PERSPECTIVES: Mental Health Policy in India: Seven Sets of Questions and Some Answers.

BACKGROUND: This paper frames the state of mental health policy in India in terms of seven sets of questions, and seeks to provide at least partial answers to these questions, based on a meta-analysis of existing research. The context of the analysis is the arguably poor state of mental health care in India, as well as an unprecedented level of policy attention to the issue. AIMS OF THE STUDY: In brief, the questions we pose pertain to (i) the provision of such care in hospitals, (ii) non-hospital provision, including by non-medical providers, (iii) issues of education and social acceptance, (iv) affordability, (v) within-country variation of care and possibilities for benchmarking, (vi) aggregate resource impacts of a concerted effort to change policies and improve care, and (vii) the shape of a more effective "continuum of care" for mental health issues. METHODS: Given the complexity of the subject, this paper is meant to serve as a framing of issues for further research, but in doing so, to clarify what issues are most pressing, those that are most difficult and perhaps those that can be tackled more readily, to create some momentum in changing the relatively poor state of mental health care in India. RESULTS: While new laws and policies being introduced in India propose ideas and changes that are groundbreaking for that country, leading to cautious optimism, there still are many gaps in the understanding of the challenges of the provision of increased access to, as well as better quality, mental health care in India. These challenges can be understood on two fronts: one is the psychiatric and medical aspect of the issues, and the other is the management and administration of the system. DISCUSSION: Perhaps the highest priority in achieving the goals of greater access and better quality is to increase the number of trained personnel at all levels of specialization and skilling that are relevant. Further, while the new legal framework and policy identify the importance of information technology in rapid expansion of access to mental healthcare, more context-specific research and trials are needed. With respect to the administration and management needs of the public system, important challenges will be the need for significant organizational innovations in the education system, and cultural changes that allow specialized medical professionals to accept the use of software and less-qualified, more dispersed, frontline providers. A final area is the interface between the public and private sectors, including the role of non-profit organizations: challenges include information sharing, division of responsibilities, and resource allocation. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Our analysis suggests that incorporating information technology, along with training professionals at a variety of skill levels in its use, may provide a resource-feasible approach to improving access to mental healthcare at reasonable cost and quality in the Indian context. IMPLICATIONS FOR HEALTH POLICIES: India's mental health policies are already undergoing major changes, and our analysis emphasizes the need for translating these generic policies into specific and implementable versions that can be tested at the local level across different regional and social contexts in India. IMPLICATIONS FOR FURTHER RESEARCH: The overall challenge is daunting, being the need to expand access and improve quality, while still managing costs, all within an overall healthcare system that is itself struggling to achieve these goals. Further research based on piloting and trials of assistive software and training programs will likely be useful.