National Mental Health Program and the Bellary model of DMHP
The impetus for NMHP in India came initially from W.H.O., which passed a formal resolution in the meeting of the W.H.O. Mental Health Advisory Group in Manila in 1979, urging all member countries to adopt a NMHP. The work done by NIMHANS in Sakalawara and by Post Graduate Institute of Medical Education and Research, Chandigarh in Raipur Rani, Haryana in demonstrating the feasibility of integrating mental health care with general health care and the tools developed by them provided the basis for development of NMHP.
After several meetings and workshops attended by the Director General of Health Services, psychiatrists and other stake holders, the National Mental Health Program (NMHP) was approved for countrywide implementation in 1982. The main objective NMHP was to ensure the availability and accessibility of minimum mental healthcare for everyone, particularly to the most vulnerable and poorest sections of the population. However at that time it was not specified as to who would fund it – the central or state governments, and no provisions were made in the central budget. NMHP was met with skepticism by psychiatrists themselves as to feasibility of implementing it in larger populations, as no real life case studies existed.
NIMHANS realized that the know-how for providing psychiatric care through existing primary health care system had to be scaled up to larger areas of target population and its success had to be demonstrated in order to convince the stakeholders of the feasibility of NMHP. The community mental health unit of NIMHANS developed the District Mental Health Program during 1984 – 85.
One of the problems identified during earlier surveys was that while health workers had identified cases of epilepsy and mental illness, and referred them to the nearest PHC, the patients failed to turn up. Seeing the low number of cases, many PHC doctors and the District Health Officer (DHO) thought that prevalence of these disorders in their areas was low. To instill confidence in the general public that neuropsychiatric cases could be treated at the PHC or PHU near their villages, and to prove to the doctors that the prevalence was high, a number of mental health camps had been organized by NIMHANS in several places in Bellary district during 1983. As many as 300 patients had turned up at each camp, and were treated and referred to PHCs. The health officials and the DHO became convinced of the need for providing mental health care at district head quarters and PHCs.
Bellary District was a natural choice for developing the DMHP since field evaluations of training given to PHC staff had been done in Bellary District and its population was large, being 1.5 million. The Bellary model had several components : implementation of decentralized training programs for health staff at all levels, provision of a minimum range of drugs, a simple recording system, a district program officer, a district mental health clinic, on-the-job training carried out during the field visits by the district team or NIMHANS team, monthly reporting and community participation.
The local government was got involved through setting up a District Mental Health Committee as part of the District Health and Family Welfare Committee. It was headed by the Deputy Commissioner and had representatives from different departments. The NIMHANS team, including CRC, consisted of more than 12 people who were involved in the Bellary DMHP at various times.
The Bellary program was successful largely due to the concentration of resources devoted to it. The model developed in Bellary was later implemented in other states. However in real-life conditions, the Bellary model failed to live up to its initial promise. This was the conclusion of an Indian Council of Medical Research– Department of Science and Technology (ICMR – DST) study done in 1987.
From the late 1980s, many workshops were held to sensitize State level health administrators, planners and mental health professionals from all the States and Union Territories to implement the national mental health program. However the states could not implement any programs since funds were not available and the officials responsible lacked interest.
NIHMANS formed 4 teams to visit the 40 mental hospitals to review their functioning. CRC visited many states from across the country as part of the NIMHANS team. The team sensitized all the people in the health care system including directors of health; many of the latter did not even know the difference between psychiatrist and psychologist. They were aware of only schizophrenia and bipolar disorder; they had no knowledge of minor disorders and treatment outcomes of major mental disorders.
CRC found that psychiatrists had an apprehension that if non-psychiatry doctors were trained, they would lose income and importance. CRC impressed upon them that training doctors in psychiatry would not deprive them of work. They were also reluctant to work outside the comfort and safety of hospitals. CRC noticed that the concept of Satellite Health Clinics was favored by the psychiatrists. The psychiatrist would go to a zilla or taluk hospital and run a clinic with the help of general doctors in the hospital. They also favored health camps : in these camps the psychiatrist would get publicity in the community, and feel like a VIP with people waiting in queue to meet him. It was a challenge to implement NMHP in many states, where the psychiatrists or the administration were not committed.
NIMHANS organized a national workshop along with the Ministry of Health and Family Welfare in February 1996. The workshop recommended that NMHP should be activated by funds being made available from the central government under the five year plans and that DMHP should be implemented in each state using the Bellay model as the template. Finally, 14 years after NHMP was approved, Government of India formulated the District Mental Health Program (under National Mental Health Program) as a centrally funded 5 year pilot scheme with a total outlay of 115.9 lakh rupees for five years under the Ninth Five Year Plan. During the period 1996 to 2001, DMHP was implemented in 27 districts across 20 states and 2 union territories.
In the Tenth Five Year Plan (2002 – 2007), it was proposed to increase the coverage of DMHP to 100 districts. The budgetary proposal was to be approved after an evaluation of the DMHP under the Ninth Five Year Plan. Accordingly in April 2003, Ministry of Health and Family Welfare asked NIMHANS to carry out the evaluation. NIMHANS constituted an expert team headed by its Director; the team included CRC. Two members of the team visited all the 27 districts to review the working of DMHP.
The evaluation team found varying levels of success in implementation of DMHP and problems in recruitment, resources available and access to funds. Most centers had been unable to recruit all of the prescribed staff. Recruitment rules of the respective state governments; rules regarding job reservations based on caste, etc; availability of persons with requisite qualifications and frequent turnover of staff were reported as major bottlenecks in maintaining the prescribed number of staff in the centers. Creation of a 10-bedded inpatient facility at the district hospital was an important component of the DMHP. Outpatient clinical services (the District mental health clinic in the model) were well established at the district hospital in 15 of the 27 centers. Only 14 of the 27 centers had established a 10-bedded inpatient facility. Outpatient services for mentally ill persons at taluk level hospitals and primary health centers were established only in 6 of the 27 centers. At two centers, no concrete work had even been started.
In the XI Five Year Plan, DMHP covered 123 districts. Based on later reviews of the program, the Ministry of Health and Family Welfare (MoHFW) concluded that the DMHP required substantial changes and planned a complete overhaul of the DMHP in the XIIth Five Year Plan (2012-2017).