Budget 2024: On Public Healthcare Access and Mental Health Infrastructure

Finance Minister Nirmala Sitharaman.

(Photo: PTI)

In terms of the fiscal weight of budgetary importance accredited to health care, Finance Minister Nirmala Sitharaman on Thursday extended the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) to all ASHA and Anganwadi workers this Interim Union Budget for FY24.

Last Budget, FM Sitharaman earmarked Rs 7,200 crore for FY24. Now, a sum of Rs 88,956 crore was allocated to the Health and Family Welfare Ministry in FY24. Despite existing challenges such as faculty shortages in current institutions, compromising the quality of medical education and hindering efforts towards achieving universal health coverage, India is set to witness an increase in medical colleges soon. 

Another area where the Union Government has failed to provide much fiscal and policy attention is issues around inadequate access to adequate mental health infrastructure (physical and human), which has become increasingly important in India’s growing struggle with a rise in mental health disorders.

“There are only 0.3 psychiatrists, 0.07 psychologists, and 0.07 social workers per 100,000 people. Tackling this deficit requires targeted funds for training programmes and scholarships. Beyond this, the prevalence of mental disorders impacting one in seven Indians, coupled with persistent social stigmas hindering help-seeking behaviours, emphasises the urgency of allocating resources for comprehensive awareness programs and establishing a dedicated fund for serious mental illnesses,” said Dr Gorav Gupta, psychiatrist and co-founder, Emoneeds (a Gurugram-based online psychiatric counselling service).

While the 2030 Sustainable Development Goals focus on mental health and call for access to quality mental healthcare services and affordable essential medicines, the Indian Government’s priority in ensuring this remains less committal and is attached to the overall low funding allocated to healthcare sector over the years.

India still has a long way to reach the goals outlined by the SDGs, as one in seven Indians, or about 14.3% of the total population, experience mental disorders. In the Indian context, mental health is considered only through the lens of mental illnesses, instead of general mental well-being. 

Given that currently, only 1% of the total budget expenditure assigned to healthcare is allocated to mental healthcare, we explore how limited attention to it has often made the public healthcare ecosystem ignore mental health needs. Especially in the context of the COVID-19 pandemic, which proved to be a grave mental health concern for different sets of people across age groups in different ways, it becomes important to address the provision of mental healthcare facilities in the country.  

Landscape of Suicides in India

The World Health Organisation reported that one in five individuals in India may suffer from depression in their lifetime, however, only 10-12% get professional help because of the attached stigma, lack of awareness, inadequate access to professional help and difficulty in affording. 

Most people do not receive quality psychiatric or professional help, pushing them towards committing suicide. Approximately one person dies every 40 minutes by suicide. Suicide is a global public health problem and India contributes significantly to this number. As reported by the World Health Organisation in 2021, out of 7,03,000 suicides, India contributed 1,70,000 deaths to this figure. 

Decriminalisation of Suicides: The Mental Health Act

Suicides were criminalised in India for the longest time but the introduction of the Mental Health Act of 2017 aimed at decriminalising suicides, by adopting a far more empathetic approach towards individuals who attempt suicide. It is focused on promoting and regulating mental healthcare services in India. The Act ensures equitable accessibility of services and takes a proactive role in preventive and diagnostic measures for mental illnesses.

However, the services provided in the Act are not evenly distributed as urban areas are better equipped with mental health facilities and a considerable disparity can be seen in the rural areas. Moreover, despite the introduction of the Act, a perennial insufficiency of mental health facilities has been reported in India. There are just 0.3 psychiatrists, 0.07 psychologists, and 0.07 social workers per 100,000 people in India.

The average national deficit of psychiatrists is estimated to be at 77%. The limited beds and inhibited inpatient care are highly worrying and so is the burnout among mental health professionals. This can lead to serious detriment in professional interventions for patients whose lives might depend on proactive treatment strategies for mental duress. 

The lack of infrastructure and human resources became much more glaring during the COVID-19 pandemic, when several people despite experiencing mental health issues, did not have access to professional help. In the 2023 financial year, a total of 6.7 billion rupees was allocated for expenditure towards mental health of which 84% was allocated to NIMHANS, while 6% of the budget was allocated in favour of the National Mental Health Programme.

COVID-19: A Grave Mental Health Concern

Initially perceived as a physical health crisis, it was especially after the imposition of lockdown, that COVID-19 was understood to also be a grave mental health concern. With economic activities coming to an abrupt standstill, social isolation due to quarantine and the loss of close ones to death aggravated the mental health crisis. The World Health Organisation (WHO)  reported that in the first year of the pandemic, the global prevalence of anxiety and depression increased by 25%. 

The pandemic has affected the mental health of different people in different capacities, with the vulnerable groups further being pushed into the corner. While several people experienced anxiety and depression because of unemployment as a result of the lockdown, others found it difficult to cope in the work-from-home scenario. The quality of work in professional settings for women changed substantially because of the added burden of household chores.

Moreover, women also reported cases of domestic violence and abuse since they were trapped with the perpetrators of their violence, with restrictions on mobility. Children were also severely affected given that they were forced to shift to online classes, and innumerable of them dropped out of schools because of lack of access to technology. 

World Health Organisation data suggests that the burden of mental health problems in India is approximately 2443 disability-adjusted life years per 1,00,000 population. According to a report on the Mental Health of Internet-enabled Youth by Krea University, the mental health of youth is worse in 2023 than it was in 2020 and a trend was seen in the poor performance of youth between 18-24 across most Indian states. 

This trend is not however attributed to economic indicators alone since poor mental well-being can be seen in youth across different economic brackets on account of a host of factors such as poor job prospects, lack of opportunities and undoubtedly the impact of social isolation and increased online presence that COVID-19 had on individuals.

The pandemic, which has been a serious mental health concern for different groups, has highlighted that the discussions around mental well-being and the institutions safeguarding mental health should not only be restricted to hospitals.  Nearly 60-70 million Indians suffer from common mental disorders, however, stigmatisation and financial barriers prevent their timely treatment. 

Along with changes in the budget, there is also a requirement for better-trained individuals, especially in the public sphere of mental healthcare so that emphasis can also be placed on increasing the quality of resources provided to patients and individuals in distress.

Additionally, given that there is a direct correlation between mental health and nutritious food, there is a need to not only address the work-life balance of individuals but equal emphasis must be laid on nutrition as well, to cater to the well-being of the population. The nutritional vulnerabilities among the Indian population across states are explored in the next part of this special series.

Given the nature of concerns plaguing the inadequate mental health infrastructure in India, the time has come for the overhauling of the ‘access’ to the mental health system, while simultaneously battling the stigma attached to it. 

“It should be mandatory for schools to have a clinical counsellor. In recent months, we have seen the government taking initiatives towards moulding the curriculum and services provided to students preparing for IIT/JEE/NEET in Kota and other cities. Including mental health in the budget is essential and crucial as we are progressing towards an increase in the incidence of conditions like autism, anxiety, and depression,” said Malik. 

Greater fiscal focus and awareness exercises/campaigns by the government will help mitigate some of the highlighted challenges but given how less a weightage of fiscal importance remains attributed to healthcare in Union Budgets-and States remain liquidity strapped due to a lower revenue base, a lot of needs in the mental healthcare ecosystem are captured by a rising, more costly, and exploitative private tertiary care infrastructure-especially in cities, ignoring the 65% of the Indian (rural) population. An indifferent approach to public healthcare and especially towards improving public access to mental healthcare support seen so far by the Modi Government may accentuate adverse costs by affecting the quality of lives for millions of Indians across age groups.  

[Deepanshu Mohan is Professor of Economics and Director, Centre for New Economics Studies (CNES), Jindal School of Liberal Arts and Humanities, O.P Jindal Global University. He is currently a Research Fellow with Birkbeck College, University of London. Samragnee Chakraborty and Hima Trisha M are Senior Research Assistants (CNES), and Aditi Desai, Amisha Singh, and Nitya Arora are Research Assistants (CNES). Authors would also like to thank public health experts, Dr Sunil Kaul, co-founder of the ANT, Dr Indranil Mukhopadhyay, Professor at O.P Jindal Global University, and Mr Murari Mohan Goswami, Senior Development Consultant for their continuous support and guidance. This is an opinion article and the views expressed above are the author’s own. The Quint neither endorses nor is responsible for them.]