Interviewees debated whether the DMHP model was appropriate in terms of its organisation of services and human resources.
Criticisms of the Bellary (DMHP) model
The Bellary model was intended to extend coverage in the northern part of Karnataka State, and had heavy psychiatric input (psychiatric outreach camps) from NIMHANS. As a Bellary programme founder explained, this model was utilised after its initial evaluation for a different aim, as a DMHP pilot for national coverage:
“It was very important to recognise that the goal was not that we would be able to reach everyone - universalised coverage; it was increasing coverage – say from 5-10% or nil, to as much as possible. This is a very important thing that needs to be recognised because if we are thinking of universal coverage, then what we were achieving was totally inappropriate.” (psychiatrist/former leader 2)
Because the motivated new NMHP taskforce were keen to start a model, they pushed forward one of the few models in existence in India.
A Bellary programme founder questioned however why, if the model was not designed with national coverage in mind, the NMHP had continued “
picking up the skeleton” of the same model (psychiatrist 2). The only adaptation was to reduce psychiatric support and PHC doctors’ length of training which proved to be detrimental. There was very little questioning of whether overburdened, poorly utilised PHCs within weak health systems [
47] should continue to be the DMHP’s main delivery mechanism.
This model was further criticised for its sole focus on medication. Jain and Jadhav [
48] argued that the pill provided a ‘technical fix’ that policy makers required to fund and popularise the programme, whilst psychosocial interventions were ignored. A human rights lawyer felt the overmedicalised model was harmful.
“The National Mental Health Programme has very limited imagination. It did not escape the medical paradigm. Whereas mental health needs […] has a much larger range: […] social injustice, […] torturous conditions at work, less than minimum wages, […] precipitators of poor mental health. Instead of addressing those structural questions we believe that we’re going to give people psychotropic medication and going to set things right. It’s hugely dangerous in a poor country.” (lawyer 1)
A senior advisor of the 10th plan defended these decisions as successful cost reduction of psychotropic drugs had made these affordable and cost effective solutions for the government:
“If I had got involved in the other thing [psychosocial interventions], we could not have got involved anywhere; because the bureaucrats want cut and dried, black and white things, you see. They can’t appreciate shades of grey.” (psychiatrist/former bureaucrat 7)
Though the overmedicalisation critique is valid in essence, there were reasons for the ‘technical fix’. Policy makers were not ready to accept wider changes and innovations. In addition, funds were limited and thus minimising costs was important. Furthermore there was a growing international evidence base for antidepressants and antipsychotics (randomised controlled trials, systematic reviews) and treatment algorithms, and very limited evidence for non-pharmacological interventions [
49].
Hardly any cultural or religious paradigms filtered down to community mental health care [
41] and some respondents felt that, hospital and community psychiatric care had remained insufficiently ‘Indianised’. The creation of the NMHP was preceded by several decades of controversy over the western versus indigenous medicine debate. At the time the Bellary model was created, few allopathic doctors’ supported integrated approaches with other medical traditions, as a recent attempt to train ‘integrated doctors’ in both medical paradigms had failed [
50].
Poorly motivated and trained health workforce
Throughout the NMHP’s three decades, building a rural mental health workforce only involved PHC doctors training. Very little was initiated to help psychiatrists adapt to their new supervisory roles.
a. Primary care doctors
Early pilot project leaders explained the initial challenge in the 1980s was to train a new human resource, the PHC doctors.
“This was a great challenge, […] so, how to train the health worker, what are his responsibilities, can we do it, how to monitor them, what kind of supervision do they require, […]. Whether it succeeded or not is a different story, and that is the next 20 years’ story.” (psychiatrist 1)
As suggested by this psychiatrist, their initial package was comprehensive but as the model was scaled up in subsequent years, the reality of health workers’ context and qualities soon disrupted this plan. One contributing factor was PHC doctors’ large workload.
“I met primary health care doctors and universally they said, that in the existing state, it was an additional burden – it was not doable, although they were trying their best to do it. So, I could make out that the original concept of Bellary was no longer suited.” (psychiatrist/former bureaucrat 7)
Retaining doctors in rural areas and their frequent transfers was also a problem [
51]. Furthermore, a bureaucrat explained that PHC doctors’ competency reduced since independence, making them more difficult to train, motivate and retain.
“The increase in the number of medical colleges and private medical colleges has meant that the quality of teaching has suffered. […] The result of this is that a very indifferent quality of doctor is coming out of the medical education system. The best amongst these are probably staying in the cities. […] The GP [family physician] in India pre-independence, […] came through a much better education system.” (bureaucrat 1)
Despite some international evidence that primary health workers could effectively diagnose and treat mental illnesses [
1], in India and elsewhere, PHC doctors only recognised between 20 and 40% of all mental illnesses [
40,
52]. The DMHP- and other health sector- planners ignored recommendations to evaluate primary health workers’ impact on patient outcomes [
49].
Respondents suggested PHC doctors were never properly trained.
“Training has been a token gesture for the departments of health to be ‘seen to be doing’ something.” (psychiatrist 14)
The training manuals produced in Bangalore and Delhi were too complex and not properly adapted. The NIMHANS PHC doctors manual, rather than being clearly focussed on the main issues in primary care, synthesised psychiatric and psychology textbooks. They became more complex throughout the editions from 1985 to 2009 [
53‐
55]. For primary care officers with no or little previous exposure to psychiatry, these increasing details were overwhelming and could not be integrated into their current practice. The same was true of the Delhi manuals [
56]. Furthermore the manuals produced for community health care workers focussed on diagnoses and health worker behaviour, but had no useful information on how to support the family or patient, or the process of referral [
57,
58]. These manuals were written by specialists at NIMHANS, who did so without evaluation of previous training or consultation with the primary-level health workers.
In addition, the delivery of training was never adequate, and ongoing training reduced over time. In the early years, though initial training was short, there was informal and organised follow-up of PHC doctors by psychiatrists during their outreach activities. In the last decade, only the training component remained, and this continued to be short and didactic (only 15 days in Karnataka for example) or non-existent (in the northern States).
More important than the content of training was the lack of ongoing support to PHC doctors – again a chronically neglected problem.
“As long as continuous support and supervision is not there, they will not perform, or you will not get the outcome.” (psychiatrist 1)
A prior leader suggested this support was absent because of supervisors’ indifference to mental health which lead to demotivated primary care staff.
“
If the health authorities higher up […] do not take [mental health] seriously, they consider it’s useless and all that, then the lower staff also loses interest. […] Most of them have been untrained and they consider it just a fashion.” (psychiatrist/prior leader 3)
Since the NMHP’s beginning, there were too few specialists interested in supervisory work. This problem remained unchanged. From 1981, NIMHANS ran several ‘Training for Trainers’ workshops to train specialists in their new supervisory roles but by 1986 only 63 Indian psychiatrists were trained. By the 1990s this training programme had stopped [
38]. Motivating psychiatrists to remain in community programmes was also a challenge. For example, those involved in the NIMHANS primary care pilot project requested to return to NIMHANS jobs after two years’ work in the programme (psychiatrist 14).
Specialists’ lack of involvement could have been due to their poor remuneration. Many psychiatrists also lost faith in this model because they felt PHC doctors’ limited training would be insufficient to provide adequate care. Psychiatrists have been reluctant to associate with other mental health professionals under the same umbrella term of ‘specialists’ probably because of a strong hierarchical structure within hospital care. A psychiatrist involved in the Mental Health Care Act revision observed:
“We have created a category called mental health professional [which] includes a psychiatrist, a psychologist, a psychiatric nurse and a psychiatric social worker.[…] Now the psychiatrists are extremely angry about it because they see themselves now being equated with the other professionals.” (psychiatrist 10)
For example psychiatrists quashed recent attempts by psychologists to lobby for greater prescribing powers and representation in decision-making. Such current tensions between mental health professional groups suggest more groundwork and involving them in decisions may be required before they accept shared responsibilities, for example in supervising primary care workers.