Australia and India commit to community mental health agreement

While international collaboration between nations in times of disaster and medical crisis is common, Australian health professionals are now turning their attention to the rising global burden of mental illness. Linda Belardi reports.

It is estimated that up to two per cent of the Indian population or some 36 million people suffer from serious mental illness. A further seven per cent or a staggering 120 million experience common mental health disorders such as anxiety and depression.

To help meet this challenge, an Australian mental health consortium has signed a memorandum of understanding with the Indian ministry of Health and Family Welfare to improve access to appropriate treatment.

According to Associate Professor Chee Ng, Co-Director of the Asia-Australia Mental Health, the sheer size of the mental health burden in the developing world is too huge for any country alone to bear.

In India between 65 and 90 per cent of those with mental illness currently do not receive care. Barriers to access include a lack of resources, uneven distribution and the stigma associated with mental illness.

While Australia is grappling with many of these same challenges, the treatment gap in India is wider and will require more profound change, Ng told Nursing Review.

Over the next two years, the project will draw on technical expertise from the Asia-Australia Mental Health partners to develop best practice community mental health models across four pilot sites in India.

Asia-Australia Mental Health is a consortium made up of the University of Melbourne's Department of Psychiatry and Asialink, and St Vincent's Mental Health.

Ng said it's important that the community mental health projects reflect the diversity of India's local conditions. In the past India's long-running district mental health program has experienced inadequate implementation and local adaptation.

The four identified pilot sites cover India's vast geography, from the urban city of Chandigarh in India's north to a large tribal population in Ranchi in the East of India. In the West, a rural-based model will be developed and run by Ahmedabad mental health facility in the state of Gujarat and down south, a mixed suburban model of care focusing on recovery will be developed in the city of Madurai in Tamil Nadu.

While the various models aim to respond to the targeted needs of the local region, common principles will guide their overall implementation.

"It is vital that that the projects are anchored in the community, are integrated with primary healthcare and existing resources and involve partnerships with the community," said Ng.

All the four pilot sites will be provided support and supervision from the peak institutes of psychiatry within each of the Indian states. "We are working very closely with these centres of excellence to deliver this program because they have a sound knowledge of the local conditions and needs."

Since 2005 high level Indian health officials have been involved in the Asia-Australia Mental Health's network of 16 Asia Pacific countries and earlier this year Delhi played host to the network's annual conference.

Ng said there is recognition from within the Indian government of the need to tackle this significant mental health challenge. The project's operational activities are funded by the Indian government and implementation will begin later this year.

"It's very important to have the government's commitment because for any type of developmental project sustainability is a very key issue. What commonly happens is that when a project is funded externally there is always a limit to that source of funding and once the funding stops you are back to square one. By engaging the Indian government and encouraging their ownership of these projects, there is much better chance of it becoming sustainable."

Ng said the ultimate aim of the partnership is to influence the government's long-term mental health policy and to scale up sustainable community health models across the country.

"In recent years, the Indian government has put more priority and emphasis on mental health issues. They have recognised that the mental health burden is going to be one of the key challenges for this decade. With increased economic development and globalisation coupled with the stress of modern living, these issues are going to be more and more relevant for Indian society."

Important economic and societal shifts are currently taking place within India, which require greater care and support for communities at the local level.

"It has been well recognised that these very powerful social changes place an enormous stress on individuals and the family. Family support structures are changing from an extended family and community type of support to a much more fragmented structure. There's also massive movement of people from rural to urban areas, so issues of overcrowding and stressful living conditions are more prominent."

These problems have led to very serious consequences such as high suicide rates, unemployment, poor physical health and poverty which aggravate the risk factors for mental health.

A significant challenge facing any initiative to close the mental health treatment gap is India's lack of a mental health workforce.

"Attracting and retaining a mental health workforce is a crisis not only in India, it is a crisis in many countries including Australia," said Ng.

"Unfortunately there is also the phenomenon of 'brain drain' where many of the trained professionals have migrated or sought work in developed countries like Australia, the UK and the US."

To address this issue, one the project's strategies will involve investigating how India can better utilise its existing workforce, including its general health workforce, community workers, volunteers and employees of NGOs.

"It is a long-term investment to train an entire workforce of mental health nurses, psychiatrists and social workers, so in the meantime we are exploring how we can work with India's existing health and non-health workforce to meet some of the mental health needs of the population."

The challenges for each pilot site will also differ according to the available resources and workforce of each community.

Beyond the issue of physical and human infrastructure, changing community attitudes towards mental illness and promoting greater awareness will also present a significant challenge for success.

"These are huge challenges and we need to take quite a big leap in changing many of these very fundamental ways of thinking about and treating mental illness in order to establish a system that can provide access to basic care for the majority of people within the community."

Like Australia, India has also inherited an institutional model of mental health from early systems of care but in recent years has shifted to more community-based healthcare models.

This process has already started in India. However most of the resources are still tied up in institutional care, he said.

A lack of current data will present its own hurdles. While the Indian health ministry has estimated at a population level the scale of the mental health problem, India still lacks sufficient epidemiological data to help gauge variations between urban and rural areas and across its many states.

Ultimately, the value of international collaboration between mental health systems is the development of local capacity.

Instead of sending in teams of international mental health professionals to work in a developing system, Ng said a much more effective strategy is to build their local knowledge and skills.

Multi-national partnerships are needed but it doesn't need to take on the form of supplying a supplementary workforce from overseas.

"The important questions are how we best transfer knowledge and skills that can be applied locally and how can we best help them develop systems that are sustainable. Those strategies will be much more effective in the long term."

While many of these developing countries would welcome increased access to overseas mental health professionals - without an understanding of the local culture and systems - their ability to make a meaningful and sustainable contribution is problematic.

"This is what we commonly see in post-disaster situations where professionals and semi-professionals have rushed in to help, but because they don't understand the local system they have become more of a burden rather than a help.

"We need to think more strategically about how best to meet the health needs of another country and I think one of the best ways to achieve that is to work with the local experts and communities, and to build their workforce capacity."

Asia-Australia Mental Health will run local training workshops with staff, as well as monitor ongoing progress of implementation. A joint India-Australia advisory committee chaired by the Directorate General of Health Services, Ministry of Health and Family Welfare, India, will also oversee the overall project.

In the long-term the plan is to roll out the community mental health models to other regions within India, with the view to national implementation.

While the project aims to begin to close the treatment gap in India, there are also important lessons for Australia on how to support the mental health needs of those from diverse cultural backgrounds and minorities.

"We have a lot to learn from countries like India. Australia is very good at providing mainstream mental health care, but we still do not have a very well established system for those living in remote areas and for minority populations including indigenous people.

The collaborative project may provide insights on how to involve the local community in mental health projects.

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