Summarising from a historical perspective, the care of the mentally ill has been an expressed concern of various governments over the past 200 years. Under British Imperial rule, and given the nature of psychiatric care and the partial penetration of both science and medicine, efforts were focused on custodial facilities, with a belief that the community was somehow indifferent or even hostile to the marginalised. After Independence, with a gradual increase in the number of experts, facilities spread out across a range of service delivery options (general hospitals, private sector, NGOs and the few mental hospitals), and with changes in psychiatric practice, several alternatives opened up. Primary prevention and care was transformed into primary-level care, and then community-based care. The various theoretical and ideological positions that have often been portrayed as polar opposites (institution vs. community, specialist vs. task-shifting, ‘Western’ ideas vs. ‘traditional family values’) have led to a wildly swinging pendulum of services.
Thus, while the affluent could access specialists and specialised institutions, others were to be ‘managed’ by tertiary workers. The absence of a middle ground did not allow a healthy compromise that realistically mirrored the complex reality of mental illness. The fact that some patients could need a prolonged stay in hospitals or protected environments, or that specialist-led care in the community might be needed (or demanded) by everyone, or even that the development of a culturally congruent yet universal, secular and humanistic framework for psychotherapy was a necessary prerequisite for mental health care was not addressed. Instead, a ‘one-size-fits-all’ model of a brief training, a simplified algorithm for rapid diagnosis and intervention, became the mainstay of policy. This was in keeping with the larger WHO advice on the need for simple models for LMICs, keeping in mind, one assumes, their supposedly simpler psychosocial situations.
In that sense, the present policy writing process has been, at least in some ways, a departure from earlier positions both in the form of a wider participation in the process, and, hopefully, a greater breadth of vision. This has, therefore, been the first attempt at incorporating different stakeholder perspectives in policy-making, and, also, in a sense, has encouraged wider consultative participation. It can and will be debated whether ‘enough’ participation happened, and how inclusive that effort was. Suggesting, as it does, a greater degree of civil society oversight, and the need to look at more complex and nuanced crosscutting themes, it may encourage more effort to address these. It does need, however, to be said that earlier, fairly comprehensive articulations exist, that, perhaps, have not had enough impact. The question as to why earlier attempts have not had their desired effect remains tantalisingly poised before us. We describe several earnest and well-articulated plans for improved services for the mentally ill that have been developed over the past century. The changing focus in psychiatry itself has resulted in an almost constant shifting of goalposts of what defines adequate care: improve mental hospitals, provide care through general hospitals and address needs of those with severe mental illness as well as the ‘common’ mental disorders. In the Indian situation, with limited medical manpower and even less manpower in the wider mental health disciplines, such a diverse set of objectives has proved difficult to address. A level playing field as far as access to mental health care is concerned has been compromised by rapid societal changes, unequal economic and social progress, and lack of planning for universal health care. The policy document tries to address some of these concerns, with suggestions derived from a wide spectrum of society. It remains to be seen, therefore, how this policy is translated to actual change in the care of the mentally ill in the community, and this will certainly be an endeavour that has to be built upon in different ways.
Acknowledgements Both the authors have been members of the Policy Group set up by the MOHFW, Government of India. We would like to, however, explicitly state that the views expressed here are strictly personal. We would like to thank the other members of the group and the Ministry for immensely enhancing understand?ings on the subject. We would also like to thank both the editors and anonymous reviewers for insightful comments and suggestions. Also, thanks are due to Aditya Sarin for his usual critical and incisive commentary and editing, and to Marina George for patient editing help.
The work is supported in part by a grant from The Wellcome Trust (WT096493MA) ‘Turning the Pages’.
Finally, a very special thanks to Sumeet Jain for his gentle encouragement and an apology for sorely testing his patience.