World Health Day 2019: Accessibility to mental health care remains a major hurdle

“If it is inaccessible to the poor, it is neither radical or revolutionary.” This quote, which is making the rounds on social media, is attributed to Jonathan Herrera, an art faculty of MCAD who may have had a different context in mind while making this statement. But his point breaks global boundaries and questions not just the accessibility of basic human rights but also the hypocrisy behind it.

The statement relevantly fits the mental health crisis in India, where overlooked treatment gaps still persist, despite progress in knowledge and public policies. Take for example the recently passed Mental Healthcare Act.

Last month, the Mental Healthcare Act 2017 came into effect stating that it is now a right of every Indian citizen to have access to unprejudiced mental healthcare in India. Dr Soumitra Pathare, one of the drafters of the act, wrote for The Hindu, “Given the historical context of denial of rights and poor quality treatment to persons with mental illness, this Bill takes an aspirational stance. The challenge lies in its implementation, not easy, but eminently possible.”

But given the history of implementation of healthcare policies in India, mental health could be a far more tougher crisis to conquer. In 2017, a major portion of the country rejected medical care provided by the government, citing reasons ranging from ‘poor quality of care’ to ’no nearby facilities’.

Challenges pertaining to access of mental healthcare go beyond discussing tedious government work and other basic fallacies. It involves the environment in which people live, where they come from and what kind of treatment proves to be suitable for them.

Here, acknowledging drawbacks in the accessibility of mental healthcare that derive from social and economic privileges becomes essential not just for a political reason but also for human ones. What, or rather who, do we miss out on when arguing the accessibility of mental healthcare? And if we do recognise these challenges, how can we devise measures to battle them?

Recognising needs based on socio-cultural context

Jaime Delgadillo, a clinical psychologist at the University of Sheffield, has spent time examining the relationship between social inequalities and mental healthcare. His recent writing published in Counselling and Psychotherapy Research puts ‘class’ on the table, highlighting the unproductive use of psychotherapy with clients who belong to lower socio-economic backgrounds.

Quoting from a summary published by Mad In America, Delgadillo writes, “Today, people living in poverty are still more likely to experience mental health problems and are less likely to access therapy, and when they do so they are less likely to recover from depression and anxiety problems.”

Delgadillo’s findings are applicable to the Indian context. The relationship between poverty and mental health in India has been well indicated, but there is little to no research on how such a relationship should be explored when providing care.

This points to the space inside which mental healthcare operates in the first place. If it can be accessed, is it inclusive of the person’s economic background, their caste, class, gender, the hierarchy of one or multiple oppressions they endure on an everyday basis, and where they come from?

Delgadillo further writes, “Social, educational and economic disparities between therapists and clients are often evident. If psychological therapy exerts its restorative influence through communication and guided action, how can effective communication take place when therapists and clients are worlds apart?”

Simply put, this would mean that methods used by a particular therapist that helped a metro-based couple reform their relationship might not work on a person belonging to a marginalised section of society trying to set up a livelihood in an urban city amid daily harassment and prejudice by its locals.

This is not to say that those methods are irrelevant or the issues are any less distressing, but to establish the fact that so far, mental healthcare has been a matter of class privilege where at one point more number of people are able to suggest ‘help’ to their friends and family, but on the other hand, the same number ignores a major population deep down in crisis which does not know how ‘help’ works.

Even for those who are aware about mental healthcare and the many modes of support it offers, the power dynamic involving the mental health professional and client, which is a result of the former’s caste, gender and class privilege (factors that seem to apply across the mental health community) ends up interfering with the care they are supposed to provide.

This is where sensitisation based on minority rights and issues becomes a more concerning challenge in care-providing than the evident decline in the Indian mental health workforce, because there is a huge dearth of the former in the country, which is less addressed.

Accessibility = acceptability

What does ‘access to health care’ mean? In a paper whose title poses exactly this question, researchers lead by Martin Gulliford, professor of public health at King’s College, London delve into the structure of accessibility and what it means to people. They conclude that more than affordability and adequacy, which are equally vital aspects, accessibility is also about acceptability.

“The extent to which a population ‘gains access’ also depends on financial, organisational and social or cultural barriers that limit the utilisation of services. Thus access measured in terms of utilisation is dependent on the affordability, physical accessibility and acceptability of services and not merely adequacy of supply,” the paper mentions.

The Mental Healthcare act under its section, ‘Rights of Persons with Mental Illness’ assures free care to citizens with or without below-poverty-line proof with no discrimination in its quality. It also mentions making psychiatric medication available for free at state-run facilities.

Acceptability, however, still poses a challenge for the law, because the representation of non-Dalit/Adivasi communities dominates healthcare services in India both on the giving as well on the receiving end.

There is ample evidence that links any possible mental health crises to systemic oppression, but are professionals and policymakers ready to incorporate this factor while implementing health policies is a serious query that bothers disability rights and mental health activists. There is hope induced by community-based interventions.

Take the example of Amitaya, a mental health self-help program led by Dr Kaustubh Joag of the Centre for Mental Health, Law and Policy along with Dr Nandita Kapadia-Kundu (a lead researcher in Public Health and Community-based programs which empower the rural population in the state of Maharashtra with resources, awareness and measures to battle distress, including common mental disorders [CMD>).

Another project, Seher, under the Bapu Trust of Pune built several programs that operate on the intersection of human rights and mental health by skill training rural community members.

Such community-based interventions have often proved helpful to get the word on mental healthcare around. But, apart from this, there is a dire need for us as a society to examine the problem of accessibility. That is, to cultivate our understanding of mental health as something that includes our social contexts and realities. The right to have proper access to care must trancensend cultural and systemic barriers to actually become a ‘right’, rather than a privilege.