Inclusion of Mental Health in National Rural Health Mission (NRHM): Challenges and Prospects

a study entitled ―Impact


INTRODUCTION
The effective plan for the nation's economic and social growth must include a much concern on health.The National Rural Health Mission (NRHM) was established by the Indian government in recognition of the crucial role that health plays in enhancing individuals' quality of life (NRHM).It indicates a plan of action to increase public spending on healthcare, decrease regional disparities in healthcare infrastructure, pool resources, merge institutional culture, decentralize and district manage health programs, and involve the community as integral parts of the strategy while adopting a complementary approach by relating health to factors of good healthcare.More precisely, all of this is done to better the accessibility and availability of high-quality healthcare for individuals, particularly for those living in rural regions, the underprivileged, women, and children.In light of the National Mental Health Program (NMHP) inconsistent performance since 1982, the absence of mental health from the NRHM mission document becomes even more significance.There has been very small effort to date to improve mental health services at the national, state, or regional level due to the NMHP's many flaws and implementation restrictions, with the exception of some southern states like Tamil Nadu and Kerala.Mental health also has not found its proper place in national or state health plans.

THEORETICAL REVIEW
By reviewing some literature focused on Mental Health, Suicides and National Rural Health Mission (NRMH), this portion of the paper aids in comprehending the implications connected to the current study.
Malla A, Joober R, Garcia A. ( 2015) conducted a study entitled -Mental illness is like any other medical illness: a critical examination of the statement and its impact on patient care and society‖.The study shows that it is important to consider new developments that is coming from the disciplines of recovery, early intervention, and good mental health in addition to the knowledge that service providers, scientists, and service users have already obtained.The study also concludes that it would be crucial to accept scientifically supported explanatory models of mental illness, including those based on biogenetic, social, and cultural factors as well as those provided by the same persons they are attempting to help.Xiong J, Lipsitz O, Nasri F, et al. (2020) The study focused on the relevant risk factors and looked at the psychological state of the general population during the COVID-19 epidemic.In the majority of investigations, unfavourable psychiatric symptoms were shown to be highly prevalent.In high-, middle-, and low-income areas, the COVID-19 epidemic poses an unparalleled threat to mental health.Schäfera SK, Soppa MR, Schanza CG, et al. (2020) conducted a study entitled -Impact of COVID-19 on Public Mental Health and the Buffering Effect of a Sense of Coherence‖.The findings of this study help us better understand how COVID-19 may affect mental health.Our findings reveal that a group of respondents with low levels of SOC may be at risk for the development of clinically significant symptom change from pre-to post-covid, despite the fact that the majority of respondents showed no clinically significant symptom change.
Ransing R, Kar SK, Menon V. (2021) reveals that the field of mental health research is fairly young.Some of the obstacles to mental health research in India include the small research capacity, the shortage of qualified mental health professionals (MHPs), the lack of financing, the lack of training opportunities for researchers, and the government's low priority for mental healthcare.Numerous institutions and professional organisations have implemented numerous novel strategies, such as capacity building and research technique training, to enhance mental health research and overcome some of the current constraints.
Venkatashiva RB, Arti G, Ayush L, et al. ( 2013) conducted a study entitled as -Mental Health Issues and Challenges in India: A Review‖ the examines that the burden of mental illness is much more than what the general public is aware of.According to several studies, women, the elderly, those who had just survived a tragedy, industrial employees, kids, teenagers, and those with long-term medical illnesses were more likely than others to suffer from mental disorders.Better living circumstances, primary healthcare, and women's empowerment are all necessary.To stop mental problems from progressing from milder cases to more severe and persistent ones, several interventions are required.Improved basic healthcare is urgently in need of straightforward diagnostic procedures that are readily accessible, as well as affordable treatments.

METHODOLOGY
In this present study the objective has been made to analyses the importance of inclusion of mental health in National Rural Health Mission and to examine the role of NMHP and DMHP since its inception.The present study is based on purely secondary source.Data has been collected from various secondary sources, like World Health Organisation, World Bank, NRHM, National Family Health Survey-4(NFHS-4), National Mental Health Programme(NMHP), different mental health institutions, Ministry of Health Family and Welfare(MoHFW) Government of India, National Crime Records Bureau, Union Budget for Mental Health.Various books and articles published in different health journals.

RESULTS AND DISCUSSION
Unfortunately, despite having a National Mental Health Programme (NMHP) after seventy-five years of independence, we lack any national epidemiological statistics on mental diseases.However, study investigations from various regions of the nation have proven that mental illness is as prevalent in India as it is everywhere, and it is as prevalent in rural and urban regions, despite the fact that we lack epidemiological statistics.Even though this hardship may not be apparent to others, mental problems place a heavy strain on those who are affected, their families, and society.
Mental illnesses are important for public health, according to data on their frequency and distribution in rural-urban populations, schoolchildren, and communities exposed to specific pressures such disasters and migrations.According to estimates, 10 to 15 percent of the population experiences mental health issues.According to a 1993 World Bank research, the Disability Adjusted Life Year loss caused by neuro-psychiatric disorders is substantially larger than the combined costs of diarrhoea, malaria, worm infestations, and TB.By 2020, it is predicted that the loss of DALYs from mental illnesses would account for 15% of all disease burden worldwide.Numerous epidemiological research carried out in India over the past 20 years reveal that serious mental disorders are quite common around the world.According to these studies, the prevalence varies from 18 to 207 per 1000 people, with a median of 65.4 per 1000, and at any given moment, 2 to 3% of the population suffers from extremely disabling mental illnesses or epilepsy.The majority of these people reside in rural regions far from any contemporary mental healthcare facilities.Adult patients (10.4 -53%) who visit the general OPD have a high rate of mental illness.However, because medical officers or primary care doctors at the primary health care unit seldom request a thorough mental health history, these people are frequently neglected.Due to the patients' misdiagnosis, pointless tests and treatments are recommended, placing an excessive financial strain on the patients.

Mental Health Scenario
Even though India falls behind the rest of the world in terms of medical personnel and spending on mental-health concerns, at least 60 million people there-more than the whole population of South Africa-suffer from mental diseases.
The worldwide epidemic that killed millions of people in most developed nations, including India, the year 2021 saw a swift economic recovery.Suicide, however, is still a quiet pandemic that claims thousands of lives each year.Data for 2021 was made available by the National Crime Records Bureau, which showed that 1,64,033 people lost their life in that year through a variety of causes.This suggests that there are a shocking 450 suicides that are officially reported per day of the year.Since the COVID-19 outbreak, there has been a noticeable rise in suicide rates in India, according to a new research.The report noted that the National Crime Records Bureau suicide data may be under-estimating the real suicide rates, making the 2021 number even more alarming.
The year 2021 was characterised by labour market instability, protracted isolation, increasing inflation, and financial stagnation, which led to an increase in the prevalence of mental illness.According to recent data from NCRB, as many as 50 persons in India commit suicide each week as a result of professional or workplace issues.In 2020, a record 2,593 persons committed suicide for these reasons, a startling 41% increase from the year before.The highest number of suicides in 2021 were reported among daily wage employees, the self-employed, the jobless, and homemakers, according to the NCRB, which splits the data on suicide into nine occupational groups.Daily wage workers made up one out of every four suicide cases; approximately 42,000 incidents were documented in 2021.With 37,666 suicide fatalities out of 1.5 lakh, daily wage workers had the highest rate in 2020.The data is important because during the two pandemic years, thousands of people who made a living on a regular basis lost their jobs.In 2021, there were 23,179 suicides in the "housewife" category, 14.1% of all suicides, a little rise from 22,374 in 2020.

The Number of Suicides in States and Cities of India
The major cities in India, where many people relocate in quest of better employment opportunities and means of sustenance, have elevated suicide rates.Notably, over 35.5% of all suicides recorded from 53 megacities occurred in the four main cities of Bengaluru (2,292), Chennai (2,699), Mumbai (1,436), and Delhi City (2,760).The report states that there was a 12% increase in suicides in Mumbai (from 1,282 to 1,436), an 11.1% increase in Chennai (from 2,430 to 2,699), and a 4.4% increase in Bengaluru (from 2,196 to 2,292).Delhi stood out as an outlier, with a slight drop in instances from 2020 to 2021.The majority of suicides occur in Maharashtra (22,207 incidents), followed by Tamil Nadu (18,925), Madhya Pradesh (14,965), West Bengal (13,500), and Karnataka (13,500).(13,500).In 2021, these five (5) states accounted for more than half of all suicide fatalities nationwide.

National Mental Health Programme (NMHP)
The National Mental Health Programme (NMHP) was introduced by the Government of India in 1982.Considering the widespread prevalence of mental disease in the population and the complete lack of adequate mental health care infrastructure in the nation.The District Mental Health Programme(DMHP) was added to the NMHP in 1996.The fundamental aim of the DMHP is to deliver community mental health services and integrate mental health with general health services by moving treatment from specialised mental hospitals to basic health care facilities.The DMHP envisions a community-based approach to the issue, which includes: Training of mental health teams at designated nodal institutions, raising awareness and reducing stigma associated with mental health issues, offering services for early detection and treatment of mental illness in the community (OPD, Indoor and follow up), and providing useful data & experience at the community level at the state and centre for future planning and improvement in service and research.
The NMHP was designed to achieve the following goals: 1. Ensure that everyone has access to minimal mental healthcare in the near future, especially the most helpless and poor groups of the people; 2. Enhance the use of information about mental health in social development and overall healthcare; and 3. Encourage community involvement in the creation of mental health services and attempts to encourage community-wide self-help.Source: Union Budget for NMHP (2021-2022) Central government financing for the NMHP has been constant.The revised forecasts, however, were lowered to approximately a tenth of the allotted expenditure budgets due to underutilization of funds.The underutilization of resources at the lowest stages of the governance system, which led to a vicious cycle of low supply owing to low demand, might be blamed for this drop.It is clear that the direct budget for mental illness is insufficient to fulfil the need for assistance from individuals who are affected by the Covid-19 epidemic and those who are dealing with mental illness.But there are more issues with funding the mental healthcare system in India than just a lack of money.One such new insight is the severe underuse of funds.Another reason is insufficient data available at DMHP.

Challenges in Implementation of the NMHP
Over time, independent scholars and professional groups have conducted several evaluations that have shown that despite the existence of the programme is a nationwide one.Itself has not advanced too much in coverage, totality, scope, and excellence of services for mental health in India.Numerous difficulties have been reported in the NMHP's implementation, which include: 1.The NMHP lacks full-time, committed programme officers in several areas.2. Cooperation problems between centre, state, together with the areas of health and no health.3. Issues with mental health professionals' retention and recruiting in the DMHP.4. Shortcomings in the PHC staff's training.5. Lack of accessibility to basic data regarding patients receiving care at different facilities (such as frequency of care, results of care, drop-out rates, etc.).6. Absence of participation from the commercial sector and NGOs.7. Inadequate community awareness and education programmes for mental health.
8. Drug shortages or limited availability, particularly at peripheral levels, notwithstanding an increase in financial allocation.
The necessity for decentralised mental health treatment in metropolitan areas was also emphasised because the NMHP's main focus was on rural communities.The majority of clinicians need assistance treating medically inexplicable somatic symptoms, which their expertise in mental health may not have given them.Despite advances in understanding, doctors were still unable to treat patients with mental illnesses on their own.

National Rural Health Mission(NRHM) and Mental Health
Although the NRHM makes no mention of mental health, the 10th Five Year Plan has designated thrust areas for it that support expanding and improving the District Mental Health Programme (DMHP) to encompass the entire nation and streamlining/modernizing mental institutions to change their current custodial function.Even if certain states, like as Gujarat, Tamil Nadu, and Kerala, are implementing the DMHP better than others, the overall development remains pitiful.
According to the NRHM's mission statement, the nation's rural population will get high-quality healthcare, with a focus on the 18 states with the weakest infrastructure and/or public health indices.However, it makes no mention of mental health or how it would deliver quality treatment in the absence of sufficient mental health specialists or staff members who are trained to deal with instances involving mental diseases.Additionally, NRHM pledges to repair the health system's architectural flaws and advance laws that will improve the nation's public health administration and service provision.It is also a well-known reality that in states like Bihar, where there are no mental hospitals that may serve as DMHP's nodal agency, because government is unable to execute the DMHP as a component of the (NMHP).
Despite having a National Mental Health Programme (NMHP) that has been in place for 23 years, the NRHM discusses incorporating integrated illness monitoring programmes under the Mission as well as national disease control programmes for TB, Kala Azar, filaria, blindness, and iodine deficiency.Additionally, NRHM promises to enhance already-existing PHCs and CHCs and to improve treatment services to a normative level (Indian Public Health Norms outlining people, equipment, and management standards).Additionally, it pledges to construct and carry out the District Health Mission's multi-sectoral District Health Plan.But it is a well-known fact that there are currently relatively few CHC-level mental health services available in many jurisdictions.

CONCLUSIONS AND RECOMMENDATIONS
The debate above makes it abundantly evident that mental healthcare is a crucial aspect of the wellbeing and social advancement of people, and that it cannot be neglected for an extended period of time.It is more challenging and impractical to attain health for all, especially the rural population, when mental health is ignored in NRHM.To attain Health for All, it is vital to combine NMHP and DMHP as well as to incorporate mental health within NRHM.No civilization and country has attained health of its people disregarding mental health.The goal was to evaluate the mental health systems thoroughly, broadly, and most crucially, to establish a baseline measurement, not to uncover weaknesses or loopholes.
The suggestions below are included to help enhance India's mental health systems: 1.The existing National Mental Health Programme and its major implementation branch, the District Mental Health Programme, must be greatly improved (DMHP).2. At the state level, it is necessary to identify training institutions, trainers, resources, schedules, and funding in order to establish mechanisms for human resource development at all levels.3. Support for all Indian states is necessary to create and put into action a targeted annually updated mental health action plan.4. It is important to receive training in the leadership skills necessary at the district level.5.The funding for mental health programmes has to be made simpler with thorough planning, greater money, performance-based timely payment, guaranteed full use, and dependable systems for monitoring and accountability.