Building the Mental Healthcare Continuum

In the last few weeks, I have been involved in several conversations relating to what can be done to improve mental health outcomes for Indians. I am no expert on this complex topic, but I have become very interested in this question through these conversations and my long years of association with The Banyan. Based on my current understanding of the situation, I have developed an initial point of view, which I am sharing here. As I get feedback on this document, I hope to deepen my understanding and refine it further.

1. Reducing the Burden of Disease must be the starting point: The burden in the country is high across diseases. Mental health is no exception. And unless we make a serious attempt at reducing this burden, no matter how well we design our health systems, I fear we will get overwhelmed. Jointly with other faculty, I offer an introductory course on Public Mental Health at the Banyan Academy of Leadership in Mental Health. It is based NOT on my own work but rather a curation of publicly available material.  The journey towards prevention is not only about addressing significant structural barriers such as poverty and gender inequality, which, while important, could take a very long time to resolve. From the course materials, it can be seen that there are many, more near-term, interventions that can be implemented cost-effectively, which can reduce pathogenic mental stress at a systemic level and improve population-wide resilience. The Banyan was involved in drafting the recently announced Meghalaya Mental Health Policy. Some of the preventive measures have been included in that policy.
2. Mental healthcare needs to be integrated within the larger health system: Designing health systems with components which focus end-to-end on narrow disease categories has the appeal of apparent simplicity and visible impact. However, very quickly, as we have seen in India with maternal and child health, it becomes difficult to sustain and produces suboptimal outcomes. For mental healthcare to be successful, it, too, needs to be designed to be a part of the larger health system. For a task force on health systems design for the state of Chhattisgarh, I wrote a report which attempted to develop an integrated design.
3. Primary mental healthcare can be provided locally: Given our resource constraints, organising curative healthcare for all health conditions, including mental health, is challenging for us in India. There is, however, clear evidence that with some support, several conditions can be managed in primary care settings by suitably trained local lay health workers working off structured protocols (see my list of primary care protocols and a paper on advanced-practice community health workers). Work by, among others, CMHLP and Sangath, show how this can be done for mental health.
4. The understanding of who can provide primary care needs to be broadened: There is also an opportunity to do more with other primary care channels, including faith-based structures, named caregivers within the family, and community pharmacies. I am working on a series of papers in this area – the CHW and Pharmacy papers are published, and work is in progress on the other two. There is a need for more research and experimentation here before a definitive structure evolves, particularly for mental health.
5. For more advanced care, collaborative approaches are the only way forward: The challenge is providing more advanced care. For this, the collaborative approach taken by Possible and Nyaya Health in Nepal could be a potential example, as could what Brazil has done. In collaboration with more specialised providers such as Sukoon and NIMHANS, players such as  Cloudphysician, with their tele-ICU platforms, can support hospitals in smaller towns desirous of offering in-patient care. There will be a need for much trial and error here before a stable solution emerges.
6. Post-discharge care and rehabilitation for those with severe mental disorders need special attention: For post-discharge care and rehabilitation, models like Home Again, developed by The Banyan, are quite powerful, particularly for those for whom returning to their original homes is no longer possible. These types of programs, in my view, need to be run exclusively by NGOs, with the government partnering with them and paying them for their services. The work involved is too complex and requires a level of sensitivity that a government program may not be able to deliver. The Banyan has taken this approach in several locations.
7. Urgent need for Centres of Excellence that are willing to collaborate: For collaborative care and good primary care to work, however, there is an urgent need to establish more centres of excellence willing to offer structured guidance and partnership to on-ground players at all levels. While there are several potential candidates, all of them, for the most part, have the self-image of an end-to-end service provider and aspire for direct impact. Helping them transition to centres of excellence, which can anchor the collaborative partnerships needed for primary and more advanced care, could be a potential role for a philanthropist interested in systemic impact. There may also be a need to establish new ones (for example, a discussion is underway to build a dedicated non-profit to work on suicides among young people). With support from its donors, The Banyan, for example, has built out the Banyan Academy of Leadership in Mental Health, which offers an MSW degree with a Mental Health specialisation – it has graduated close to 500 much-needed professionals thus far.
8.  Tech platforms can also play a role: Tech platforms (such as chatbots and digital therapeutics) can also play a role, but language barriers and the high cost of data (even if phones are becoming cheap) may still be barriers. At the moment, they may be more appropriate for a more elite audience, but they could, over time, become more relevant for our markets, particularly in areas such as CBT, as local language versions start to get rolled out. Tele-psychiatry and tele-therapy, which directly work with patients, are far too expensive to be a solution for anybody but the very rich. And, as they scale, they will run into the same human resource availability problems as in-person treatment faces. In contrast, a WhatsApp-based helpline run by Nayi Disha is proving to be a powerful intervention in the field of Neurodevelopmental Disorders.  
9.  Addressing addiction and substance abuse needs a very different approach:  Emerging problems of addiction/substance abuse need a specialised long-term approach towards addressing them. Philanthropy can play a role in helping build this entire domain out.
10. For financial protection, traditional insurance may not be the answer: Insurance for mental health, while appealing as an abstract idea, is problematic for many reasons. Most mental health conditions are chronic with a lifetime impact. Insurance is best suited (because of its volatility compression role – see here) for high uncertainty, high-cost episodic diseases (like cancer or cardiac surgery). Chronic diseases are best managed using a “Managed Care” approach, in which, for example, each type of mental health condition charges a monthly/annual subscription, which covers all forms of care, including unexpected in-patient care for mental health events (and non-mental health events). These products need to be developed, and philanthropy could help with this. Additionally, the government could pay for these conditions, at least for households with very low incomes (my research suggests that in many states – twelve in 2018 – current government expenditures are adequate to offer Universal Health Coverage, including for mental health – a poor organisation of their health system is the principal barrier that they need to address).

In summary, it is my understanding that, with better design thinking, even with our severely constrained resources, we can offer high-quality preventive, promotive, and curative services to our entire population. I would be eager to learn what you think about these ideas and if there are others that you have in mind.