National mental health programme (nmhp)

NATIONAL MENTAL HEALTH
PROGRAMME(NMHP) AND DISTRICT MENTAL
HEALTH PROGRAMME (DMHP):
WHAT HAS BEEN ACHIEVED AND FUTURE
COURSE
SATYAKAM MOHAPATRA
JUNIOR RESIDENT –III rd Year

NMHP AND DMHP
 Evolution and implementation
 Achievements
 Reasons for slow progress
 Future recommendations

 All kinds of mental and behavioural disorders are widely
prevalent in Indian population.
 Review of the situation of psychiatric disorders in India
highlighted the gross neglect of mental disorders
(Neki and Carstairs, 1975) due to:
 Pervasive stigma, widespread misconceptions
 Grossly inadequate budgets for mental healthcare
 Acute shortage of trained mental health personnel
“ In developing countries basic mental health care should be
decentralized and integrated with the existing system of
general health services”.

1)Recommendations by an expert committee on “organization of mental
health services in developing countries” ( World Health Organization.
1975):
 Basic mental health care should be integrated with general health services
and be provided by non-specialized health workers at all levels.
(2) Starting of “Community Mental Health Unit” by NIMHANS , Bangalore –
1975
 SAKALWARA PROJECT :Focus on developing services and model.
(3) WHO Multi-country project: “Strategies for extending mental health
services into the community” (1976-1981)
 RAIPUR RANI PROJECT- Focus on testing and evaluating models.
(4) Indian Council of Medical Research – Department of Science and
Technology (ICMR-DST) Collaborative project (1980):
 To evaluate the feasibility of training of PHC staff to provide mental health
care as part of their routine work.

NATIONAL MENTAL HEALTH PROGRAMME (NMHP)
OF INDIA
 In 1980 the Government of India felt the necessity of evolving a
plan of action aimed at the mental health component of the
National Health Programme.
 In February 1981, a drafting committee met in Lucknow and
prepared the first draft of the NMHP. This was presented at a
workshop at New Delhi on 20–21 July 1981.
 In August 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
of National Mental Health Programme (NMHP).

(1) 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.
(2) To encourage the application of mental health knowledge in
general healthcare and in social development.
(3) To promote community participation in the mental health
service development and to stimulate efforts towards self-help
in the community.

 CENTRE TO PERIPHERY STRATEGY:
Establishment and strengthening of psychiatric units in
all district hospitals, with outpatient clinics and mobile
teams reaching the population for mental health
services.
 PERIPHERY TO CENTRE STRATEGY:
Training of an increasing number of primary health
care health personnel in basic mental health skills to
provide minimum mental health care to the people.
With availability of referral service.

 Integration of the mental health care services with the
existing general health services.
 To utilize the existing infrastructure of health services
and to deliver the minimum mental health care
services.
 To provide appropriate task oriented training to the
existing health staff.
 To link health services with the existing community
development programme.

 TREATMENT
 REHABILITATION
 PREVENTION

INITIAL PROBLEMS FACED IN IMPLEMENTATION
OF NMHP AFTER 1982:
 No budgetary estimates or provisions were made for the
implementation of the programme.
 There was a very lukewarm response to the programme by
psychiatrists the country.
 Difficulty in implementing the programme in larger
populations and in real world settings.
Realizing that the NMHP was not likely to be
implemented on a larger scale without demonstration of
its feasibility in larger populations, the need for
planning for the implementation of the programme at a
district level was highlighted.

Development of the pilot district mental health
programme at Bellary district in Karnataka:
 Training in basic mental health care in a decentralized
manner.
 Provision of 6 essential psychotropic and anti epileptic drugs.
 Mental health team at the district head quarters.
 A system of simple mental heath case records, monthly
reporting, regular monitoring and feed back from the district
level mental health team.
 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.

In 1996 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 programme.

1. To provide sustainable mental health services to the
community and to integrate these services with other services.
2. Early detection and treatment of patients within the
community itself.
3. To see that patient and their relatives do not have to travel long
distances to go to hospitals or nursing homes in cities.
4. To take pressure off mental hospitals.
5. To reduce the stigma attached towards mental illness through
change of attitude and public education.
6. To treat and rehabilitate mentally ill patients discharged from
the mental hospital within the community

 The District Mental Health Programme was launched during
1996-97 in four districts. During the IX Five Year Plan DMHP
was extended to 27 districts spread all across the country.
 The DISTRICT MENTAL HEALTH PROGRAMME was started
as " a community based approach’’ , which includes:
 Provide services for early detection and treatment of mental
illness in the community itself with both OPD and indoor
treatment and follow-up of discharged cases.
 Increase awareness in the care necessity about mental health
problems.
 Training of the mental health team at the identified nodal
institutes within the State.
 Provide valuable data and experience at the level of community
in the state and Centre for future planning, improvement in
service and research.

1) BASIC MENTAL HEALTH CARE
2) FOLLOW UP OF TREATED CASES
3) INFORMATION , EDUCATION AND
COMMUNICATION(IEC) ACTIVITIES
4) SCHOOL MENTAL HEALTH PROGRAMME
5) COLLEGE MENTAL PROGRAMME
6) SUICIDE PREVENTION

 Out door facilities
 In patient facilities
 Referral services
 Follow up services

 Nodal officer
 Psychiatrist
 Clinical psychologist
 Psychiatric social worker
 Staff nurse

 Doctor
 Nurse
 Paramedical staff

 Mental health awareness programmes.
 A variety of educational and awareness building
activities on different aspects of mental disorders
and mental health.
 Use of local print media as well as other forms of
mass media like public talks, exhibitions, street
plays, use of educational slides in local movie
theatres, providing information through local
cable TV.

 Currently DMHP is
being implemented in
123 districts in the
country.

MENTAL HEALTH IN 11TH FIVE YEAR PLAN (2007-
2013): (GOI, 2007, Planning commission, 2006, Srinivasa
murthy,2007)
(1) FUNDING:
 During the 11th Five Year plan, there has been
substantial increase in the funding support for
NMHP.
 The total amount of funding allotted is Rs.1000
crores ( a three fold increase from the
previous Five Year Plan).

SCHEME (A)
 Establishment of 11 Centres
of Excellence in the field of
mental health by upgrading and
strengthening existing mental
health hospitals/institutes.
 44 psychiatrists
 176 clinical psychologists
 176 psychiatric social workers
 220 psychiatric nurses
SCHEME (B)
 setting up/strengthening 30 units
of psychiatry, 30 departments of
clinical psychology, 30
departments of psychiatric social
work, and 30 departments of
psychiatric nursing with the
financial support to postgraduate
department.
 60 psychiatrists
 240 clinical psychologists
 240 psychiatric social workers
 600 psychiatric nurses
Together, these two schemes will produce 1756 qualified
mental health professional annually.

(3) Spill over activities of the 10th Plan :
 Up gradation of the psychiatric wings of Government medical
colleges/general hospitals
(4) Modernizations of state run mental hospitals.
(5) To integrate NMHP with the National Rural Health
Mission (NRHM).
(6) Importance on added components of DMHP i.e. Life
Skills training and counselling in schools, counselling
service in colleges, work place stress management and
suicide prevention services.

(7) Research-There is huge gap in research in mental health which
needs to be addressed.
(8) IEC-An intensive media campaign is planned for 11th Plan
duration.
(9) NGOs and Public Private Partnership for implementation of
the Programme. This would increase the outreach of community
mental health initiatives under DMHP.
(10) Monitoring ,Implementation & Evaluation-Effective
monitoring at Central/State/District level will facilitate
implementation of various components of NMHP.

 The evaluation of DMHP carried out
during 2009, by the Indian Council of
Marketing Research(ICMR), New
Delhi, covering 20 of the 123 districts of
DMHP. 20 DMHP districts and 5 Non-DMHP
districts (as control) were compared.

MENTAL HEALTH SERVICE UTILIZATION:
 Site of contact of beneficiaries under DMHP
 61%-district hospital
 12.7%-CHCs
 11.5%-PHCs
 18% of the total respondents were referred to district level for
treatment.
“So mental health services have been decentralized at least to
the district level if not to the level of PHCs, from mental hospitals
and medical college hospitals with partial integration of these
services with the general health services”

 DRUG SUPPLY UNDER DMHP
 25% of the districts under DMHP have regular inflow of
drugs.
 80% beneficiaries received at least some medicines from the
health centres.
“This is because of lack of dedicated drug procuring
mechanism for DMHP”

 90% of the patients were of the opinion that diagnosis was
explained to them.
 61% of the beneficiaries confirmed that the possible side
effects of the medicines were explained to them.
 25% of the beneficiaries received counseling services
under DMHP.
“More than 50% of the respondents from the DMHP
districts agreed that proper medications and
counselling can help in the treatment of mentally ill
people against only 30% in Non DMHP districts”

 Awareness about the types of mental illness were
found to be significantly higher in DMHP districts
as compared to non-DMHP districts.
 Consulting traditional practitioners was
suggested by only 47.3% of respondents from
DMHP districts as against over 70% of non-DMHP
respondents.
“This indicates that DMHP has been able to
spread awareness in the districts where it was
being implemented”

 FUND UTILIZATION:
 One third of the districts utilized over 99%, one third has
utilized 63-91%, and rests have utilized 37-47% of the
total amount they have received.
 Only 10% of the districts, utilized funds allocated for IEC
activities. 20% of the districts did not utilize funds under
IEC and rest 70% district had partially utilized.
“This is mainly due to administrative delay, difficulty in
recruiting and retaining qualified mental health
professional, low utilization in training and IEC
components”

 TRAINING:
 55% of the health personnel confirmed that they had
received training.
 More than half of the health personnel (54.7%) trained
were satisfied with the training programme.
“Training and IEC components which require a lot of
ground work, coordination and networking in the
community is below par in most of the districts”

 To increase the availability of trained personnel required for
mental health care, 7 Centres of Excellence have been
funded against the 11 that are to be set up during the
Eleventh Plan.
 Support has been provided to 19 PG (postgraduate)
departments during the year 2009–10 for manpower
development.
(Annual Report on Health of the Ministry of Health and Family
Welfare, September, 2010, relating to mental health )

 The National Human Rights Commission carried out 2
systematic reviews of mental hospitals in India in 1998 and
2008.
 Following the initial report, as part of the NMHP, funds were
provided for upgrading the facilities of mental hospitals.
 This has resulted in positive changes over the past 10 years
as shown by the 2008 (NIMHANS) report:
 Admissions through courts has decreased from about 70% to 20%
 Long-stay patients has decreased from 80% to about 35%.
 Rehabilitation facilities have increased from 10 to 23 institutions.
 Use of electroconvulsive therapy (ECT) has reduced and use of modified
type ECT has increased from 9 to 27 institutions.
“Overall there were more changes in the past 10 years than in the
preceding 5 decades”

APPRAISAL OF THE EXISTING NMHP

NMHP has expanded steadily across the country
during the past two Five Year Plan periods, so
appraisal of the existing situation is required.

(1) ASSESSMENT OF THE FEASIBILITY OF INTEGRATION OF
MENTAL HEALTH WITH PRIMARY CARE:
The soundness of this approach has been emphasized by
several international organizations .
 This integration is “the only realistic option” due to
continuing resource constraints in developing countries
(WHO).
 It will take years to place psychiatrists/psychologists in 600
districts in the country when there is not even a general
physician (GP) available in those area.

(2) EFFECTIVENESS OF THE IMPLEMENTATION OF NMHP:
Several reports on the assessment of implementation of
DMHP suggest that the current implementation is far
from optimal and the reasons are numerous:
 LACK OF MOTIVATION AND COMMITMENT OF THE
STATE HEALTH AUTHORITIES (From Directorate of
Health Services to chief medical officers):
 Partial integration
 Differential effectiveness

 Limited development of the DMHP in its
operational aspects by the Central agency:
 The core idea of integration has not been fully developed to
operational level so that the states could follow the guidelines.
 The components of the programme like the training
manuals, treatment guidelines, IEC activities have been
developed to a limited extent.
 Limited state level capacity to implement the DMHP:
 In most states the mental health programme is under the
responsibility of non-psychiatrists and often as one of the
many other responsibilities.
 As a result the technical inputs required for the programme
have not been invested in the programme.

.
 Inadequate technical support from professionals:
 At the initial stages of the programme, NIMHANS, Bangalore and few other
centres provided the technical inputs (training manuals for PHC
personnel) and field level experiences of implementing programme on a
regular basis.
 All of these developments needed further field level
application, modification when the DMHP moved from demonstration
project to programmatic stage of expansion to a large number of centres.
 Location of the DMHP with teaching centres:
 The teaching centres did not have the knowledge of public health as well as
did not work with the field level personnel to make the programme
effective.
 Training at medical colleges without involving the DMHP team

Difficulties in recruitment and retention of mental health professionals
in the DMHP
Lack of mental health indicators:
 Simple indicators to address the objectives
 Clinical outcome
Lack of monitoring:
There is no central/state level technical advisory committees to monitor the
programme and carry out the evaluation.
Lack of emphasis on creating awareness in the community:
IEC activities are the most important need and least emphasized till recent
times.
Lack of involvement of the non-governmental organizations (NGO) and the
private sector in DMHP.

 No adequate data on long term effects of primary
mental health care are available to make
meaningful interpretations.
 Mental health training programmes for primary care
personnel has brought improvements in their
mental health knowledge and diagnostic
sensitivity.
 But there is only little evidence of changes in actual
practice of health workers and better outcomes for
patients.

(4) INDEPENDENT EVALUATION OF THE
DMHP
 Regular independent evaluation of DMHP is lacking.
 Last independent evaluation was carried out by the
Indian Council of Marketing Research (ICMR) during
2008-2009.
 Regular evaluations will provide recommendations
and suggestions for improvements in implementation
and future expansion of the programme.

 Lack of motivation and commitment
 Lack of manpower

 India with a population of about 1.2 billion and extremely limited number of
trained mental health professionals, the basic approach of the NMHP
continues to be an acceptable and feasible method of extending basic
mental health services to the whole country.
 The main component of the NMHP namely the district mental health
programme was developed more than 15 years ago and has not changed
much since then.
 The approach needs a major technical and operational review and certain
corrections following the review are necessary.
 The situation across the country varies significantly in different states .
Local issues should be identified, and feasibility of programme
implementation should 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:
1. Strengthening of mental health services at the
sub-centre, PHC and CHC levels to make the service
more accessible.
2. NMHP is currently a fully centrally funded Plan programme.
The financial responsibility for the programme will have to
be gradually shifted to the state governments and mental
health services will have to be integrated in the State and
District Implementation Plan.

3. To enhance the capacity in the country to train mental
health professionals.
 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.

4. Increase massively the IEC activities and integrate mental
health messages and information as part of all community
messages through mass media and local level community
radios.
The programme has given more emphasis on the curative
services to the mental disorders and preventive measures are
largely ignored.

5. Detailed operational guidelines for
implementation of the schemes required.
There should be 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.
6. A set of specific, measurable outcome indicators for the
DMHP have to be developed and used for regular and
continuous reporting and monitoring of the programme.

7 . Collaboration and partnerships with the private and
non-governmental sectors in the NMHP will have to be
developed.
To support NGO initiatives, especially in the areas
of:
I. Setting up of self-help groups of patients/families.
II. Imparting public mental health education to reduce
stigma.
III. Providing financial and technical support for the
establishment of a spectrum of rehabilitation facilities
such as day care, long-stay homes.
IV. Promoting income-generating activities by patients and
families.

8 . INTEGRATION OF DMHP WITH THE NATIONAL RURAL
HEALTH MISSION (NRHM):
This will contribute numerous advantages
to the DMHP-
 Optimal use of existing infrastructure at various levels of health care
delivery 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
 Building of credible referral chains for appropriate management of
cases detected at lower levels of the health care delivery system.

9. REHABILATION:
 There is no provision to treat and rehabilitate mentally
ill patients discharged from the mental hospitals
within the community.
 Treatment of severe mental illness is incomplete without
effective care, rehabilitation and reintegration of
recovering mentally ill person into the society.
 Social and culturally acceptable and affordable
rehabilitation measures need to be developed and
implemented.

10. There are areas of mental health
programme that have not been given adequate
attention.
 The life skills education for children and adolescents is
still in its initial phase in few centres.
 In spite of the attention to suicide by farmers, the number
of centres providing suicide prevention is limited to a few
centres when it should be available in a few hundreds.
 The excellent models of disaster mental health care have
not been a part of the past NMHP efforts.

The last 29 years of NMHP can be summarized as :
 It is possible to develop a National Mental Health
Programme but it has been a gradual process.
 The developments in the area of mental health has
brought mental health care from the closed confines
of mental hospitals to the larger community.
 The full potential of the DMHP has not been realised
and the objectives outlined have not been achieved.

 It is important to understand the reasons for the
current state of programme to be an “extension”
service rather than “integration” of mental health
with general health care.
 India has the opportunity to develop a viable and
effective mental health care programme by giving
attention to certain areas that need attention.

 Director General of Health Services (DGHS): National Mental Health Programme for
India. New Delhi, Ministry of Health and Family Welfare; 1982
 Gururaj G., Isaac M.K. Psychiatric epidemiology in India: moving beyond numbers. In
Agarwaal S.P, Goel D.S, Ichhpujani R.L, et al (eds); Mental Health- An Indian perspective
(1946-2003). New Delhi: Elsevier for Directorate General of Health Services, Ministry of
Health and Family Welfare; 2004: 37-61.
 Neki J.S. Psychiatry in South-East Asia. British Journal of Psychiatry. 1973; 123: 257-269.
 Wig, N.N. , Srinivasa Murthy , R. , and Harding T.W. A model for rural psychiatric services-
Raipur Rani experience. Indian Journal of Psychiatry,1981, 23, 275-290.
 Jain,S., Jadhav,S. Pills that swallow policy: clinical ethnography of a Community Mental
Health Program in northern India, Transcultural Psychiatry, 2009, 46:60-85.
 National Human Rights Commission (NHRC) Mental health care and Human Rights, Eds.
Nagaraja.D., Murthy,P., NHRC-NIMHANS, New Delhi. 2008.
 Planning Commission. Towards a faster and more inclusive growth- an approach to the
11 Five Year Plan, Government of India, Yojana Bhavan, November 2006, P.72)

 Agarwaal, S.P., Goel, D.S., Ichhpujani, R.L., Salhan, R.N., Shrivatsava, S(2004) Mental Health- An Indian
perspective(1946-2003), Directorate General of Health Services, Ministry of Health and Family
Welfare, New Delhi. Pages 75-91.
 Government of India. Implimentation of National Mental Health Programme during the Eleventh Five
Year Plan-approval of the manpower development component, Ministry of Health and Family
Welfare, New Delhi.Dtd.24 April 2009.
 Indian Council of Marketing Research, Evaluation of District Mental health Programme-final
report, 2009, New Delhi.
 National Mental Health Programme: Time for reappraisal; Mohan Isaac (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).
 Annual Report on Health of the Ministry of Health and Family Welfare, released in September, 2010
 Sinha SK, Kaur J. , National mental health programme: Manpower development scheme of eleventh
five-year plan., Indian J Psychiatry 2011 , 11 Oct 31 53:261-5
 mhGAP: Mental Health Gap Action Programme: Scaling up care for mental, neurological and substance
use disorders. Geneva: World Health Organization; 2008.
 Srinivasa Murthy R. Mental health programme in the 11th Five Year Plan. Indian Journal of Medical
Research 2007; 125: 707-711
 Indian Council of Medical Research. Department of Science and Technology (ICMR-DST). A collaborative
study of severe mental morbidity. Indian Council of Medical Research, New Delhi, 2005.

National mental health programme (nmhp)

More Related Content

What's hot

Similar to National mental health programme (nmhp)

Recently uploaded

National mental health programme (nmhp)