Advancing Inclusion: Addressing Marginalized Communities

in Mental Health Policies in India

Bhavika Rawat
Jia Mehra
Manasi Chordia
Mannat Nandwani
Raeeka Sengupta
Vedant Dashore

Written for
The Banyan
 CONTENTS

1. Introduction
1.1 Mental health in India
1.2 Defining marginalized communities
1.3 Barriers to accessing mental health services by marginalized communities

2. Evolution of mental health policies in India

3. Mental Healthcare Act of 2017

3.1 Background and objectives
3.2 Challenges in addressing marginalized communities

4. State policies without comprehensive provisions for marginalized

communities
4.1 Jharkhand

5. State policies with comprehensive provisions for marginalized

communities
5.1 Meghalaya’s Mental Health and Social Care Policy of 2022

6. International best practices

6.1 Canada
6.2 Zimbabwe
6.3 Pakistan
6.4 Thailand

7. Recommendations for advancing inclusion

7.1 Community-based mental health services
7.2 Inclusivity and culturally sensitive approaches
7.3 Equity in access
7.4 Training and public awareness

2
 1. Introduction

1.1 Mental health in India

A ’mental disorder’, as defined by the World Health Organisation (WHO), is when there is a
clinically significant alteration in one’s thoughts, emotions, behaviour or a combination of
these. This could lead to distress or even impairment in one’s ability to function in different
aspects.1 ‘Mental health’ is so much more than just the absence of mental disorders in an
individual. It is a term that describes a state of overall well-being, which encompasses the
ability of one to be productive, create and nurture positive relationships, cope with the
regular stresses of life, and meaningfully contribute to their community. However, the
concept of mental health is unattainable for many individuals, since people experience life in
varying degrees of difficulty due to different circumstances and stressors.2

The treatment gap refers to the proportion of people who do not receive treatment when
they need it compared to the entirety of those with the disorder. India’s National Mental
Health Survey of 2015-2016 reports a treatment gap of 83% for all mental disorders.3
According to the WHO, India only has 0.2 psychiatrists for every 100,000 people, which is
much less than the global average of 3.3 These statistics reveal a critical insufficiency of
facilities to treat those struggling with mental health issues.

1.2 Defining marginalized communities

The term ‘marginalised communities’ refers to groups within society who are socially
excluded and relegated to the margins.4 These groups arise due to the hierarchical structure
of our society. They experience discrimination throughout the course of their lives and
limited amenities are put aside for them, which leaves them with less opportunities and
more barriers when accessing things like healthcare, education, work etc. as compared to
others.5

1
Mental disorders,
https://www.who.int/news-room/fact-sheets/detail/mental-disorders#:~:text=A%20mental%20disorder%20is
%20characterized,different%20types%20of%20mental%20disorders
2
Mental health,
https://www.who.int/news-room/fact-sheets/detail/mental-health-strengthening-our-response
3
Arun Kumar Tiwari, Financing Gaps, Poor Implementation Mar India’s Programmes to Tackle Mental Illness,
https://thewire.in/health/financing-gaps-poor-implementation-mar-indias-programmes-to-tackle-mental-illnes
s
4
Prakash Bhadury, The Marginalized Groups in Indian Social Construct: A Critical Study of Mahesh Dattani, P.
109-114,
https://www.researchgate.net/publication/273382528_The_Marginalized_Groups_in_Indian_Social_Construct
_A_Critical_Study_of_Mahesh_Dattani
5
Nikita Ghodke, Marginalised communities and mental health talk 101,
https://www.pratisandhi.com/marginalized-communities-and-mental-health-talk-101/

3
The well-being of an individual does not exist in a vacuum, and is largely affected by their
interactions with their environment. As coined by Dr Meyer, The concept of ‘minority stress’
refers to the fact that individuals who belong to marginalised groups are victims of unique
stressors such as stigmatisation, inequality and discrimination, which detrimentally affect
their mental health.6 These communities can be divided in many ways based on their
identity: their gender, sexuality, religion, caste, class and age can all affect the way that they
are categorised in society. There are also non-identity based marginalised groups that
struggle to get access to mental health facilities such as the homeless, the poor or
unemployed, people struggling with substance dependency, migrants and refugees, children
of the mentally ill, people with disabilities, as well as people living in rural areas.7

Intersectionality refers to the amplified discrimination that results from the overlap of an
individual’s various social identities such as their sexuality, gender, race, religion, caste, class
etc.8 For example, a woman who is homosexual and disabled would have a harder time
getting access to mental health care as compared to an abled heterosexual woman in India.
She would experience double stigma, not only due to her gender, but also because of her
sexual orientation and disability. The compounding of these different aspects of her identity
leads to a unique set of experiences and barriers. Since there is a lack of specialised mental
health services that cater to her specific needs, she would find it harder to get help. With
each additional part of one’s identity that is marginalised, there is an added level of
inaccessibility to mental health care.9

1.3 Barriers to accessing mental health services by marginalized communities

All societies are controlled by those in power. These people create important policies and
make decisions that determine who has access to what kinds of opportunities. Even in
democracies, marginalised communities struggle to gain equal access to facilities, and
experience obstacles in accessing mental health services due to discrimination and stigma.10
This exacerbates the disparities they encounter in various aspects of their lives and leads to
a vicious cycle of always being at a disadvantage, which affects generations. Women,
LGBTQIA+ individuals, disabled people, lower-caste individuals and tribal populations,
religious minorities, and so many other marginalised communities have to deal with
countless barriers such as social stigma and judgement, limited resources, financial

6
Ilian Meyer, Prejudice, social stress, and mental health in lesbian, gay and bisexual populations: conceptual
issues and research evidence, P. 674-697, https://pubmed.ncbi.nlm.nih.gov/12956539/
7
Priti Sridhar, Why there is a need to provide mental health services to marginalised groups,
https://www.firstpost.com/health/why-there-is-a-need-to-provide-mental-health-services-to-marginalised-gro
ups-11402741.html
8
Julia Seng et al., Marginalized identities, discrimination burden, and mental health: Empirical exploration of an
interpersonal-level approach to modelling intersectionality, P. 2437-2445,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3962770/#:~:text=Intersectionality%20is%20a%20term%20us
ed,social%20identity%20and%20affect%20health
9
Tiasha Mukherjee, Mental Healthcare Act: issues of intersectionality and stigma need to be addressed,
https://theleaflet.in/mental-healthcare-act-issues-of-intersectionality-and-stigma-need-to-be-addressed/
10
LibertiesEU, What is Marginalization? Definition and Coping Strategies,
https://www.liberties.eu/en/stories/marginalization-and-being-marginalized/43767

4
constraints, physical inaccessibility, and inadequate representation in the mental health care
industry which deter individuals from seeking timely and appropriate care.11

The manifestation of gender inequality has led to women becoming a marginalised

community. Statistics show that symptoms of depression, anxiety and other unspecified
distress are 2-3 times more likely in women than in men.12 According to a United Nations
report in 2018, 18.4% of women in India between 15-49 years of age reported that they
experienced physical and/or sexual violence by a former or current intimate partner in the
last 12 months.13 Domestic violence, harassment, mental and physical torture, coerced sex,
rape, sexual trafficking, dowry disputes, the expectation to bear children, the consequences
of infertility, pregnancy, child-birth and menopause – these and countless other experiences
are why woman face life-long emotional distress and mental health issues. Also, Factors
including biases against women, limited financial independence, unequal opportunities to
education, work etc. make it incredibly difficult for women to seek and receive mental
health care.14

Being a part of the LGBTQIA+ community also leads to struggles when trying to access
services for mental health. Although homosexuality under section 377 was decriminalised in
2018, this marginalised community is still overlooked and under-represented: It was found
to be one of the 12 groups least represented in health equity research in India.15 According
to research, people who are part of the LGBTQIA+ community are more than twice as likely
as heterosexual people to have a disorder in their lifetime.16 Members of the community
fear the use of negative medical interventions such as conversion therapy, which is found to
be largely ineffective and very harmful.17 They also experience stereotyping, labelling,
judgement, as well as verbal, mental and physical abuse which leads to a heightened risk of
disorders, especially post-traumatic stress disorder (PTSD).18 These unwelcoming
environments, alongside the lack of specialised mental health services to meet their needs,
largely discourage individuals from seeking mental support.

11
Debasis Barik, Issues of Unequal Access to Public Health in India,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4621381/
12
Savita Malhotra, Women and mental health in India: An overview,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4539863/
13
India – Country Fact Sheet,
https://data.unwomen.org/country/india#:~:text=As%20of%20February%202021%2C%20only,in%20the%20pr
evious%2012%20months
14
Piyush Verma, Destigmatizing mental health care for women,
https://timesofindia.indiatimes.com/blogs/voices/destigmatizing-mental-health-care-for-women/
15
Jagruti Wandrekar, What Do We Know About LGBTQIA+ Mental Health in India? A Review of Research From
2009 to 2019, P. 26-36,
https://www.researchgate.net/publication/340892224_What_Do_We_Know_About_LGBTQIA_Mental_Health
_in_India_A_Review_of_Research_From_2009_to_2019
16
Diversity and Health Equity in Education: Lesbian, Gay, Bisexual, Transgender and Queer/Questioning,
https://www.psychiatry.org/psychiatrists/diversity/education/lgbtq-patients#:~:text=Mental%20Health%20Fac
ts%20for%20Lesbian,health%20disorder%20in%20their%20lifetime
17
What Does the Scholarly Research Say about Whether Conversion Therapy Can Alter Sexual Orientation
Without Causing Harm?,
https://whatweknow.inequality.cornell.edu/topics/lgbt-equality/what-does-the-scholarly-research-say-about-w
hether-conversion-therapy-can-alter-sexual-orientation-without-causing-harm/
18
Sarah Valentine et al., Trauma, Discrimination and PTSD Among LGBTQ+ People,
https://www.ptsd.va.gov/professional/treat/specific/trauma_discrimination_lgbtq.asp

5
Having a disability can lead an individual to struggle when trying to get access to mental
health care. People with disabilities experience bullying and name-calling, social isolation,
and many face a lack of educational and employment opportunities which leads to them not
being able to afford help. Internally, they are made to feel like a burden, and research shows
that discrimination from an early age can have a seriously negative impact on their mental
health.19 Many mental health facilities and services are not physically accessible for
individuals with physical disabilities. Those with hearing or speech impairments also face
challenges to effectively communicate with mental health professionals, making their
journey to recovery that much harder. Also, there are limited mental health professionals
who have sufficient training and experience working with people who have disabilities. All of
these factors together stop them from receiving the help that they need.

The caste system in India is a social system that divides communities into a hierarchy based
on historical notions of purity. Around 80% of India’s population belongs to historically
disadvantaged Castes, Tribes or religious minorities.20 Scheduled Castes and Scheduled
Tribes face stigmatisation based on their caste or ethnic backgrounds. Upwards of 9,000
crimes against Adivasi people and 50,000 suspected crimes against members of Scheduled
Castes were reported in 2021.21 The exclusion and constant discrimination these groups
experience could lead to internalised oppression, lower self-esteem and distress. Historically,
disadvantaged castes typically overlap with low-income communities, who according to the
National mental health survey of 2016, have a 40% higher rate of depression than the
national average.18 These socio-economic disadvantages can lead to stress, anxiety,
depression and many other disorders.22 There is also a major lack of awareness, due to
culturally different beliefs, practices and languages. The scarcely available professionals in
rural and remote areas and the lack of representation of these groups as mental health
professionals also deters members of the communities from seeking help.

There are also many religious minorities in India that experience discrimination when
attempting to access mental health care such as Muslims, Christians, Sikhs, Parsis, etc. For
example, in a research paper published in the Journal of Health Sciences, it was discovered
that Muslims were at a higher risk of anxiety compared to Hindus in India.23 The identity of
being a ‘Muslim’ can subject individuals to heightened vulnerability due to the increasing
discrimination towards the Muslim community. Aiman Khan, A Muslim activist who works
with survivors of hate crimes, told TRT World, “When hate becomes so deep-rooted, how do
you even explain it to the therapist?”. This is why, many Muslims prefer professionals from

19
The Significance of Mental Health and People with Disabilities,
https://udservices.org/mental-health-and-people-with-disabilities/
20
Maroosha Muzaffar, When Mental Health Collides with Caste Identity,
https://thewire.in/caste/mental-health-caste
21
Human rights in India,
https://www.amnesty.org/en/location/asia-and-the-pacific/south-asia/india/report-india/
22
Paula Nurius, Intersection of Stress, Social Disadvantage, and Life Course Processes: Reframing Trauma and
Mental Health, P. 91-114, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4343539/
23
Rishabh Jain, The ‘othering’ of Muslims is triggering mental health issues in India,
https://www.trtworld.com/magazine/the-othering-of-muslims-is-triggering-mental-health-issues-in-india-5389
3

6
their own religious background while discussing their mental health, since upper-caste
Hindu psychologists would lack the necessary understanding to relate to their experiences.

The field of therapy is largely not inclusive, since the multiple social conditions that shape an
individual and their mental health are kept in mind only by a small proportion of
professionals. A very small percentage of psychiatrists in India belong to the Dalit, Bahujan
and Adivasi communities.24 This underrepresentation in the mental healthcare workforce
leads to misinterpretation and ignorance of the experiences of an entire community. A
power dynamic is created if the therapist is from a privileged caste and the client is a
member of an oppressed caste. Only those who have undergone the same experience can
truly have a profound understanding of the pain endured by the oppressed. Even individuals
who claim to be progressive may possess inherent biases and a lack of genuine
comprehension, which could hinder the therapeutic process and lead to the patient feeling
judged or misunderstood.25 It is clear that although policies in India have evolved overtime,
these communities require specialised attention to ensure they receive the mental
healthcare they deserve.

2. Evolution of mental health policies in India

24
Zeba Vagh, How Crises Affect The Mental Health of Different Communities Differently,
https://feminisminindia.com/2021/07/02/mental-health-intersectionality-india/
25
Preeti Nangal, Psychiatrists, psychologists working with survivors of caste and gender-based trauma need to
be trained for it, say human rights activists,
https://www.firstpost.com/health/psychiatrists-psychologists-working-with-survivors-of-caste-and-gender-base
d-trauma-need-to-be-trained-for-it-say-human-rights-activists-9007661.html

7
 3. Mental Healthcare Act of 2017

3.1 Background and objectives

This is an integral piece of legislation that was passed by the parliament. On March 27, 2017,
the Lok Sabha in a unanimous decision passed the Mental Healthcare Act 2017 which was
passed in Rajya Sabha on August 2016 and got its approval from the Honourable President of

8
India on April 7, 2017.26 It goes to show a significant step towards promoting the rights of
people with mental illnesses and problems to ensure that they have access to quality mental
healthcare and to reduce the stigma around this issue. It is split into 16 chapters and itself
defines mental illness as a broader term- “a substantial disorder of thinking, mood,
perception, orientation, or memory that grossly impairs judgement or ability to meet the
ordinary demands of life, mental conditions associated with the abuse of alcohol and
drugs.”27

It was enacted to replace the Mental Health Act of 1987 which had been active in India. It
was driven because there was a need for a more comprehensive and modern legislation that
would be highly specific. There are a few key parts that are distinctly different. It
decriminalized suicide attempts and ensures that people can undergo rehabilitation. In an
overall manner, it ensures that every person should have the right to access mental healthcare
services along with dignity and autonomy.28 It also introduces the concept of “Informed
Consent” where people now have the right to decide what type of treatment, if any, they want
to undergo.29 Furthermore, medical professionals are obliged to provide in-depth information
about the procedure, its risks, and probabilities to the patients. Even if individuals do not have
the capacity to make decisions, they are allowed to express their preferences for treatment.
Last but not the least, it also includes new concepts such as special provisions for women and
the vulnerable population for example the poor and the homeless people (those under the
poverty line have free access). This mean that they are entitled to free treatment through
government facilities including halfway homes, sheltered accommodation, day care centres,
quality psychiatric services, etc. States are required to put efforts for social inclusion and
provide opportunity and equal participation for fair treatment of everyone. If services are not
available people with mental illnesses are entitled compensation from the state itself to
provide them with a sustainable lifestyle. The act is aspirational on the financial expense part
and does not mandate the state to allocate budget for the smooth functioning of state authority
and respective district boards.30

Budgets for the Indian Government for the year 2023-2024 have been estimated to be around
1,199 crore rupees. Mental health institutions categorically receive over 85% of the total
funding for mental health. This year, T-MANAS (Tele-Mental Health Assistance and
Nationally Actionable Plan through States), which has been introduced as a new line-item in
the budget, received 15% of the mental health funds.31 Although the mental health budget this
year has increased by 16%, there are some notable absences. In November 2022, along with
T-MANAS, the MoHFW also released the National Suicide Prevention Strategy (NSPS)
addressing a crisis of rising suicide rates in the country. NSPS and other policies plus sectors

26
Abhisek Mishra et al., Mental Healthcare Act 2017: Need to Wait and Watch, P. 67-70,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5932926/
27
Mental Healthcare Act, 2017, https://www.indiacode.nic.in/handle/123456789/2249
28
Toolika Payak, Our Journey to Mental Healthcare Act, 2017,
https://timesofindia.indiatimes.com/readersblog/eccentricdimensionist/our-journey-to-mental-healthcare-act-
2017-24432/
29
Furkhan Ali et al., Consent in current psychiatric practice and research: An Indian perspective, P. 667-675,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6482676/
30
Suresh Bada Math et al., Mental Healthcare Act 2017 – Aspiration to action, P. 660-666,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6482691/
31
Sayali Mahashur and Tanya Fernandes, What the Union Budget 2023–24 tells us about the government’s
mental health priorities,
https://cmhlp.org/blogs/what-the-union-budget-2023-24-tells-us-about-the-governments-mental-health-priori
ties/

9
do not have enough funds earmarked for its implementations let alone this budget being
insufficient to provide a mighty impact on the marginalized communities over India.
Although uncalculated how much money is required for the reduction in mental health
problems in marginalized communities, the current effects as explored by the budget do not
come close to mitigating this issue in the larger scale of things.

3.2 Challenges in addressing marginalized communities

Often, these vulnerable populations fall under the category of marginalised communities. The
act lacks structured legislation in order to cater to these marginalised communities such as the
LGBTQIA+, Scheduled Castes (Dalits), Tribes, Other Backward Classes (OBCs), etc. People
belonging to marginalised communities have their own unique and variety of challenges in
accessing Mental Healthcare. Many among them belong to the lower socio-economic strata
which affects their accessibility and affordability of mental healthcare.32 Although the
Poverty Line is used, many of these suppressed communities are not considered when they
are right above the poverty line (the minimum amount of money a person needs to fulfil the
basic necessities of life, like shelter and food) and the other social stigma they face. This
insinuates that the people barely meeting their daily requirements are ignored to an extent.
Hence, the poverty line method fails to address a group of people. Additionally, to provide
adequate medical infrastructure the government would need to increase or shift a larger
portion of their budget for mental health care to be readily available.24

Furthermore, while the act addresses the issue of stigma, its impact on marginalised
communities requires more targeted efforts. The case of “intersectionality” and multiple
marginalisation is also not considered. Individuals at the intersections of caste, gender, class,
and other social identities face numerous challenges and barriers to mental healthcare.

These communities face innumerable mental health issues. Firstly, minority stress as
discussed earlier. This leads to higher anxiety, depression, and PTSD (Post Traumatic Stress
Disorder) rates in these communities. The Act mentions everyone’s access to mental
healthcare, but in actual implementation and statistics, it fails to consider the aforementioned
people. The difference in treatment is fuelled also by the internalised and externalised
oppression due to their inability to contribute to the society and be accepted as “normal.”

4. State policies without comprehensive provisions for marginalized

communities

4.1 Jharkhand

The “right to access mental health care” – Section 18 of the Mental Health Care Act (MHCA,
2017) states that “every person shall” have the right to access mental health care and
treatment from mental health services run or funded by the appropriate government, and the
government shall make sufficient provisions as may be necessary for a range of services
required by a person with mental illness (PMI). A good mental health system has the
responsibility of reducing the substantial burden of untreated mental disorders, decreasing
human rights violations, ensuring social protection, and improving the quality of life,
32
Dr Jayakumar C and Dr Chiranjeev Bhattacharjya, Mental Healthcare for All: Leaving No One Behind,
https://www.undp.org/india/blog/mental-healthcare-all-leaving-no-one-behind

10
especially of the most vulnerable and marginalized subgroups in a society. Moving beyond
care, it should also integrate and include mental health promotion and rehabilitation
components.33 In this correspondence, we have attempted to highlight the status and deficits
in mental health-care provision in Jharkhand. We hope that it would facilitate policymakers in
prioritizing key domains for improvement.

According to the National Mental Health Survey of India, the prevalence of mental illness in
Jharkhand was reported to be 11.1%, which is slightly higher than the national average of
10.6%.[3] In terms of individual psychiatric disorders, the prevalence of depressive disorder
was 3000 per lakh population, anxiety disorder was 3500 per lakh population, and
developmental intellectual disability was 5000 per lakh population (1.7%).34 A National
Survey by the Ministry of Social Justice and Empowerment depicted that about 0.4% of the
population in the state has dependence on alcohol (national average, 2.7%), 0.06% has
dependence on cannabis (national average, 0.25%), and 1.09% have opioid dependence
(national average, 2.06%).35 As per the National Crime Record Bureau, the average suicide
rate is increasing in Jharkhand, which was 3.60 suicides/day in the year 2018 and 4.5
suicides/day in 2019, having further increased during the initial 6 months of 2020 to an
average of 5.5 suicides/day.36 Witch-hunting is yet another manifestation which is attributable
to psychiatric illness and absolute neglect of “mental health literacy” among tribal and rural
population. Jharkhand was ranked third in witch-hunting cases and recorded 15 murders
related to crime during 2019, and 123 people, mostly women, were branded witches and
killed from 2016 to May 2019.37 These figures speak loudly for the need of building
awareness about mental health.

For a population of 3.29 crores, the medical colleges and hospitals run only outpatient
services and are not equipped with providing emergency care and hospitalizations. The
mental health institutions, such as the Central Institute of Psychiatry (CIP) and Ranchi
Institute of Psychiatry and Allied Sciences (RINPAS), are the only available facilities which
are overburdened with severe psychiatric illnesses. The patients with common mental
disorders (CMDs) and those with comorbid medical conditions thus struggle to receive the
rightly deserved multidisciplinary care. The district mental health program (DMHP) is
operational in only three of 24 districts within the state, despite being approved for all the
districts. None of the primary health-care centres provide any form of mental health services.

In the state, there are three mental hospitals solely providing mental health care in the capital,
located within 2–3 km away from each other and run under separate jurisdictions.38 These big
institutions represent century-old custodian care for psychiatric patients, but cannot be an

33
Everybody’s Business – Strengthening Health Systems to Improve Health Outcomes,
https://apps.who.int/iris/bitstream/handle/10665/43918/9789241596077_eng.pdf
34
R. Srinivasa Murthy, National Mental Health Survey of India 2015-2016, P. 1-26,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5419008/
35
Atul Ambedkar et al., Magnitude of Substance Use in India,
https://socialjustice.gov.in/writereaddata/UploadFile/Survey%20Report636935330086452652.pdf
36
Accidental Deaths and Suicides in India (ADSI) – 2019,
https://ncrb.gov.in/sites/default/files/Chapter-2-Suicides_2019.pdf
37
ASRP Mukesh, Witch-hunts: Superstition kills more than naxals in Jharkhand,
https://timesofindia.indiatimes.com/city/ranchi/witch-hunts-superstition-kills-more-than-naxals-in-jharkhand/
articleshow/70336295.cms?utm_source=contentofinterest&utm_medium=text&utm_campaign=cppst
38
S. Haque Nizamie, Central Institute of Psychiatry: A tradition in excellence, P. 144-148,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2738340/

11
alternative to general hospital psychiatric services in these modern times. The community
care model is still in its infancy. While both the state-aided and the central government-aided
hospitals run their community extension clinics, they have not been adequately integrated
within the infrastructure of the mental hospital. There is an absence of any community
support system for noninstitutionalized patients and the family remains the only source of
support. The lack of adequate primary and district-level support for treatment is a hindrance
in avoiding unnecessary mental hospital admissions that could have improved with the
provision of community support and facilities.

Even after so many years of independence, the medical colleges in Jharkhand do not have
psychiatry departments. The society has consistently appraised the Government of India and
the then Medical Council of India, the current National Medical Commission (NMC), about
the necessity for mandatory psychiatric training of the budding doctors (MBBS students) to
address the gap in mental health services. However, its disproportionate focus on the
undergraduate and postgraduate training has fallen short of highlighting the glaring
deficiencies in the basic standards of psychiatric education throughout the country. The forum
of Indian Teachers of Psychiatry (Ito) formed in 2016 can take up a survey of the states to
map the minimum standards of psychiatric training. The annual general body can discuss the
issue with immediacy and handhold the respective state branches in establishing contact with
their respective medical education and health departments. A close liaison and networking
with the government can work toward achieving the goal.

Jharkhand is tribal state with widely prevalent psychiatric problems, alcoholism, and
practices like witch-hunting with low mental health literacy and inadequate mental
health-care provisions. Such a scenario necessitates an urgent need to develop training in
mental health-care delivery to a wide range of professionals (specialists, MBBS doctors,
AYUSH doctors) and peripheral health functionaries ( Accredited Social Health Activists,
Urban Social Health Activists, Auxiliary Nurse Midwifes, Lady Health Visitors, registered
nurses). The short-term training programs by digital academies such as National Institute of
Mental Health and Neurosciences and CIP can be a useful resource. Equipping general
hospital psychiatry units with beds for acute admission and provision of long-term residential
facilities in the community have been long-standing requirements. There is an increasing
need by mental health policymakers to enhance the budgetary allocations to the GHPUs and
equip them with full potential.

The teleconsultation services can be operationalized and mapped to districts with poor service
delivery. The state government can liaison with institutions such as CIP to provide the needed
support. Project “Garima” launched by the state of Jharkhand to identify women suffering
from accusations of witchcraft is a welcome beginning. The potential of civil society
organizations (CSOs) remains untapped within the state of Jharkhand. The technical expertise
of the mental health professionals along with the service delivery and outreach potential of
the CSOs can serve a very potent solution to address the unmet needs of the rural and tribal
communities. The state society needs to harness the potential of all its mental health
professionals in promoting mental health awareness and for advocacy of situations that are
local to the state. The strength lies in the local partnerships and shared vision to improve the
mental health affairs of the state of Jharkhand.

5. State policies with comprehensive provisions for marginalized

communities

12
5.1 Meghalaya’s Mental Health and Social Care Policy of 2022

The prevalence of mental disorders in Meghalaya may be gleaned from the Global Burden of
Disease (GBD) study, 1990-2017.39 This is as follows:

Mental disorder Prevalence (per 1,00,000)

Idiopathic developmental intellectual disability 4,755 (3,170–6,331)
Depressive disorders 3,340 (3,089–3,649)
Anxiety disorders 3,117 (2,846–3,439)
Conduct disorders 961 (754–1,202)
Bipolar disorders 527 (447–624)
Attention-deficit/hyperactivity disorders (ADHD) 441 (361–534)
Autism spectrum disorders 354 (315–396)
Schizophrenia 220 (191–254)
Eating disorders 171 (135–215)
Other mental disorders (personality disorders) 1,544 (1,316–1,760)

Meghalaya, along with Jharkhand, Bihar, Uttar Pradesh, Nagaland, and Arunachal Pradesh
are states with the greatest frequency of conduct disorders. Similarly, Meghalaya,
Maharashtra, Arunachal Pradesh, and Bihar have the highest rates of ADHD. Meghalaya has
been noted as one of the states with a high frequency of mental disorders as a result.

Depressive and anxiety disorders rank 6th and 9th, respectively, among the top 15 causes of
years of healthy living lost due to disability (YLDs) in Meghalaya, according to the Health of
the Nation's States report.

226 deaths by suicide were reported in Meghalaya in 2021, i.e., around 6 for every 10,000
residents, of which 172 men and 54 were women. The most frequent causes of suicide were
illness, familial troubles, and marital problems.

Concerns about substance use are also extremely prevalent. According to the National
Survey of Substance Use, 2019, conducted by the Ministry of Social Justice and
Empowerment and the National Drug De-Addiction Centre at the All India Institute of
Medical Sciences (AIIMS), Delhi, 6.34% of the population used opiates and 2% needed
urgent assistance. These figures exceed the national average by three times.

Overall, the review of current statistics reveals that Meghalaya has a high prevalence of
mental disorders and related issues, such as substance abuse.

39
Sagar et al., The burden of mental disorders across the states of India: The Global Burden of Disease Study
1990-2017, P. 148-161, https://doi.org/10.1016/S2215-0366(19)30475-4

13
Meghalaya is the third state in India to adopt a comprehensive mental health policy,
alongside Kerala and Karnataka.40 The goal of Meghalaya's mental health policy is to enable
access to care for those with mental health issues and to promote overall mental health and
well-being. It seeks to lessen the severity of social misery, morbidity, and mortality. In order
to achieve this, it aims to address the socio-economic causes of mental illness, maintain
cultural safety, and engage in cooperative relationships with the communities it hopes to
serve.

Sensitive public healthcare approach, community awareness and engagement, care

pathways, and support for vulnerable populations are the four dimensions that the policy's
structure is broken down into. Following is further information on the final dimension:

1. Strengthening women's affinity and support organisations: Aiming to prevent postpartum

depression and promote mental health both during and after pregnancy, community health
workers and women's collectives encourage improvements in maternal mental health. To
boost self-esteem and mental health, economic empowerment for women is prioritised, and
advocates for increased job development and economic opportunities. Women are
encouraged to become politically empowered so they may confront issues related to their
mental health and fight for solutions.

2. Positive youth, adolescent, and child development: The strategy places a focus on early
childhood care through the Integrated Child Development Scheme (ICDS) and Anganwadis,
which offer socio-emotional support and care. It is recommended that schools and facilities
provide care teams and counselling services for their students. Adolescents and youth
participate in numerous evidence-based treatment modalities, de-addiction therapies and
life skills training.

3. Elderly care and support: To enhance the quality of life for the elderly population, the
policy suggests educating professionals in geriatric mental health care and encouraging
community-based activities and involvement.

4. Individuals with substance use concerns: The strategy aims to provide treatment facilities,
conduct awareness campaigns and train medical professionals and counsellors for substance
use concerns. A harm reduction strategy and testing for Hepatitis-C and the human
immunodeficiency virus (HIV) are also suggested.

5. Caregivers: The strategy emphasises the need for increased support, particularly for
elderly, young and lone parents, as well as the mental health issues that caregivers may
encounter. Family caregivers will be covered by provisions from the Mental Healthcare Act of
2017 and the National Mental Health Policy of 2014.

6. Homeless people with mental health issues: The policy emphasises the necessity for
police to receive training in recognising and referring homeless people with mental health

40
Meghalaya cabinet approves mental health policy,
https://economictimes.indiatimes.com/news/india/meghalaya-cabinet-approves-mental-health-policy/articles
how/95857237.cms?from=mdr

14
issues to the proper treatment facilities. In regions where there are a lot of homeless
people, emergency and acute care facilities will be built.

7. Individuals with intellectual impairments: The policy aims to improve services for people
with intellectual disabilities, including early identification, assistance for families, inclusive
education and care standards.

8. LGBTQIA+ community: The policy places a strong emphasis on the freedom to self-identify
as a gender and the outlawry of discrimination based on it. Training in understanding LGBT
identities and utilising affirmative treatment techniques will be provided for mental health
practitioners.

9. Migration and related distress: With a focus on sensitive treatment from the first point of
contact, including strict training protocols for police, the strategy extends health services
and social welfare systems to migrants seeking jobs in Meghalaya.

6. International best practices

6.1 Canada

Area of intervention: Primary healthcare

Intervention: Partnership between a dedicated health clinic for government-assisted
refugees, a local reception centre, and community providers.
Targeted marginalized community: Refugees

The country has implemented an intervention aimed to collaborate between specialised

health clinics catering to government assisted refugees (GARs), a local reception centre, and
community healthcare providers on wait times and referrals.41 The findings of a study
indicated a significant 30% reduction in wait times for healthcare access following the
establishment of the dedicated refugee health clinic and a 45% decline in referrals to
physician specialists for GARs. Referrals to non-physician specialist healthcare providers
nearly doubled once the clinic became available. The study highlights the necessity of an
integrated, community-based primary healthcare intervention that addresses the
time-sensitive and intense health needs of GARs.42 It stresses the importance of dedicated
health system navigators to ensure timely, culturally appropriate care, and successful
integration. Previous research conducted in India has demonstrated that the COVID-19
pandemic had a significant negative effect on the mental and psychosocial well-being of
migrants in the country. Studies highlight the necessity for further investigation in the
regions most affected by the pandemic and emphasise the importance of devising
intervention strategies aimed at mitigating the adverse consequences on the mental and
psychosocial health of migrants. Hence, there exists a need for India to implement similar

41
Elena Riza et al., Community-Based Healthcare for Migrants and Refugees: A Scoping Literature Review of
Best Practices, P. 115, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7349376/
42
Josephine McMurray et al., Integrated primary care improves access to healthcare for newly arrived refugees
in Canada, P. 576-585, https://pubmed.ncbi.nlm.nih.gov/24293090/

15
programs.43 However, implementing dedicated healthcare services for government-assisted
refugees in India would face challenges related to scale, infrastructure, funding, cultural
diversity, policy alignment, social acceptance, data collection, coordination, and long-term
sustainability. Overcoming these obstacles would be crucial for promoting refugee
well-being and successful integration.

6.2 Zimbabwe

Area of intervention: Mental healthcare (related to depression and anxiety)

Intervention: Friendship Bench Program
Targeted marginalized communities: Those affected by poverty and HIV/AIDS.

This program was successfully implemented in Zimbabwe to address the mental health
needs of marginalised populations. It involves utilising trained lay health workers to provide
problem-solving therapy on park benches, making mental health support easily accessible
and reducing stigma. These benches are located in medical clinics, and each bench has a
trained community member who counsels people struggling with depression, rejecting
western terms and medicines so as to reduce associated prejudices. To adapt this program in
India, it should be culturally adapted to suit the diverse cultural norms and beliefs prevalent
in India. This might prove especially challenging considering caste and gender contexts
which to overcome would need raising awareness and normalising talking about mental
health.44 To make the process easier, it should involve local community leaders, traditional
healers, and religious figures to support mental health outreach and engagement. Adequate
training of mental health workers (keeping in mind marginalised communities) is also
necessary to provide basic mental health support, counselling, and referrals.

6.3 Pakistan

Area of intervention: Mental health insurance

Intervention: Naya Jeevan
Targeted marginalized communities: low-income families with lack of access to healthcare

This community-based mental health program in Pakistan employs culturally adapted

interventions to address the mental health needs of marginalised individuals Naya Jeevan
provides its members with 24/7 guidance and healthcare accessibility through mobile
services, allowing them to access medical support from the comfort of their homes. The
organisation conducts awareness campaigns on a wide range of health issues, including
hepatitis, diabetes, sanitation, and women's health. Additionally, Naya Jeevan has
implemented a cashless network of healthcare facilities nationwide, enabling members to
use their mobile wallets for hassle-free payment of medical procedures without the need for
reimbursements. These healthcare plans are co-financed by corporations employing Naya
Jeevan members, serving as loyalty incentive programs, and fostering a sustainable
framework with benefits for all stakeholders involved.[4] This process is in sharp contrast to

43
Gurvinder Pal Singh, Psychosocial and Mental Health Issues of the Migrants Amongst COVID-19 Pandemic in
India: A Narrative Review, P. 473-478, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8826203/
44
Asanda Mcoyana, The Friendship Bench therapy – why has it been so successful?,
https://www.mhinnovation.net/blog/2017/feb/2/friendship-bench-therapy-why-has-it-been-so-successful

16
any mental health insurance plan in India. Lack of funding, lack of proper research and data
collection of mental health disorders and long hospitalisation periods are some of the
reasons for a failing insurance plan for mental health in India.[8]To address India's cultural
diversity, the Naya Jeevan program can be regionally customised to incorporate culturally
appropriate healthcare practices and awareness campaigns. Also, utilising mobile services
and telemedicine can enhance healthcare accessibility for remote and underserved
communities in India.

6.4 Thailand

Area of intervention: Mental health services

Intervention: Village Health Volunteers (VHVs)
Targeted marginalized communities: Remote marginalised communities.

Thailand has employed Village Health Volunteers to deliver mental health services to remote
and marginalised communities. These trained volunteers provide basic counselling, support,
and referrals to appropriate services. VHVs are selected by village or community members,
and they have to pass the required village health volunteer standard training courses. This
ensures that barriers of stigma and community are less noticeable. Their training was
especially helpful during the COVID-19 period. Thailand home health care (VHVs) for the
dependent elderly living in rural areas has been mobilised as a multidisciplinary health team
that delivers comprehensive care.4546 The Village Health Volunteers (VHV) program can be
adapted to India's context by considering the following factors:

● Training and empowerment: Provide comprehensive training to village health

workers to equip them with essential healthcare skills and knowledge. Empower
them to offer basic medical services and preventive care.
● Localization: Tailor the VHW program to the specific needs of different regions and
communities. Consider cultural norms, beliefs, and language preferences to ensure
the program's relevance and acceptance.
● Integration with existing healthcare system: Integrate the VHW program into India's
existing healthcare system, collaborating with local healthcare providers, community
health centres, and government health initiatives.

These countries (excluding Canada), being almost identical to India in terms of

socio-economic characteristics (similar economies, agriculture dominance, gender and caste
inequalities and healthcare challenges), have implemented innovative approaches to mental
health programs that can serve as valuable references. By studying these international best
practices, India can adapt and tailor these strategies to its specific context, ensuring the
development of inclusive mental health policies that address the needs of marginalised
communities effectively.

45
Poonnatree Jiaviriyaboonya, Anthropological study of village health volunteers’ (VHVs’) socio-political
network in minimizing risk and managing the crisis during COVID-19,
https://www.sciencedirect.com/science/article/pii/S2405844021027572
46
Nonglak Pagaiya, From village health volunteers to paid care givers: the optimal mix for a multidisciplinary
home health care workforce in rural Thailand,
https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-020-00542-3

17
 7. Recommendations for Advancing Inclusion

Mental health is a crucial aspect of overall well-being and quality of life. However, in India,
marginalised communities often face significant barriers in accessing mental health services
and support. Marginalised communities, which include but are not limited to lower-caste
individuals, tribal populations, religious minorities, LGBTQ+ individuals, persons with
disabilities, and economically disadvantaged groups, are disproportionately affected by
mental health disparities. This section of the research paper aims to propose
recommendations for advancing the inclusion of mental health support and services for
these marginalised communities in India. Potential unintended consequences that might
come up include the avoidance of certain policies due to stigma, discrimination of
healthcare advocates, government budget cuts on other areas of research and burnout of
staff due to increased expectations.47 The benefits of implementing the policies (after
adequate testing) mentioned below, however, far outweigh its potential drawbacks.

7.1 Better implementation of existing policies

Effective implementation of existing policies is crucial for advancing the inclusion of mental
health for marginalised communities in India. By identifying gaps, building capacity,
monitoring outcomes, engaging stakeholders, and allocating resources appropriately,
policymakers can ensure that mental health services reach the intended beneficiaries and
address the unique needs of marginalised populations. This comprehensive approach will
contribute to reducing disparities and creating a more equitable and inclusive mental health
support system for all citizens.48 For example, The Mental Healthcare Act 2017 act could
provide more specific provisions or guidelines to address these intersections. For example,
specifically, the act can ensure that the LGBTQ community or any person cannot be
discriminated against with mental healthcare based on sexual orientation. This is a
cost-effective option as mechanisms for the policy to be executed are already in place and its
implementation should also be considerably easier keeping in mind the fact that the
foundation of the policy has already been set up.49 Limitations in the form of lack of
sensitised and trained personnel, accessibility and sustainability might arise if authorities do
not allocate sufficient budgets and update policies regularly.

7.2 Adopting best international and state practices

By learning from successful approaches implemented elsewhere and within the state,
organisations and governments can enhance efficiency, effectiveness, and innovation in their
operations. Along with the analyses done on select programs in this paper, taking the
example of an intervention called the Perinatal Mental Health Project undertaken in South
Africa that provided mental health services for perinatal women in limited resource settings,

47
Urvashi Priyadarshini et al., Recommendations for maternal mental health policy in India, P. 90-101,
https://link.springer.com/article/10.1057/s41271-022-00384-4
48
Madhurima Ghosh, Mental health insurance scenario in India: Where does India stand?, P. 603-605,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8793698/
49

18
can also help in effectively thinking of new policies and solutions.42 While adapting such
programs from different countries might raise issues due to India's unique cultural diversity,
it still has more benefits as opposed to its cost considering the success already associated
with these programs and the variety of countries with different backgrounds that have been
evaluated.

7.3 Inclusivity and culturally sensitive approaches

Developing culturally sensitive mental health policies is essential for engaging marginalised
communities effectively. A culturally sensitive policy entails the development and
implementation of mental health strategies that respect and accommodate the diverse
cultural backgrounds, beliefs, and practices of the targeted communities. Such policies
recognize the influence of cultural factors on mental health perceptions and help-seeking
behaviours, aiming to eliminate cultural barriers and stigmas surrounding mental health. To
be culturally sensitive, the policy should be able to provide culturally competent mental
health services, recognize language barriers, increase community engagement and aim to
raise awareness reducing preconceived stereotypes and stigmas.

Policymakers can collaborate with community leaders, religious institutions, and grassroots
organisations to understand the unique cultural beliefs, practices, and stigma associated
with mental health. It is crucial to involve community members (this includes leaders, active
participants, panchayats, existing trained personnel and volunteers of the community) in the
design and implementation of mental health programs to ensure they are acceptable and
effective. To increase the feasibility, controlled tests in select vulnerable areas can be
undertaken and proper data gathered so as to improve the efficiency of the idea of
introducing collaborations with diverse stakeholders.

Moreover, in this respect it is also essential to consider intersectionality, which is a concept

that recognizes that individuals belong to multiple marginalised groups simultaneously, and
their experiences are shaped by the intersecting effects of various forms of discrimination.
Policymakers should adopt an intersectional approach when designing mental health
policies to address the unique needs of individuals who belong to multiple marginalised
communities, such as Dalit women or transgender individuals.

To address disparities in access to mental health services, policymakers should focus on

reducing barriers for marginalised communities. This can be achieved by providing financial
support, such as subsidies or insurance coverage (can take inspiration from the Naya Jeevan
program), specifically targeted at these populations. Additionally, ensuring the availability of
mental health services in remote and rural areas, where marginalised communities are often
concentrated, can improve accessibility.

7.4 Training and public awareness

Policymakers should emphasise trauma-informed care approaches that consider the

experiences of marginalised communities, such as caste-based discrimination, gender-based
violence, or systemic marginalisation. Mental health policies should incorporate strategies to
train mental health professionals in trauma-informed care, as well as to provide specialised

19
support for survivors of trauma.50 Efforts to reduce stigma and increase awareness about
mental health should be targeted towards marginalised communities. Policymakers can
implement public awareness campaigns that are culturally appropriate and address the
specific concerns and challenges faced by these communities. Educational initiatives in
schools and community centres can also play a crucial role in promoting mental health
literacy. Resources in the form of ASHA workers and SHGs can also be tapped into
considering that they, being part of similar communities, wouldn't face as many barriers.
There will be a need for capacity building and training in this respect. Furthermore, giving
basic training to community healthcare centres would also help break barriers of stigma and
marginalised communities would consider them to be more accessible and understanding.51

50
Sylvia Reitmanova and Diana L. Gustafson, Mental Health Needs of Visible Minority Immigrants in a Small
Urban Center: Recommendations for Policy Makers and Service Providers, P. 46-56,
https://sci-hub.ru/https://link.springer.com/article/10.1007/s10903-008-9122-x
51
Anugraha Raman, Mental healthcare in India fails marginalized people,
https://timesofindia.indiatimes.com/blogs/developing-contemporary-india/mental-healthcare-in-india-fails-ma
rginalised-people/

20