Is the govt passing the buck on taking care of mentally ill patients to private players?

Illustration: Prathap Ravishankar

We’ve all interacted with people who suffer from mental illnesses, whether it’s that friend who’s struggling with depression or that ‘crazy’ person who wanders the streets everyone avoids. Yet, as a society, we hem and haw when it comes to addressing the issue of mental healthcare. The stigma around mental illness remains severe, thereby creating a vicious circle of inadequate facilities and systems to care for patients.

Tamil Nadu, which has better mental healthcare facilities than most states in the country, is in a state of flux right now in this matter. As it attempts to find a balance between the services provided by government institutions and those by private players and NGOs, the question is — what is best for the patient?

The Institute of Mental Health (IMH), Chennai, the only government hospital that treats mental illnesses in Tamil Nadu, has been working with NGOs on several counts. For instance, Shraddha takes over patients from northern India who have recovered and reunites them with their families there. The Banyan ran a service called ‘Dial 100’ through which it rescued mentally ill people from the streets of Chennai and admitted them to IMH.

Independently, The Banyan runs a hospital that treats mentally ill women who are destitute. It has also pioneered a ‘Home Again’ programme in which the patients who have recovered are integrated with the community and given vocational training for eventual rehabilitation. Earlier this year, The Banyan signed a memorandum of understanding with the Tamil Nadu government through which some 620 recovered IMH patients who are destitute will be handed over to The Banyan for rehabilitation through the ‘home again’ concept.

This has set off a flurry of complaints from IMH doctors who fear this will lead to slow decay and eventual closure of IMH. The IMH says its in-house rehabilitation programme, where vocational training is given, is working fine and needs no tinkering. IMH doctors question the concept of ‘home again’ and are sceptical about The Banyan’s service.

But The Banyan doctors insist that theirs is a tried-and-tested process that helps to rehabilitate and integrate former patients with rest of society. Citing their 25-year record in mental healthcare, they say their credibility rests in the work they have done.

The questions that Tamil Nadu is wrestling with may have wider repercussions for mental healthcare in the government system that is woefully inadequate.

What led to the MoU

The MoU between the TN government and The Banyan was triggered by a 2017 public interest litigation petition in the Supreme Court seeking the discharge of around 300 patients who were cured of their mental illness but still staying at mental health hospitals in Uttar Pradesh.

After hearing the petition, the court ordered all the 43 government mental health hospitals in the country to set up ‘rehabilitation homes’ or ‘halfway homes’ within one year, paving the way for their discharge. A committee was formed under the Ministry of Social Justice and Empowerment that set guidelines to be followed by the states. But after a year, only nine states responded to the apex court, of which Tamil Nadu was one. The state gave details of its interactions with NGOs.

A contempt petition was filed in March 2019, against the states for not setting up the halfway homes mandated by the court. Hearing the petition, the apex court observed that these halfway homes can be set up in two ways: One, the state governments can expand their existing homes or construct a new home at their own cost. However, the court did not say whether the home must be located inside the campus or outside. Two, the state governments can encourage NGOs in the field to help out. These NGOs can be funded by the Centre following the recommendation from the state governments.

The TN-The Banyan MoU followed this. “It is because of this that private players are entering into agreements with the government. Public institutions like us become a feeding ground for the NGOs,” accuses a senior medical officer of IMH who requested anonymity. The NGOs will only provide space for the inmates but the medical services and other resources are provided by the hospital, for which the NGOs get funds from the Centre, he adds.

Can NGOs reach where governments have failed to access?

While public healthcare has achieved varying levels of success in India, there is a big gap in mental healthcare in the government sector. And NGOs insist that their pioneering mental healthcare methods can help to fill that gap. For instance, The Banyan doctors talk about ‘deinstitutionalisation’. “But deinstitutionalisation will be successful only if the cured patients are trained in some kind of occupation,” says a senior office bearer of the Indian Psychiatric Society, Tamil Nadu Chapter, on condition of anonymity. “At IMH, such rehabilitation programmes are provided. But it is doubtful whether such kind of training is provided by NGOs. However, at government hospitals, the love and affection shown by doctors is lacking. They see it as their duty. That is where the NGOs score,” he says.

Though acknowledging the services of NGOs, he is cautious. “IMH has 1,800 beds. If cured patients are handed over to the NGOs for rehabilitation, then the government will reduce the number of beds. If beds are decreased, the admissions will also decrease. If admissions decrease, the funds allocated to the institution will reduce. Over a period, the outpatient ward may be closed. Then the patients will go in search of other illegal, unlicensed homes,” he says.

But officials at The Banyan refute the accusations and say they go beyond halfway homes to give an idea of how advanced their methods are. “Halfway homes are also a kind of institution. What we follow is a concept called ‘home again.’ It is a community living model,” says Dr KV Kishore Kumar, senior psychiatrist and director, The Banyan. In an institution such as halfway homes the recovered patients are dependent on others for everything, but in a community set up, they are able to lead independent lives, he adds.

“Whether in hospital or at halfway homes, the inmates are kept in a restricted environment. They feel stigmatised. They lack positive thinking. Their quality of life will never change. At The Banyan, we developed the ‘home again’ model five years ago. In this model, the recovered patients live in a community like any other person. However, instead of living alone, they live with other recovered patients in a family set up,” Kumar says. This kind of a model is similar to ‘group homes’, which are used in developed countries and are in place for the past two decades.

The Banyan has four such ‘home again’ centres, in Kovalam and Mogappair in Chennai, Trichy and Kerala. The NGO signed an MoU with the Kerala government recently and the model is in place for the last one year. “Now, we will set up such homes in Maharashtra,” says Dr Archana Padmakar, assistant director, The Banyan.

Around 207 inmates reside in these homes. Most of them are employed in the various units of employment training like tailoring, service at cafes and more, located inside The Banyan campus. They are paid for the work they do, says Archana.

The Banyan conducted an 18-month research on the efficiency of the ‘home again’ concept with the help of Grand Challenges Canada. “This is the first of its kind research in Asia conducted in Chennai,” says Kumar. It was through the study that around 623 patients were identified at IMH who will soon be relocated to ‘home again’ centres run by The Banyan.

“In an institution set up, the expenses met for a patient per month stands between ₹45,000-50,000. In 2007, when I was working at NIMHANS, Bengaluru, we carried out a study along with London School of Economics to gauge mental health costs. We came to know that in the community set up, the expense for an inmate per month stands at ₹2,000. Also, we found that the quality of life of an inmate increases in the ‘home again’ model,” says Kumar.

“We will implement this project for three years and then it will be entrusted to the government to sustain it on its own. The MoU was signed between the Tamil Nadu government and The Banyan. Further details of the MoU cannot be shared at this time since the Election Commission’s model code of conduct is in effect,” says Kumar.

The director, IMH, Chennai says she is unaware of the details listed in the MoU since it was signed by higher officials in the health department of the state. The higher officials of health department were unavailable for comment.

Another IMH doctor says deinstitutionalisation has its dodgy elements as well. For instance, the recovered patient’s movements are restrained and the level of freedom he enjoys is suspect. He says instead of delivering on their duty to provide mental healthcare, governments are resorting to such shortcuts to evade responsibilities. A comprehensive policy on mental healthcare is needed, he adds.
What do patients want?
The patients The Federal spoke to are unwilling to leave their present homes in IMH and The Banyan, indicating that rehabilitation and eventual integration with rest of society defies simple solutions. Victor (name changed), a recovered inmate in IMH and who is now employed as an attender in a government institution, says that though he is able to live independently, he is not comfortable staying outside the hospital campus. He has been there for more than 15 years. Likewise, Kaveri (name changed), a recovered inmate at a ‘home again’ centre of The Banyan, says that she is unwilling to reunite with her family or live separately. She was admitted to The Banyan in 2009 and she was relocated to the ‘home’ after her recovery in 2015. “This is my home. The other inmates are my family,” she says.