<h2 class="sub-title">At the heart of the recent controversy over the management of the Institute of Mental Health in Chennai, rests a deep desire to improve services for those in need of mental health care and support. Setting this situation in context, Serena Josephine M. tries to trace the progress of the mental health movement in the State, looking at State and non-State actors, and examines the crucial question of what more needs to be done.</h2>
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<p>In October, two internal official communiques on improving the 230-year-old Institute of Mental Health (IMH) in Chennai unexpectedly set the cat among the pigeons. In the first, Health Secretary Supriya Sahu wrote to Director of Medical Education and Research J. Sangumani expressing disappointment with the lack of measures taken to improve the living conditions of IMH residents, and instructed the implementation of certain decisions already taken — including modernisation of kitchen, budgetary allocation for food, attire and self-care kit, an MoU between IMH and an NGO, additional caretakers, and independent third-party evaluation of IMH. </p>
<p>In the second, she said that there was a need to bring several institutional reforms to ensure that IMH emerges as the premier institution providing “gold standards” of care for its inmates. The institute has huge opportunities to raise resources from national and international organisations as well as from Corporate Social Responsibility (CSR) funds and needs guidance from experts working in mental health care programme, administrators and people with extensive knowledge in the field of treatment, care, rehabilitation and integration of recovered patients with their families and communities. “It is therefore essential that IMH is managed by a not-for-profit, wholly government-owned company registered under section 8 of the Companies Act. This will ensure that the government company set up will have the financial and administrative flexibility and is able to get the required expertise from the board of the company.” </p>
<p>Over the days, however, this move, intending to set the system in order, came to be interpreted as the State abdicating its responsibility towards its patients, and professional doctors’ bodies expressed strong opposition.
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<p>While Health Department officials insist that the current situation must be seen as an opportunity to clarify the role of the various actors in the mental health sector, and move forward sufficiently fortified to serve those with mental illness in the best possible way — to ensuring treatment, human rights, continuum of care, and psychosocial rehabilitation — there are detractors to the proposal to make IMH a ‘company’.</p>
<p>G.R. Ravindranath, general secretary, Doctors Association for Social Equality, said: “This stems from the National Mental Health Policy that encourages Public Private Partnerships, utilising services of civil society organisations and obtaining CSR funds. We are not opposing donations per se but it is the State’s responsibility to identify the deficiencies and take up measures to rectify them.”
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<p>The problem, however, will not be solved with a few donations, and in this instance, the government does not intend to give up control over the institution, as has been clarified several times since the controversy broke out. A senior official points out that the Tamil Nadu Medical Services Corporation Ltd. (TNMSC), which has a streamlined procedure for drug procurement, storage, and distribution, was incorporated under the Companies Act. It has since been able to bail out the State during shortages with Centre-supplied drugs, and has won plaudits for its functioning. In fact, contesting the narrative that the State had abdicated its responsibility, the official says, the proposed move would increase accountability and transparency, and bring in audits. In fact, the Special Purpose Vehicle envisaged in this case, is a model that brings in flexibility and the opportunity to tap funds. It helps in avoiding delays, and action can be quick in providing care, and certainly cannot be considered privatisation. </p>
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<p>R. Sathianathan, former director of IMH, points out that for several years, funding was grossly inadequate, and manpower was insufficient for IMH. He suggests the need of the hour is investing funds to improve the infrastructure of the institute and renovate the wards.
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<h4 class="sub_head">The road so far </h4>
<p>From a time when rescue and care of wandering mentally ill were difficult due to tedious processes, the State has come a long way and has simplified procedures to enable the same, P. Poorna Chandrika, professor and former director of IMH, points out. “The establishment of Emergency Care and Recovery Centres (ECRC) has reduced the homeless mentally ill to an extent in the State,” she adds. </p>
<p>At the IMH itself, treatment and rehabilitation has helped a number of residents to be employed in various places; at least 20 to 30 persons have jobs at present. Many IMH residents (wandering mentally ill) have been reunited with their family members in India and abroad. M. Malaiappan, Director of IMH, said on an average, every year, 5,000 patients are admitted and an equal number are discharged from the institute: “We have a system in place to trace and reunite patients with their families.” </p>
<p>At the district-level, Tamil Nadu has facilitated easy access to mental healthcare services through the District Mental Health Programme (DMHP). “Tamil Nadu offers extensive mental health services through DMHP clinics in government hospitals and block Primary Health Centres (PHC) across all districts. Over 600 government institutions offer psychiatry speciality Outpatient Department services under the mental health programme on a regular basis. Tamil Nadu’s DMHP model ensures sustainability, continuity, and comprehensive mental health services,” R. Karthik Deivanayagam, Monitoring and Evaluation Officer for Mental Health Programme, Tamil Nadu, said. </p>
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<p> The day care centre at Institute of Mental Health, Chennai. File photo<br />
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 B. JOTHI RAMALINGAM
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<p>DMHP has enabled accessibility — DMHP Satellite clinics extend services to all GHs and block PHC levels, and screening, referral, and follow-up services are available from PHC level and regular services — and outreach clinics are being provided based on Fixed Tour Programme to ensure fixed-day services in specific hospitals, he said, adding: “DMHP in T.N. has decentralised psychiatry services, bringing them within the reach of the common man.” Essential psychiatry drugs and speciality psychotropic drugs including clozapine, amisulpride, olanzapine are provided free of cost, enabling each family to save around â¹2,500 to â¹3,000 a month, he added. </p>
<h4 class="sub_head">The role of NGOs </h4>
<p>NGOs that have been working in mental health for long also acknowledge the DMHP’s reach. Vandana Gopikumar, co-founder, The Banyan, said the DMHP has penetrated underserviced areas; people largely have access to psychiatrists and psychotropic drugs. However, the State should increase the number of psychiatrists on duty, she added. </p>
<p>Lakshmi Vijayakumar, psychiatrist and founder, SNEHA, suicide prevention centre, said the fact is that T.N. is one of the best-performing States in the DMHP, under which every district has a psychiatrist and a social worker. So, the rural poor have better accessibility to mental healthcare services, she observed. </p>
<p>In comparison to other States, Tamil Nadu does have a psychiatry department in all government medical colleges. In most institutions, the department has a bed strength of 30, while smaller institutions have 10 to 20 beds.
</p>
<h4 class="sub_head">How T.N. has fared and gaps in services </h4>
<p>R. Thara, vice chair, Schizophrenia Research Foundation, said that mental health services are far better in Tamil Nadu when compared to other States, particularly north Indian States. “We have worked in States like Bihar where there are districts with no psychiatrists. Of course, there are still gaps in mental health care in T.N.; many people requiring care are not getting treatment. To improve access, DMHP needs to train PHC doctors to treat persons with mental illness. Larger PHCs can be equipped with psychiatric medicines and training to reduce the gap,” she said. She pitched the idea of having a separate Accredited Social Health Activists-like cadre for mental health care for early detection and follow-up of patients.</p>
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<p> Sports training for inmates at the Institute of Mental Health, Chennai. File photo<br />
 | Photo Credit:<br />
 B. JOTHI RAMALINGAM
 </p>
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<p>Employment opportunities for persons with mental health issues are still lacking and insurance does not pay for mental health treatment, Dr. Vijayakumar added. </p>
<p>A government psychiatrist acknowledged the shortfalls: “Drug shortages occur now and then. Such shortfalls lead to relapse in patients.” He added: “What we need are halfway homes and rehabilitation. The government should have a policy in place to enable persons with mental illnesses to participate in the workforce, and corporate companies should step in to provide employment. We have to accept the fact that a certain percentage of persons have severe mental illnesses and are difficult to integrate. Such persons need long-term care.” </p>
<p>As far as ECRCs are concerned, continuum of care remains a question, said another government doctor. “Many are lost without follow-up. There is no mechanism to keep track of patients. In addition, there is no plan in place for social integration. Take this for instance: at least five to six patients continue to stay for nearly 1.5 years in one of the ECRCs,” the doctor added. </p>
<p>Official sources said there is a need for additional funding and human resources for DMHP at the block level, one counsellor per block and an additional psychiatrist for district headquarters hospital.
</p>
<p>“When we started in the 90s, mental health care was sporadic and fragmented, and awareness and access, minimal. We are an aware society now; however, prejudice and discrimination persists,” Ms. Gopikumar observed. Robust integration of community inclusion into care protocols will help, she said. “Convergence between the health and social sectors should be emphasised (with focus including on disability allowance, housing, livelihoods) to address social determinants that impact mental health ranging from poverty, violence, devaluation, grief, or intergenerational distress. Social workers and psychologists should be better integrated into care systems to ensure adoption of value and justice-based approaches. A cadre of mental health champions, who might be lived-experience experts or members of Self Help Groups and panchayats, to form neighbourhood solidarity networks that aid crisis response and support continuity of care, is mandatory,” she added. </p>
<h4 class="sub_head">Defining the role of voluntary organisations</h4>
<p>Tamil Nadu has done well to foster a sense of collaboration; the ECRCs being a case in point that have improved access to appropriate care for ultra vulnerable groups, Ms. Gopikumar said, adding: “The task at hand is complex and large. To put the person with mental illness at the centre is key: the State is the primary stakeholder and accountable, and therefore, should nurture impactful and engaged partnerships. We need to encourage and inspire a culture of collaboration and dialogue to ensure better outcomes, especially in an area fraught with inconsistencies and multifactorial causal pathways.” </p>
<p>Dr. Vijayakumar said that the government has its own machinery, while NGOs have their ears more to the ground; organisations are flexible, adaptable, and respond faster to needs of the community. “We need to find a seamless system where NGOs could be entrusted to improve awareness, mental health literacy, identify and refer cases seamlessly to the health system that treats the person and then, the person is brought back to the society for follow-up and rehabilitation; this will be a perfect scenario for a patient with mental illness,” she said.</p>
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</div>
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Putting patients in the centre
