on the pharmacological treatment of psychiatric disorders at the exclusion of
community participation and psychosocial approaches. They contend that
psychotropic medication has become the embodiment of Indias community mental
health policy and argue that community psychiatry has, in practice, become an
administrative psychiatry focused on effective distribution of psychotropic
medication43
While funding itself has not been a problem, delayed receipt of funds, irregular
dispersal of funds, administrative blocks in the full utilization of available funds and a
variety managerial issues have bogged down the proper implementation of the NMHP
in many states and Union Territories. A former senior consultant to the Ministry of
Health and Family Welfare, Government of India on mental health notes that Even
adequately funded programmes sometimes fail due to factors such as top-down
approach to planning divorced from ground realities, poor governance, managerial
incompetence, unrealistic expectations from low- paid and poorly motivated primary
care staff44
3) Is there any evidence for the effectiveness of primary care mental health?
A comprehensive review of effectiveness of primary care mental health services in
developing countries as varied as Botswana, Guinea Bissau, Iran, Nicaragua, Nepal,
Tanzania and India noted that adequate data on long term effects were not available
from any of these countries to make meaningful interpretations.34 While mental health
training programmes for primary care personnel may bring about improvements in
mental health knowledge and attitudes, there is only little evidence of changes in
actual practice of health workers. Although diagnostic sensitivity of trained workers
increases, there is no evidence if such improvements result in better outcomes for
patients. Many reports mention the numbers of patients with various mental disorders

11

identified and treated in primary care but do not provide any information on long term
clinical outcomes. Most training programmes consist of short courses focusing on
diagnosis and pharmacological management without much emphasis on skill
acquisition and application in clinical settings.45 Numerous other factors such as
erratic drug supplies, high rates of attrition of trained staff, lack of continued on-thejob training and inadequate support and supervision also influence the effectiveness
and long term sustainability of primary care mental health programmes.
A review of the current practice in delivering care to adults with common mental
disorders in primary care settings of low income countries, point out that much
remains unknown, undocumented and unshared.46 Whether primary care staff can
improve outcomes for these disorders is yet to be established widely. While there is
evidence that epilepsy can be treated effectively by primary care staff, evidence for
effective management of severe mental disorders is limited and largely inadequate.34
Even though the majority of persons with common mental disorders who receive
treatment in developing countries, just as in developed ones, do so in general or
primary care settings, only a very small proportion of such persons receive minimally
adequate treatment.47,48 This inadequacy of service seems to reflect both the lack of
adequate training for primary health care providers and the pattern of health service
delivery in those settings. A large cross-national WHO collaborative study suggests
that primary health care service in developing countries is often characterized by lack
of continuity of care and poor record keeping.49, 50
The most convincing evidence for the effectiveness of the DMHP comes from North
Kerala. During the past few years, the DMHP is being implemented in the five
districts of Kozhikode, Kannur, Malappuram, Kasargod and Wayanad under the
overall co-ordination of the Institute of Mental Health and Neuro Sciences
(IMHANS), Kozhikode, Kerala an institution selected by the Ministry of Health and
Family Welfare, Government of India for elevation as a Centre of Excellence in
mental health during the current 11th Five Year Plan. Persons requiring inpatient
treatment for severe mental disorders from all the above districts are generally
admitted to the mental hospital located in Kozhikode. The annual number of
admissions in Kozhikode mental hospital in 2005 was 2622. The total annual
admissions in the hospital steadily came down to 1836 in 2009. Similarly, the total
annual outpatient follow-ups of discharged patients too came down from 31802 in
2005 to 24610 in 2009, while the total annual number of new outpatient registrations
went up from 2243 in 2005 to 2944 in 200951
4) Has there been any independent evaluation of the DMHP?
One of the major criticisms of the NMHP and particularly its DMHP component was
that it was not independently evaluated before its larger scale expansion during 10th
and 11th Plans. Such an independent evaluation was commissioned by the Ministry of
Health and Family Welfare, Government of India and was carried out the Indian
Council of Marketing Research (ICMR), a division of Planman Consulting (India)
Private Ltd, New Delhi during 2008-2009. The terms of reference for the evaluation
included, besides objective and critical assessment of the DMHP, providing
recommendations and suggestions for improvements in implementation and future
expansion of the programme.52

12

20 districts (4 each from five zones of the country East, West, North, South and
Central) and 5 non-DMHP districts (control) were selected for the evaluation. The
beneficiary districts were chosen proportionately from those started during the 9th and
10th Five Year Plans. Primary data was collected from 15 th October to 15th November
2008. Perceptions of medical professionals, beneficiaries (patients) and community
members were systematically obtained. 60 respondents from the beneficiaries, 30
respondents from the community and 10 respondents from the health system, a total
of 100 respondents from each district (total respondents from 20 districts = 2000)
were interviewed. Various aspects of the programme including sanction and utilization
of funds, recruitment and retention of personnel, quality and effects of training, nature
of IEC activities, availability of drugs, satisfaction with quality of services and
community awareness of mental health were evaluated. While the report ovides
numerous recommendations and suggestions, perhaps one of the most important
recommendations is: It was observed that implementation of DMHP has resulted in
availability of basic mental health services at district / sub-district level. As such it is
recommended to expand this programme to other districts of the country
A wide variety of administrative and managerial bottlenecks were identified by the
evaluation. It was observed that irregular flow of funds had affected the
implementation of the programme adversely. There were significant delays in
initiation of the programme even after the release of funds in some districts. Shortage
of trained and motivated mental health professionals and difficulties in retaining
recruited staff were problems in many states. Low utilization of funds, meant for
training and IEC activities was noticed in many districts. It was observed that most
beneficiaries (61%) accessed the district hospital as their first point of contact for
availing mental health services. Community Health Centres (CHC) (8.7%), Primary
Health Centres (7.6%) and sub-centres (2.3%) were accessed to a much lesser extent.

Future of NMHP
For a country as large as India, with a population of about 1.3 billion and extremely
limited number of trained mental health professionals, the much maligned basic
approach of the NMHP continue to be an acceptable and feasible method of extending
basic mental health services to the length and breadth of the country. However, the
approach needs a major technical and operational review by mental health and public
health experts and certain corrections following the review. The main component of
the NMHP namely the district mental health programme was developed in Bellary
district more than 20 years ago and has not changed much since then. The situation
across the country is so varied in different states and union territories that one size
will not fit all. Local issues should be identified, and feasibility of programme
implementation assessed. Appropriate local modifications to the basic programme will
have to be made in different parts of the country.
For more efficient and quick countrywide implementation of the programme, many of
the salient recommendations of the recent independent review of the DMHP will have
to be seriously considered.52 To make mental health care more accessible to those who
most require them, the services will have to be strengthened at the sub-centre, PHC
and CHC levels. NMHP is currently a fully centrally funded Plan programme. To
ensure continuity of the programme beyond the 11th Five Year Plan, the financial
responsibility for the programme will have to be gradually shifted to the state
13

governments and mental health services will have to be integrated in the State and
District Implementation Plan. There is an urgent need to enhance the capacity in the
country to train mental health professionals. The various staff positions in DMHP will
have to be made more attractive to motivate and retain professional staff. The DMHP
staffs also require training in programme management and organizational activities.
Appropriate non-pharmacological interventions will have to be introduced into the
programme and the PHC staff trained adequately. The community participation and
ICE components of NMHP need strengthening. Plans and proposals are most likely to
lead to action, only if they are accompanied by: detailed specifications and clear
instructions of what needs to be done, what the likely barriers are to implementing the
proposal, how these barriers could be overcome and how progress towards specific
goals could be measured. Besides everything else, a set of specific, measurable
outcome indicators for the DMHP will have to be urgently developed and used for
regular and continuous reporting and morning of the programme.
One of the proposals for better implementation of NMHP is its integration with the
National Rural Health Mission (NRHM). NRHM was launched by Government of
India in 2005 to carry out necessary architectural correction in the basic health care
delivery system for better delivery of primary health care. NRHM contributed to a
major increase in public expenditure on health in the country. The mission focuses on
decentralization and district management of health programmes. By induction of
management and financial personnel into district health system, NRHM efficiency is
enhanced. NRHM focuses also on community participation and ownership of assets
and aims to enhance capacity of panchayat raj institutions to own, control and manage
public health services. The mission promotes access to improved healthcare at
household level through the female health activist who is referred to as Accredited
Social Health Activist (ASHA). Every village/large habitat will have a female
Accredited Social Health Activist (ASHA). Planning for integration of DMHP with
the National Rural Health Mission will contribute numerous advantages to the DMHP
such as optimal use of existing infrastructure at various levels of health care delivery
system and sustenance of DMHP beyond the expiry of the period of central assistance
by its integration in the district health system. An integrated IEC under NRHM,
involvement of NRHM infrastructure for training related to mental health at the
district level, use of NRHM machinery for procurement of drugs to be used in DMHP
and building of credible referral chains for appropriate management of cases detected
at lower levels of the health care delivery system are all additional advantages of
integration of DMHP with NRHM. Specific details and mechanisms of such
integration will need to be developed.
Currently there is almost no involvement of the private and non-governmental sectors
in the NMHP. Collaboration and partnerships with these sectors will have to be
developed. The growing number of carers and users (of mental health services)
organizations will have to be actively involved in further planning and
implementation of NMHP. Ultimately, there will have to be a whole of government
response to the numerous problems in the field of mental health care.

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