Journey Of Advancing Mental Health Initiatives— Insights From A Retired Officer

Mental health, for a long time, belonged to the realm of charity and NGO activism, with the government providing treatment and hospital facilities and sometimes homes for stay. But over the last 25 years or so, there has been an increasing realisation that the rights of the mentally ill need to be respected and nurtured, and their dignity and agency must be accepted and acted upon. Some of the personal experiences in pushing mental health initiatives in different stages of my career, while in service and post-retirement, are summed up below:

• As a young officer in the Integrated Tribal Development Project (ITDP) of Attappadi in Kerala, my field visits convinced me that the prevalence of mental health issues was higher among deprived tribal communities mainly due to the breakup of the traditional systems, influx of exploitative outside settlers, and loss of material and cultural resources—all resulting in alienation and hopelessness. At that time, my only solution was to identify a motivated doctor with the Government Mental Hospital in Thrissur and follow the conventional approach of treating those affected, including some of them in hospitals—but with a personal touch.

• Later, as the Secretary of Kerala’s Local Self Government Department in the early 2000s, a very dedicated judge of the High Court took cognisance of the issues in mental hospitals, particularly of those inmates who needed to be discharged, but were not taken back by their families. Instead of using the high-handed power of pulling up officers and issuing directions, he came down to Thiruvananthapuram and held a meeting with the stakeholders, including the heads of elected local governments, NGOs and, of course, officials. What he attempted was to identify the issues and address them systematically. After a great deal of discussions, we arrived at a series of solutions and fixed responsibilities for each item.

  He went back and issued them in the form of a High Court direction, which we happily carried out, the most important of which was the setting up of a Half Way Home. This was to be funded by the district panchayat; run in an unoccupied public facility, but managed by an eminent local NGO, Abhaya, which was then run by the eminent Malayalee poet, Sugathakumari, who was the first to file a public interest litigation in the mid-1980s against the abysmal conditions of the Government Mental Hospital in Thiruvananthapuram and got positive directions from the High Court.

• Much later, in 2013, when I was Additional Secretary in the Ministry of Rural Development, the Directorate of Rural Development of Tamil Nadu, I was informed about an extremely innovative and interesting initiative, which can be summed as “work therapy” for mental health. With the help of the leading NGO, The Banyan, Tamil Nadu conducted a study to identify suitable work that could be entrusted under the Mahatma Gandhi National Rural Employment Guarantee Scheme (MGNREGS) to persons with mental health problems. It goes to the credit of Tamil Nadu that it identified a basket of activities suitable for this purpose and the initial results were encouraging. Absolutely lost human beings, when they started working and, more importantly, earning money at the end of the day, improved their self-esteem and this had a positive effect on their mental health. This remarkable experiment was shared with the then Secretary of the Ministry of Health.

• Keshav Desiraju, a bureaucrat who served in the Union health ministry, had also come to know of it from The Banyan, and both of us enthusiastically promoted it by sending an advisory to all states to try this model. Though many states initiated action, the initiative was not sustained. But the concept has much validity.

• It was around this time that Desiraju—motivated by NGOs and listening to the people from the field and observing the situation on-ground—came out with the Mental Health Policy, showing what a high-level policymaker could contribute to the cause of mental health. In fact, The Mental Healthcare Act, 2017, was built upon this policy. From my experience in Delhi, I can safely say that an informal alliance of genuine civil society organisations, activists and experts can help policymakers to take a leap in different sensitive social issues.

• When I became the Chief Secretary of Kerala, I facilitated a dialogue between the state government and The Banyan and came out with an MoU to essentially recognise the fact whether a number of people in mental hospitals have to be there. They could be taken out—after detailed assessment based on protocols—and reintegrated with their families, or if that was not possible, facilitate them to live a normal life in small groups of five in real houses in real neighbourhoods, of course, with 24x7 care and appropriate medication—a real Home Again. This contributed to an increase in self-worth, doing simple tasks, interacting with the neighbourhood and coming back to usual life.

• Over the last seven years, The Banyan has succeeded in taking out 481 patients from the three mental hospitals in Kerala, reintegrating 191 of them with their families, 122 into other institutions and putting up the remaining 168 in Home Again dwellings. Based on the success of this model, the MoU was extended for another three years recently.

• Ironically, going against the core values of religion, pilgrim centres have become places where heartless families abandon the mentally ill, where they loiter around and are abused. The Banyan people spotted a number of such people in need, in and around Guruvayur, the famous Temple Town in Kerala. They initiated a dialogue with the Guruvayur Devaswom, which agreed to spare a building to start an Emergency Care and Recovery Centre (ECRC)—a mini-mental hospital. Of course, it has run into some problems due to the dilapidated nature of the building, but the institution will survive. This is a great model of cooperation between a religious organisation and an NGO to address a human issue that has been long ignored.

• Of all the local governments in the country, probably those in Kerala are the most autonomous, with substantial untied funds and sufficient autonomy to utilise them for local priorities. Without any direction, the government, the Ponnani municipality in Malappuram district of Kerala, identified mental health as a priority need, and in partnership with The Banyan, started an ECRC. Based on its success, it is possible that more local governments, especially acting in clusters, can set up ECRCs that will lead to scaled-up operations.

• As several activities have taken place in the state in the last two decades, there is growing sensitivity among policymakers, politicians and officials. And prodded by civil society, Kerala decided to formulate a Mental Health Policy and set up the Centre for Management Development, of which I am the Chairperson. I started drafting it with active help from The Banyan. We hope that the policy will have an action plan embedded in it, leading to easy realisation, unlike most policies in the country that are only pious statements of intent.

• Another great opportunity, which has been identified and action initiated, is the use of the vast network of self-help groups (SHGs)—under Kudumbashree in Kerala—to develop a community-based mental wellness programme by giving specific training to Community Resource Persons (CRPs) to address mental health issues through collective action and identify cases requiring higher levels of intervention, including medical care. If this ambitious programme takes off, it could become an international best practice, again an instance where policymakers, NGOs and the community can develop a constructive cooperation silently and effectively.

• One area where Kerala is the national leader is in Palliative Care, acknowledged internationally, even by The Lancet Com­mission Report. Now, a working relationship is emerging between Pallium India, which is the leading professional NGO in the field of Palliative Care, and The Banyan. This has led to the realisation that there are a lot of mental health issues among not only patients of Palliative Care, but also the over-stressed caregivers. So it has been decided that The Banyan would launch a quick research study to identify mental health issues in this field and come out with a plan for remedial action.

The Way Ahead

Mental health is often not a natural priority, but if nudged properly, it will receive attention and even get proactive involvement. Therefore, it is necessary to identify people in the government at the highest level as well as professionals working in the field of mental health—mostly government doctors and civil society organisations—to share ideas and information; this can set off a virtuous cycle. While NGOs have the inherent right to criticise inaction and inappropriate action by the government in the field of mental health, we could probably achieve more if we do not gloss over the failures and wrongdoings, but collectively address them.

The aforementioned snippets show that there are enough spaces for joint public action. Another important lesson learned is that mental health is a complex subject and the responsibility of addressing these issues spans across departmental boundaries—health, social justice, women and child development, SC/ST development, local government, police and so on. In government, transboundary action is well-nigh impossible. But mental health calls for convergence; beginning with bringing together resources and services, and later, integrating them to ensure it is perfectly and organically provided as a unified service. This calls for careful planning based on data and expert opinion incorporating appropriate best practices from within and outside the country. Ideally, such plans should emerge from below, preferably at the village panchayats and municipalities, with the involvement of community-based organisations and civil society agencies, and health personnel playing the most active role.

Experience shows that while there are several challenges, the most important one is the initial coming together of individuals to develop a basic understanding. This can be achieved by a small group of right-minded people. Yes, then there is hope. It has to be realised that The Mental Healthcare Act, 2017, is a rights-based law enacted by the current government. It has to be read with the Rights of Persons with Disabilities Act, 2016, as mental illness is also a specified disability. Without concerted action led by civil society, and supported by professionals and policymakers, the best of laws can remain dead letters.

But there is enough scope for optimism, based on the significant experiences from not only in Kerala, but across the country—in Tamil Nadu, Karnataka and Maharashtra.

(Views expressed are personal)

S. M. Vijayanand is Former Chief Secretary, Government Of Kerala, and Former Secretary, Ministry Of Panchayati Raj, Government Of India

In its August 21 issue Every Day I Pray For Love, Outlook collaborated with The Banyan India to take a hard look at the community and care provided to those with mental health disorders in India. From the inmates in mental health facilities across India—Ranchi to Lucknow—to the mental health impact of conflict journalism, to the chronic stress caused by the caste system, our reporters and columnists shed light on and questioned the stigma weighing down the vulnerable communities where mental health disorders are prevalent. This copy appeared in print as 'A Difficult And Necessary Place’