|Year : 2021 | Volume
| Issue : 4 | Page : 366-370
Role of nongovernmental organizations in community mental health
Thara Rangaswamy, D Kotteswara Rao, Sujit John
Schizophrenia Research Foundation, Chennai, Tamil Nadu, India
|Date of Submission||20-Oct-2021|
|Date of Acceptance||03-Nov-2021|
|Date of Web Publication||25-Nov-2021|
Dr. Thara Rangaswamy
R/7A, Noth Main Road, Anna Nagar West Extn, Chennai - 600 101, Tamil Nadu,
Source of Support: None, Conflict of Interest: None
This article focuses on the work done by nongovernmental Organizations (NGOs) in mental health (MH) in India and will illustrate in broad strokes the growth of NGOs in the MH sector. It describes the evolution of MH services over the years with specific emphasis on community MH activities undertaken by NGOs. The role of the MH NGO in bridging the MH gap and the activities that have been undertaken ranging from primary prevention work to tertiary care is discussed. The inherent strengths that the NGOs have in working with communities and their ability to provide holistic care and services beyond the medical model by involving a wide array of workers ranging from MH professionals to peer support providers is examined. The need for private–public partnership in MH is emphasized as the way forward along with leveraging digital technologies that has now come into sharp focus following the COVID pandemic.
Keywords: Community-based interventions, community mental health, India, mental health nongovernmental organization, nongovernmental organization activities, nongovernmental organization
|How to cite this article:|
Rangaswamy T, Rao D K, John S. Role of nongovernmental organizations in community mental health. Indian J Soc Psychiatry 2021;37:366-70
|How to cite this URL:|
Rangaswamy T, Rao D K, John S. Role of nongovernmental organizations in community mental health. Indian J Soc Psychiatry [serial online] 2021 [cited 2022 Aug 14];37:366-70. Available from: https://www.indjsp.org/text.asp?2021/37/4/366/331125
| Introduction|| |
This article focuses on the work done by nongovernmental organizations (NGOs) in mental health (MH). The nomenclature of NGO used in the context of this article refers exclusively to nonprofit, voluntary, and charitable organizations. We acknowledge that there are several NGOs actively providing MH care services across various sectors, but their work remains largely unknown, especially to the scientific and academic communities as their efforts are not recorded or published. It is also important to recognize that there are several NGOs such as those working with the youth, the homeless, victims of abuse, migrants, and sexual minorities whose primary focus is not MH per se, but they provide vital service as enablers and facilitator of MH within their area of work.
In India health has conventionally received low budgetary support from the union and state governments and MH, in particular, has not been a priority which is reflected in the quantity and quality of the service available. The National MH Survey of India (2016) identified a treatment gap of about 85% for those with mental disorders. India's limited MH resources are largely concentrated in urban areas and to an extent to the southern states. Over half of all inpatient beds are located in just 40 odd mental hospitals. As such people from rural areas have restricted access to affordable MH care. Although the last decade has witnessed encouraging progress in public MH services and the district MH program much still needs to be done to address the gap.
| Mental Health Nongovernmental Organizations|| |
It is this gap that the MH NGOs are trying to bridge. While the reach of their work cannot parallel that of government agencies, the quality of care and their efforts in reaching out to the various stakeholders give them a distinct advantage. Their method of operations is holistic and they cater to their various needs while the public health services are largely confined to providing care within a medical model.
The various challenges they face range from accessing funds, dealing with stigma, superstition, and human resource crunch. Despite this many MH NGOs have made their mark in the field with a larger presence in urban areas and in states with relatively better-established health systems.
However, many MH NGOs have a strong rural presence through their community-based programs. They usually serve a defined community; however, the work of some has spread to more than 1 center or geographical region. Examples of such NGOs are the Alzheimer and Related Disorders Society of India, which was started in Cochin, and has now spread and has a presence in 24 cities In India. Similarly, Sangath and the Banyan have also widened their base of operations.
The growth of MH NGOs in recent years has been aided by three concurrent factors, an increased level of professionalization of NGOs, the wider availability of funds from national and international donors, and the arrival of secular NGOs.
The activities of the MH NGOs can be broadly classified as: (a) treatment including care and rehabilitation, (b) community-based activities for early identification and referral and also prevention, (c) research and training, (d) advocacy and empowerment including legal initiatives and using a right-based approach with an inclusive process. There are obvious overlaps between these broad categories and many MH NGOs over time expand their activities and change their approach based on their experience and the evolving needs of the community that they serve.
As might be expected there are fewer NGOs working in the latter two domains with specific reference to MH. Sangath in Goa, Schizophrenia Research Foundation (SCARF), Sneha both from Chennai, and the George Institute based in Hyderabad are some of the NGOS actively involved in MH research. Examples of NGOs working in the space of and advocacy include MANS, Parivartan and the Center for MH Law and Policy, all from Maharashtra.
| Evolvement of Mental Health Nongovernmental Organizations and Their Focus Areas|| |
Developmental disorders and services for children
The oldest MH NGOs in India are those working in the field of developmental disorders and focused on children. Services for child MH has evolved from its earlier focus on learning disabilities (mental retardation) to include autism, hyperactivity, and conduct disorders. Many MH NGOs such as Vidya Sagar, Sangath, Umeed, etc., provide outpatient and (special) school-based services.
Severe mental disorders
The other early MH NGOs prioritized severe mental disorders such as SCARF in Chennai, Manas in West Bengal, and Shristi in Madurai and were started by psychiatrists who were faculty in medical colleges. These MH NGOs attempted to bridge the gap between hospital-based medical interventions and community-based psychosocial interventions and as such, they provided services ranging from family counseling to vocational rehabilitation.
Alcohol and substance abuse
Another area which has attracted considerable attention is substance and alcohol abuse, with drug abuse in specific receiving much public attention and generating media interest especially during the decades of 1970s and 1980s. The obvious need for community-based rehabilitation services for persons affected by substance abuse led to the development of numerous MH NGOs working in this area. The TTK Hospital in Chennai, the TRADA in Kerala and Karnataka, Parivarthan in Maharashtra, Alcoholics Anonymous, and the Samaritans in many parts of the country and the National Addiction Research Center in Mumbai are some of the MH NGOs that pioneered in this area. Dr. B. S. Chavan and associates in a series of work,,, that explored innovative community-based treatment for substance and alcohol abusers successfully demonstrated the effectiveness of the “camp approach” wherein with the support of the local community a physical infrastructure was identified in the community which had a high prevalence of substance users to accommodate about 25 beds along with adequate security and support services, these camps would be run for 10 days during which those admitted would be detoxified and treated. A home-based detoxification strategy was also evaluated by Chavan et al. and found effective.
With India being identified as the suicide capital of the world several MH NGOs have now emerged in this area. Helplines for suicide prevention have also been taken up by public health services and the department of psychiatry Govt. Medical College Chandigarh was the nodal center for one such effort which demonstrated a fall in suicide rates in the city over a period of 1 year. They also lobby for changes in the laws (decriminalizing suicide, banning/restricting access to particularly toxic pesticides, etc.,) and work to reduce the stigma related to suicide. Sneha (Chennai), and MPA (Bangalore) are some of the pioneers in this area.
Common mental disorders
More recently, the scope of activities of MHNGOs has broadened to include Common Mental Disorders (CMD) such as anxiety and depression. Vulnerable sections such as students in schools and colleges, workplace stress, the elderly in old age homes, etc., and women in cross-cutting areas of domestic violence, sexual abuse, trafficking, etc., have all been addressed.
The advent of affordable smartphones and the availability of relatively cheap access to Internet has revolutionized the work of NGOs. There are several web-based services available through phone apps and, on websites that offer information, MH screening, support, and even consultation and therapy that are provided through artificial intelligence programming. The web-based services have the potential of reaching a global audience provided, the services adopt local languages. Many MH NGOS are now investing in and developing digital services to cater to the needs of the community.
Homeless and the “Wandering” mentally Ill
The Shraddha Foundation begun by Dr. and Mrs. Bharat in 1989 brought into focus the cause of the homeless mentally ill, a complex problem, a combination of health, socioeconomic, and human rights issues. Other players in this area are the Banyan and Anbagam in Chennai, Ashadeep in Guwahati, and Samarpan in Indore. Their activities include outpatient and inpatient care, running emergency care and recovery service, establishing community group homes, social entitlement facilitation, livelihood interventions, education and, when possible, identification and reunification with families.
| Nongovernmental Organizations Incorporating Mental Health Component in their Mandate|| |
As mentioned earlier, several NGOs working in the health sector have now included MH into their mandate. Ashagram in Madhya Pradesh whose primary focus was physical disabilities, especially persons affected by leprosy expanded to include severe mental disorders in their Community-Based Rehabilitation (CBR) program. Other such examples of broad-based NGOs are the Innovation in Health (Bihar) who expanded their maternal health program to include screening for depression among pregnant women and the Voluntary Health Associations of India.
The cross-cutting nature of MH becomes especially apparent during postdisaster situations (the tsunami of 2004, Gujarat earthquake, etc.,) and during pandemics such as the present COVID-19. Many NGOs engaged in relief work take up the MH component due to the psychological trauma faced in the community. Many NGOs dealing with the immigrant crises during the lockdown worked with MH service providers to address the MH needs of the immigrants stuck in shelters far from home. Psycho-social interventions were developed and tested and found effective.
Rights-based nongovernmental organizations and user-led movements
A welcome development has been the emergence of rights-based NGOs in the field of MH that looks to tackle the legal aspects of how MH care is provided, defining the role of the various stakeholders while protecting the rights of the person with the disorder. The Quality Rights Gujarat project, implemented in 2013, for 3 years at nine institutes in Gujarat, by the Centre for MH Law and Policy, Pune in collaboration with several other agencies including the Government of Gujarat is an example of the work that can be done by such MH NGOs and is truly a public-private partnership. This program also led to the development of peer support volunteers to bridge the gap between service users and MH service providers resulting in Government of Gujrat approving 50 posts of Peer Support Volunteers in the state.
The other gratifying developments have been the growth in user/family NGOs and the inclusion of People with Lived Experiences of MH as co-designers, advisors and also as care providers in MH programs. ACMI (Bangalore) and Aasha in Chennai are entirely run by, and focus on, families of those affected by severe mental disorders. The growth of these, nonprofessional, family-oriented MH NGO sectors is to be encouraged as the needs of MH care users and families can differ greatly from the viewpoint of MH professionals.
| Community Activities of Mental Health Nongovernmental Organizations|| |
The National MH Program delivered through the District Mental Health Programme model by the National Health Mission (NHM) seeks to ensure minimum standards of MH care in the community. However, the almost complete biomedical emphasis of the program which primarily dispenses medication has been a rate-limiting step. In the past few years, there has been a greater effort by some state governments to improve its delivery of MH services by including MH NGOs. The activities identified by the Govt. of Tamil Nadu that can be provided by MH NGOs in partnership with the Public Health System (PHS) is provided in [Table 1].
|Table 1: Activities identified for public-private partnership by Government of Tamil Nadu|
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MH NGOs have initiated several community-based MH programs in a variety of community settings. They seem to be better placed to approach and win the trust of local communities, establish ties with them and locate their programs in and for the community.
MH NGOs deliver their services through what can broadly be categorized into four types of providers (a) MH professionals, (b) other health professionals such as General Practitioners (GPs), nurses, etc., (c) formal providers outside the health system such as teachers, police personnel, social workers, etc., and (d) nonformal providers such as laypersons and peers.
The community platform utilized by the MH NGOs increases the reach of the program while offering an alternative to primary care (that may not be available). They augment clinical care and include the family in the process, address the economic barriers, and link the patient/family to eligible benefits. They also look at reducing stigma and discriminatory practices and improving social inclusion by conducting awareness programs and educating the community about the illness through its various activities.
The community programs delivered by MH NGOs cover a wide spectrum, from population-wide programs to group and individualized psychological treatments encompassing both primary prevention activities and secondary prevention that focuses on reducing the disability resulting from an existing mental disorder.
SCARF for example provides the services as shown in [Table 2] in its community outreach programs.
|Table 2: Community mental health activities of the schizophrenia research foundation|
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Primary prevention programs
Primary prevention activities frequently provided by MH NGOS include suicide prevention, provision of treatment in community outreach clinics and camp settings, and increasing awareness. Empowerment of the local community is essential and awareness programs are conducted in an open format to ensure the involvement of key and influential persons in the community such as teachers, religious heads, and local administrators who can largely determine the outcome of any community initiative undertaken by the MH NGO as part of its program strategy.
Some examples of primary prevention programs are the telephone helplines for depressed and suicidal persons, early intervention for infants at risk for developmental delay, and education programs in schools and workplaces for the prevention of substance abuse. There is now increasing focus on screening for depression and other common mental disorders in children and adolescents and conducting awareness among students. A number of schools based MH promotion activities are implemented by MH NGOs dealing with academic stress and other interpersonal issues. The strategies used to promote MH in schools include skill training, tapping creativity and delivering arts-based interventions as well as games, meditation, and yoga. Training parents and teachers to recognize and deal with problem behaviors are also on the agenda of several of the MH NGOs that deal with children and youth.
Even before the advent of the COVID pandemic, some NGOs like SCARF used extensively telepsychiatry as part of their community programs. The Mobile Telepsychiatry unit of SCARF is a viable model as demonstrated by the STEP project in Pudukottai. Similarly, the George Institute has developed the Systematic Medical Appraisal Referral and Treatment MH Project where services are delivered using technology-based solutions customized for rural India.
Secondary prevention programs
Secondary prevention focuses on minimizing the disability associated with an existing mental disorder.
Examples of such programs include CBR programs for child and adult mental disabilities and school programs to help children with hyperactivity and dyslexia stay in school.
Psychoeducation for adults with common mental disorders, and for family caregivers for those with psychoses and in perinatal programs were typically delivered in the home of the individuals by health workers. These psychoeducation programs for severe mental disorders typically included information about symptoms, illness course, treatment, relapse prevention, treatment, and adherence to medication.
Skills Training and CBR is essential ingredient of community care. For perinatal mental disorders, most programs by MH NGOs included parenting skills training that included supporting secure infant attachment and training on childhood development, apart from educating parents about food and nutrition needs of the infants and nursing mothers and about the vaccination schedule that must be followed.
CBR for persons with psychosis was multi-faceted and components included family activities, social and independent living skills' training, medication adherence support, and dealing with stigma apart from support for livelihood or vocational activities. SCARF, as part of vocational support activities, has distributed livestock, cows and helped the expansion of petty shops in rural areas to help persons with schizophrenia. This is not only a means of livelihood but has also improved their functioning and community involvement in many ways. Basic Needs is another MHNGO which emphasizes on such CBR activities as the core component of its MH program.
Facilitating individuals to access community resources and organizations including legal benefits, employment opportunities, self-help groups, and other informal care networks is an essential part of the community program that the MH NGOs endeavor to provide.
| Conclusion|| |
MH NGOs play a vital role in addressing MH needs and to bridge the gap between the burden of mental disorders and access to appropriate care in the Country. The MH NGOs extend the reach of MH services where primary and secondary care exists at some level and fill the gap in settings where MH services do not exist in primary care. A more meaningful and comprehensive partnership between MH NGOS and the Primary Health Services (PHSs) of the Government is long due. Pandemics such as the COVID-19 have revealed the cross-cutting nature of MH across all sections of society and have also explicitly exposed the large gap in terms of the need for MH services and their availability of the same.
The pandemic has also through serendipity revealed the potential of technology in bridging this gap. MH NGOs and the government must utilize this momentum to scale up their services and explore areas where they can work in partnership. The MH NGOs also have a major responsibility in ensuring that the voice of the service users is not lost in this effort and must make sure that they are included as partners in co-designing and implementing programs. MH NGOs should also document their activities and process so that they can better monitor their own programs and facilitate the transfer of knowledge.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Thara R, Patel V. Role of non-governmental organizations in mental health in India. Indian J Psychiatry 2010;52:S389-95.
] [Full text]
National Mental Health Survey of India, 2015-2016 Prevalence, Patterns and Outcomes, Supported by Ministry of Health and Family Welfare, Government of India, and Implemented by National institute of Mental Health and Neurosciences (NIMHANS) Bengaluru: In Collaboration with Partner Institutions; 2015-2016.
Alzheimer's & Related Disorders Society of India (ARDSI). Available from: https://ardsi.org/
. [Last accessed on 2021 Oct 15].
Chavan BS, Priti A. Treatment of alcohol and drug abuse in cAMP setting. Indian J Psychiatry 1999;41:140-4.
] [Full text]
Chavan BS, Gupta N, Raj L, Arun P, Chanderbala. Camp approach-An effective, alternate inpatient treatment setting for substance dependence: A report from India. German J Psychiatry 2003;6:17-22.
Chavan BS, Gupta N. Camp approach: A community-based treatment for substance dependence. Am J Addict 2004;13:324-5.
Raj L, Chavan BS, Bala C. Community 'de-addiction' camps: A follow-up study. Indian J Psychiatry 2005;47:44-7. [Full text]
Chavan BS, Sidana A, Singla R. Home based detoxification – A pilot study. J Men Health Human Behav 2010;15:101-4.
Chavan BS, Garg R, Bhargava R. Role of 24 hour telephonic helpline in delivery of mental health services. Indian J Med Sci 2012;66:116-25. [Full text]
Vijayakumar L, Daly C, Arafat Y, Arensman E. Suicide prevention in the southeast Asia region. Crisis 2020;41:S21-9.
Narasimhan L, Gopikumar V, Jayakumar V, Bunders J, Regeer B. Responsive mental health systems to address the poverty, homelessness and mental illness nexus: The Banyan experience from India. Int J Ment Health Syst 2019;13:54.
Singh GP, Arun P, Chavan BS. Migrant workers' needs and perceptions while lodged in a shelter home in India during the COVID-19 pandemic. Prim Care Companion CNS Disord 2020;22:20m02753.
Chavan BS, Arun P, Singh GP. Psychosocial intervention model for migrant workers during extended lockdown: The Chandigarh model. Indian J Psychiatry 2021;63:175-8. [Full text]
Mehta R, Shah A, Vankar GK, Chauhan A, Bakre R. Golden roots to golden fruits of mental health in Gujarat. Indian J Psychiatry 2018;60:S227-35.
Samudre S, Shidhaye R, Ahuja S, Nanda S, Khan A, Evans-Lacko S, et al.
Service user involvement for mental health system strengthening in India: A qualitative study. BMC Psychiatry 2016;16:269.
Health and Welfare Dept. Govt. Of Tamil Nadu. Tamil Nadu Mental Health Care Policy and Implementation Framework. GO (MS) No. 301; 4 July 2019.
Kohrt BA, Asher L, Bhardwaj A, Fazel M, Jordans MJ, Mutamba BB, et al.
The role of communities in mental health care in low- and middle-income countries: A meta-review of components and competencies. Int J Environ Res Public Health 2018;15:1279.
Fazel M, Patel V, Thomas S, Tol W. Mental health interventions in schools in low-income and middle-income countries. Lancet Psychiatry 2014;1:388-98.
Thara R, Sujit J. Mobile telepsychiatry in India. World Psychiatry 2013;12:84.
Maulik PK, Kallakuri S, Devarapalli S. Operational challenges in conducting a community-based technology-enabled mental health services delivery model for rural India: Experiences from the SMART Mental Health Project. Wellcome Open Res 2018;3:43.
Thara R, Padmavati R, Aynkran JR, John S. Community mental health in India: A rethink. Int J Ment Health Syst 2008;2:11.
[Table 1], [Table 2]