Cost estimation for the implementation of the Mental Healthcare Act 2017.

The Mental Healthcare Act, 2017 (MHCA) was a step that was essential, once the Government of India ratified the United Nations Convention on the Rights of Persons with Disabilities in 2007. The MHCA looks to protect, promote, and fulfill the rights of persons with mental illness (PMI) as stated in the preamble of the Act. Further, there is an onus on the state to provide affordable mental health care to its citizens. In India, mental health has always been a lesser priority for lawmakers and citizens alike. The rights-based MHCA looks to overhaul the existing system by giving prominence to autonomy, protecting the rights of the mentally ill individuals, and making the State responsible for the care. The decision to make all this happen is commendable. The annual health expenditure of India is 1.15% of the gross domestic product, and the mental health budget is <1% of India's total health budget. This article systematically analyses and describes the cost estimation of the implementation of MHCA 2017, and it is not an estimation of mental health economics. The conservative annual estimated cost on the government to implement MHCA, 2017 would be 94,073 crore rupees. The present study estimation depicts that investing in the implementation of MHCA, 2017 by the government will yield 6.5 times the return on investment analysis benefit. If the State is not proactive in taking measures to implement the MHCA, the rights promised under this legislation will remain aspirational.

INTRODUCTION

The Government of India (GOI) ratified the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) in 2007,[1] which mandated and obligated the laws of the country to align with the Convention. A task undertaken to review the Mental Health Act, 1987[2] and The Persons with Disabilities Act, 1995[3] revealed shortcomings. In order to align and harmonize the national legislation with UNCRPD, the GOI started to make efforts to improve the mental health services in the form of drafting new policies and laws like the National Mental Health Policy, 2014,[4] Rights of the Persons with Disability Act, 2016[5] and MHCA 2017 (MHCA, 2017; notified on May 29, 2018).[6] The preamble of the MHCA 2017 aims to provide mental health care and services for Persons with Mental Illness (PMI) and also protect, promote and fulfill the rights of such persons during delivery of mental health care and services.[7] The Act is progressive, patient-centric, and rights based. The whole dedicated chapter 5 (Section 18–28) on “Rights of the PMI” is the heart and soul of this legislation. However, Section 18 applies to everyone, but Sections 19–28 are specifically applicable to PMI only. The drafters and the government had a vision of social welfare responsibility and appropriately articulated. Section 18, “everyone” has the right to access mental health care.

”Right to access mental healthcare” – Section 18 of the Act articulates that “every person shall” have a right to access mental health care and treatment from mental health services run or funded by the appropriate government, and government shall make sufficient provision as may be necessary, for a range of services required by PMI. If the government fails to provide the right to access mental health care to everyone, then it is the responsibility of the government to reimburse the costs of treatment according to section 18, 5 (f) of the MHCA 2017. Section 18 is for “everyone” because a person who is on prophylaxis (on follow-up and do not meet the criteria of PMI) can access mental health-care services and free essential medicines; a person who does not meet the criteria of PMI (had illness but improved currently) can access a range of rehabilitation services; and another person can seek help before he/she develops mental illness (prevention and promotion). It is very important to note that only Section 18 of the MHCA, 2017 says every person has the right to access to mental health care and beyond doubt, it applies to everyone. However, Section 19–28 applies only for PMI.

Justiciability of right to access to mental health care

The Act has taken a paradigm shift of providing “mental healthcare” as a “justiciable rights.” Justiciability refers to the amenability of an issue to be adjudicated on in judicial or quasi-judicial statutory body under the legislation. This right is meant to ensure that services be accessible, affordable, and of good quality. It also mandates the provision of mental health services to be established and available in every district of the country. Now, all States are legally bound to provide this right to their citizens under the MHCA, 2017. This is a landmark legislation in terms of making the government accountable for a socioeconomic right – the “right to access mental health care.”

MHCA, 2017 also recognizes the right to community living; right to live with dignity; protection from cruel, inhuman, or degrading treatment; treatment equal to persons with physical illness; right to relevant information concerning treatment, right to confidentiality; right to access their basic medical records; right to personal contacts and communication; right to legal aid; and recourse against deficiencies in mental health-care services. However, the estimate of the expenditure required to meet the obligations under the law is not available.[8] The annual health expenditure of India is 1.15% of the gross domestic product, and the mental health budget is <1% of India's total health budget.[9] However, the ground realities are far from adequate with regards to economic readiness and willpower to implement this rights-based legislation. This article assesses the economic impact on the Government for fulfilling the rights of the PMI, as promised under the MHCA 2017.

QUANTIFYING THE MAGNITUDE OF THE PROBLEM

Various epidemiological studies done in India report the prevalence of psychiatric morbidity ranging between 6% and 18%[1011] depending on the population studied, methodology, instrument chosen, and definition of case. These psychiatric disorders contribute to significant morbidity, disability, and even mortality among those affected. Due to the prevailing stigma, these disorders are often concealed by the society and consequently lead to a higher treatment gap and then poor quality of life.[210]

The Ministry of Health and Family Welfare, GOI, commissioned NIMHANS, Bengaluru, to undertake a nationally representative mental health study to understand the burden and patterns of mental health problems.[12] The study assessed 39,532 individuals across 720 clusters from 80 talukas in 43 districts of the 12 selected States. This landmark study has provided us with major insights into the magnitude of the problem and the state of service and resources to strengthen the mental health programs. As per the survey, the overall weighted prevalence for any mental morbidity was 13.7% lifetime and 10.6% current mental morbidity.[12] According to this “National Mental Health Survey” (NMHS), 13 crore population (130 million people) require mental health services. Mental disorders are not only highly prevalent and disabling medical conditions but also have huge treatment gap.[1314] The treatment gap is defined as the percentage of individuals with mental illness who are not on treatment.[13] Another issue of serious contention is that the treatment gap for mental disorders according to NMHS ranged between 70% and 92% across different disorders. This huge treatment gap raises serious questions regarding the accessibility, affordability, and acceptability of the available mental health services.[12] Further, approximately 50% of the PMI access public mental health-care sector.[12]

A National Survey on Extent and Pattern of Substance Use in India, which was commissioned and funded by the Ministry of Social Justice and Empowerment, GOI, had depicted disturbing results. About 5.2% of Indians (5.7 crore people) are estimated to be affected by harmful or dependent alcohol use, 2.8% (3.1 crore people) report of using cannabis, and 2.06% (2.4 crore people) report of using opioids. This huge burden of mental, behavioral, and substance use disorders in India calls for immediate attention of political leaders, policy makers, health professionals, opinion-makers, and society at large.[15]

Epidemiological studies which were exclusively conducted in the child and adoloscent population report prevalence rates ranging from 9 to 16%.[10] Math and Srinivasaraju estimated that 10% of the child and adolescent population has mental health morbidity[10] requiring professional attention.

Against this background, the lawmakers of the largest democratic society thought through and envisaged the release of the National Mental Health Policy.[4] The policy was based on values and principles of equity, justice, integrated and evidence-based care, enhanced quality, and participatory and holistic approach to mental health.[4] Further, to show its commitment, the Republic of India implemented the MHCA. From the international standpoint, the human rights protection perspectives of the MHCA has attracted most attention across the world.[161718]

METHODOLOGY

This article systematically analyses and describes the cost estimation of the implementation of MHCA 2017. This is not a “health economics article” but cost estimation of implementation and fulfilling the obligation by the government under the “MHCA, 2017” This analysis is based on close reading of all the sections of the legislation, discussions, consensus meetings, and expert opinions on the key issues in implementation and financial aspects of the Act.

The cost estimation for the implementation of the MHCA, 2017 has been assessed in this article by assuming that (a) prevalence of mental illness is 10%; (b) majority of the PMI are accessing public mental health-care services (although NMHS study[12] reports that only 50% of the people access mental health care through public health establishment); (c) treatment gap is zero; (d) the definition of mental illness is the clinical definition of mental illness, as mentioned in Section 3 read with Section 18 of the MHCA, 2017 for providing rights; (e) three mental health human resources (respectively in each category) per lakh population; and (f) the appropriate government will implement the act in true spirit without interpreting Section 18(11) of MHCA, 2017 in terms of “priority!”

According to the Constitution of India, health is a State subject, but the mental health-care falls into the ambit of concurrent list, and it is titled as “Lunacy and mental deficiency, including places for the reception or treatment of lunatics and mental deficient.” Hence, both central and state are responsible for providing the rights enshrined in the MHCA, 2017. Hence, authors of this article did not categorize into Central or State budget; both are responsible for providing the mental health care.

The researchers mapped the existing mental health resources such as human resources (psychiatrists, clinical psychologists, psychiatric social workers, and psychiatric nurses) for providing care, treatment, and rehabilitation. The researchers then calculated the deficits by comparing the existing resources to the standards reccomeded in developed countries. The researchers estimated the annual recurring cost required for implementation (statutory) agencies (Central/State Mental Health Authorities [SMHAs] and Mental Health Review Boards [MHRBs]). The researchers then estimated the costs for treatment, care, and rehabilitation of PMI. The costs were calculated per unit per month and then translated into per annum costs. There are certain sections where the obligations are cast on the government to be fulfilled within a time frame. Such estimations were calculated per annum after dividing by the time frame specified by the MHCA 2017. For the purpose of easy calculation, the nearest numbers were rounded off.

AVAILABLE RESOURCES TO ADDRESS MENTAL HEALTH ISSUES

India is the second largest country in the world in terms of population. This poses clear challenges in delivering mental health care to India's 1.3 billion people spread across a vast expanse.[17] The greatest challenge presented by the MHCA 2017 relates to the resourcing of both mental health services and the new statutory structures proposed in the Act. Mapping of India's mental health system generally reveals that it is under-resourced, and a rough estimate of the human resources[1920] is shown in Table 1.

Table 1

Magnitude of mental illness and available resources in India

Variable	Numbers
Population of India	130 crores
Number of people suffering from diagnosable psychiatric conditions (current)	10% or 13 crores
Number of people suffering from severe mental disorders (current)	0.8% or one crores
Number of beds for patients with psychiatric disorders (approximately)	60,000
Number of psychiatrists	9000
Number of psychiatric nurses (mental health nurses)	2000
Number of psychiatric social workers	1000
Number of clinical psychologists	1000

For the purposes of calculation, the values have been rounded off to the nearest highest number

MENTAL HEALTH HUMAN RESOURCES IN INDIA

According to the World Mental Health Atlas (2014), there were 0.3 psychiatrists per lakh of population in India. Psychologists and psychiatric social workers were even fewer. The median number of psychiatrists in India is only 0.2/100,000 population compared to a global median of 3 per 100,000 population. Similarly, the figures for psychologists, social workers, and nurses working for mental health are 0.03, 0.03, and 0.05/100,000 population.[19202122] The Indian Psychiatric Society enlists <7000 registered psychiatrists in this country. There is a gross deficit in human resources needed to deliver care for PMI in India. The estimated number of psychiatrists available in India in 2018 is approximately 9000.[21]

Section 31(3) of the MHCA, 2017 casts an obligation on the government to make efforts to meet internationally accepted guidelines for a number of mental health professionals based on the population, within 10 years from the commencement of this Act. At the international arena, Canada advocated an optimal target ratio of 1:6500 but recommended a more attainable pragmatic ratio of 1:8,000 for the foreseeable future.[2223] The Royal Australian and New Zealand College of Psychiatrists recently recommended that a range of 1:7500–1:10,000 is applaudable.[23] A recent assessment done by Garg et al. 2017, recommended in a letter to the editor that the median requirement of a psychiatrist is at least 3 per 1 lakh population.[21] However, the implementation of rights-based mental health legislation needs to be comprehensive and similar to that of the developed countries. The requirement of psychiatrists in Canada, Australia, the UK, and the USA, is one psychiatrist per 10,000 population.[2324] As per international standards, to provide mental health care for 10,000 persons, at least one psychiatrist, one psychiatric nurse, one psychiatric social worker, and one clinical psychologist are required. However, in this study, we have assumed three mental health human resources per lakh population for the estimation of the cost.

Based on the calculation, the difference between available human resources and the required human resources yields the deficit. The division of deficit with the number of professionals produced per year will yield the required number of years to achieve the mental health human resources target for 130 crore population [Table 2].

Table 2

Mental Health Professionals in India

Serial number	Human resources	Required per population	At present the numbers are	Required per 130 crore population	The deficit for 130 crores population	Human resources produced per year	Years required to reach the desirable numbers
As per the developed countries mental health human resources one per 10,000 population[23]
1	Psychiatrist	1/10,000	9000	1.3 lakh	1.2 lakh	700/year	171 years
2	Psychiatric nurses	1/10,000	2000	1.3 lakh	1.28 lakh	500/year	256 years
3	Psychiatric social worker	1/10,000	1000	1.3 lakh	1.29 lakh	500/year	258 years
4	Clinical psychologist	1/10,000	1000	1.3 lakh	1.29 lakh	500/year	258 years
As per the median requirement of the mental health human resources is at least three per one lakh population[21]
1	Psychiatrist	3 per lakh	9000	39,000	30,000	700/year	42 years
2	Psychiatric nurses	3 per lakh	2000	39,000	37,000	500/year	74 years
3	Psychiatric social worker	3 per lakh	1000	39,000	38,000	500/year	76 years
4	Clinical psychologist	3 per lakh	1000	39,000	38,000	500/year	76 years
Public psychiatric beds per 100,000 people
1	Public psychiatric beds	50 per lakh	60,000	6.5 lakh	6 lakhs	Not applicable	Not applicable

For the purposes of calculation, the values have been rounded off to the nearest lowest number. The above calculation is carried out keeping that population remains constant (both general population and mental health professionals)

If we were to assume India needs three mental health human resources (respectively in each category) per 1 lakh population,[21] we currently have 9000 psychiatrists, 2000 psychiatric nurses, 1000 clinical psychologists, and 1000 psychiatric social workers. We would need an additional 30,000 psychiatrists, 37,000 psychiatric nurses, 38,000 psychiatric social worker and 38,000 clinical psychologists.[21] As per the calculations, it will take 42 years to meet the requirement for psychiatrists, 74 years for psychiatric nurses, 76 years for the psychiatric social worker, and 76 years for clinical psychologists, for providing care for 130 crore population, provided the population (assuming both general population and mental health human resources) remains constant.

The cost of training one doctor is approximately Rs. 1 Crore,[25] but the cost of training one psychiatrist, one psychiatric nurse, one psychiatric social worker, or one clinical psychologist is not known. The estimation of the cost of training a psychiatrist (modern medicine) is not known. However, the cost of training a doctor (M. B. B. S) is one crore.[25] Hence, we have conservatively estimated one crore for training a psychiatrist, for the cost [Table 3].

Table 3

Workforce development cost to provide care to person with mental illness in India

Estimation assumed three mental health human resources (respectively in each category) per lakh population for estimation of the cost		Estimated workforce requirement	Current status	Deficits	Cost required train each person in crore rupees	Total cost in crore rupees
Workforce developments	Psychiatrists	39,000	9000	30,000	1 Crore	30000*
	Psychiatric nurse	39,000	2000	37,000	Not known	-
	Psychiatric social worker	39,000	1000	38,000	Not known	-
	Clinical psychologists	39,000	1000	38,000	Not known	-
*Total cost for human resources development over a period of 10 years (Section 31 (3) of the MHCA, 2017 dictates that the Government should achieve internationally accepted standards for the number of mental health professionals per lakh population within 10 years from the commencement of this Act. Hence, per year will be Rs. 3000 crores)						30,000

MHCA – Mental Healthcare Act

The workforce represents one key component of the mental health system and implementation of the rights-based mental health-care legislation. In India, approximately 56,600 public psychiatric beds (35,000 psychiatric beds in mental hospitals, ten beds each in 723 district hospitals, and 30 beds each in 479 medical colleges) exist for 130 crore population. In the mental hospitals, a substantial proportion of the psychiatric beds is occupied by the homeless mentally ill.[19] As per international standards (Treatment Advocacy Centre of US), the estimated requirement would be 50 beds per 1,00,000 population.[26] As per the above estimate, India requires 6.5 lakh psychiatric beds for 130 crore population, but available psychiatric beds are only 56,600. The deficit is approximately 6 lakh public psychiatric beds. Section 31(3) of the MHCA, 2017[7] dictates that the Government shall take appropriate measures to meet internationally accepted guidelines for the number of mental health professionals per lakh population within 10 years from the commencement of this Act. To address the three main shortcomings of mental health care – scarcity, inequity, and inefficiency – Indian government may have to take a comprehensive approach to achieve the objectives of the MHCA, 2017.

ESTIMATION OF THE ECONOMICS COSTS OF THE STATUTORY AGENCIES

The implementing agencies of the statute play a crucial role in realizing the objectives of the legislation. In this section, we estimate the recurring cost for the functioning of statutory agencies only. At this juncture, it would be prudent to highlight that one of the main reasons for failure of Mental Health Act, 1987 was the inability to form and allocate budget for the functioning of SMHA in many States (2).

The MHCA, 2017 has three implementing statutory agencies. They are as follows: (a) Central Mental Health Authority at the center (CMHA) (sections 33–44), (b) SMHA at every State level (sections 45–56), and (c) MHRB at each district level across the country (sections 73–84). The CMHA oversees the regulation, development, direction, and coordination with respect to mental health services of the country. They also have been entrusted to register, regulate and monitor mental health establishments under their jurisdiction. Respective authorities have the role of advising the government in matters relating to mental health. These statutory bodies also need to implement and monitor the progress of the MHCA, 2017. Section 29 of the MHCA, 2017 makes the government responsible for designing and implementing public health programs to reduce suicides and attempted suicides in the country. Further, they also need to design and implement programs for the promotion of mental health and prevention of mental illness in the country. Section 30 of the MHCA, 2017 obligates the government to create awareness about mental health and illness and reduce the stigma associated with mental illness through public media, including television, radio, print, and online media at regular intervals.

Mental Health Review Board

MHRB comprises of a 6-member committee which acts as a quasi-judicial body in the respective State for a district or a group of districts. The total number of districts in India is 723 as of 2019. Assuming one MHRB for each district, there is a responsibility for the government to set up 723 MHRBs across India to implement this legislation seriously. However, the Mental Healthcare (CMHA and MHRB) rules, 2018, Rule no. 17, mandates at least one MHRB per 3 districts. That makes an onus on the government to set up 241 MHRBs, which is a conservative estimate. The cost of the functioning of one MHRB will be at least Rs. 1 Crore.[27] This will put an onus of a minimum of rupees 241 crores per annum on the public exchequer. The recurring cost estimated will include salary, meetings, vehicle, communication, day-to-day expenditure, paperwork, serving summons, documentation, visiting, inspection, and auditing of the establishment and so forth. The MHRB will eventually have to evolve and function in every district, which requires infrastructure, supporting staff, furniture, stationery, and miscellaneous.

Mental health authorities

It is reasonable to assume that the expenses for the effective functioning of each Mental Health Authority will run into a minimum of 1 crore per year. This amount will be spent on fulfilling the obligations of the authority as per the MHCA, 2017. The estimated cost is for fulfilling the role and responsibilities entrusted as per section 43 and 55 of the MHCA, 2017. Considering there are a total of 29 States in the country, the cost of setting up SMHA will be approximately 29 Crores. The MHCA 2017 also mandates that a digital registry be made online for registration of the professionals, establishments, and advance directives. There is a need for one central registry and one registry for each State as per the MHCA, 2017.

To summarize, the conservative estimate cost of setting up and making functional implementing agencies is rupees 271 Crores [Table 4].

Table 4

Estimated cost of setting-up of functional statutory bodies to implement MHCA 2017

	Number of units	The estimated amount of Rs. required for one unit	Total cost required in crore
Central mental health authority	1	1	1
State mental health authority	29	1	29
District mental health review board	241	1	241
		Total Annual recurring cost of Rs. 271 crores

MHCA – Mental Healthcare Act

COST OF TREATMENT

Section 18 of the MHCA 2017 talks about the right to access mental health care and treatment from mental health services run or funded by the appropriate Government. This puts a responsibility on the State to provide mental health care to its citizens. The lifetime prevalence of mental illness in India is 13.7%, and the current prevalence is 10.6% according to the NMHS of 2016. By this, it would mean that India would have a total of 13 crores of persons who have a mental illness. The MHCA 2017, puts the onus of providing care to 13 crore population on the State. The public health systems should be equipped to deliver care for PMI. If the State fails to provide access to mental health-care services, the appropriate Government shall make rules regarding reimbursement of costs of treatment to the PMI under the section 5 (f) of the MHCA, 2017.

According to the NMHS, the median amount spent monthly for the care and treatment of varied disorders is estimated to be Rs. 2250 for Alcohol Use Disorders, Rs. 1000 for Schizophrenia and other psychotic disorders and Rs. 1500 for Depressive Disorders.[12] Total minimum costs based on the median out-of-pocket expenditure for the treatment of the three disorders (schizophrenia, depression, and alcohol use disorders) will be only Rs. 698 Crores per month as per NMHS.[12]

Outpatient treatment cost

The treatment costs to be borne by the government can also be estimated as the total number of persons who have mental illness as per the NMHS data multiplied by the minimum amount spent on consultations for illness. If we were to assume patients accessed outpatient care from the nearest government-run health center, then the treatment costs may be Rs. 100/month per patient only.[28] This is the minimum amount (Rs 100 per month per patient), which needs to be invested by the government for mental healthcare. This calculation was based on discussions and consensus among the researchers. However, this cost increases many folds (at least 10–15 times), if PMI access mental health care in the private health sector.

As per section 18 (6), of MHCA 2017, the government needs to make provisions for access to mental health care from community health centre upwards. Unfortunately, at present, the DMHP is not implemented in all districts of the country and even if it is implemented, one or two psychiatrist per district is not sufficient. This forces the PMI to seek treatment from private establishments.

The minimum amount spent by the government is for the treatment of mental illness on an outpatient basis is as follows: monthly estimate costs for outpatient treatment is the total number of persons suffering from mental illness × Rs. 100/month, i.e., 13 Crores × Rs. 100 = Rs. 1300 Crores/month.[10] The calculation used is similar to the one used by Math and Srinivasaraju, 2010.[10]

The annual estimated cost for outpatient treatment would be Rs. 1300 Crores × 12 months = Rs. 15,600 crores/year.[1028]

Inpatient cost

Approximately 0.6% of the mental health users may require inpatient services at least once a year.[29] That would mean there is a need to provide inpatient services to 7.8 lakhs PMI at least once a year. Approximately, the average number of days of inpatient stay is 21 days per admission.[30] The approximate treatment cost per admission is Rs. 1500 per day[31] according to the Ayushman Bharat Scheme. The total costs will hence become Rs. 31,500 per admission per person per year. The cost estimation involved inpatient stay, consultation charges of the doctor, nursing charge, documentation charges, food, investigation, psychosocial assessment, and medication. This estimate does not involve the expenditure of one person staying with the PMI as a care provider or nominated representative.

The annual estimated cost for inpatient treatment for 7.8 lakhs PMI × Rs. 31,500 = Rs. 2457 crores.

This would be the minimum estimates since the treatment costs will vary between disorders and the method of estimation involves only the minimum amount spent on the treatment of mental illness. This will be the amount the government makes available for the treatment for mental illness, considering the current prevalence according to the NMHS.

Rehabilitation services

About 1% of the total population suffer from severe mental disorders (SMDs). The number persons with SMDs in India who would require rehabilitation services is around 35.5 Lakhs (27.3%).[32] This includes the homeless mentally ill. There is a need in India for rehabilitation services for around 35.5 lakhs people with mental illness, and they would require a range of rehabilitation services such as hospital-based rehabilitation, day-boarder, community-based rehab centers, home-based rehabilitation centers, half-way homes, sheltered accommodation, and shared accommodation. For the purpose of calculation, authors have deducted the homeless mentally ill (13 lakhs) from the 35.5 lakhs of PMI requiring rehabilitation. Homeless mental ill requires comprehensive, holistic care and requires more funds, and hence their needs are calculated separately in the next section. Approximate estimated numbers require rehabilitation is 22.5 lakhs PMI.

The recent survey from an NGO based in Bengaluru explored the costs of long-term care for PMIs provided by NGOs, the private sector and costs of care at various centers. The monthly expenditure for a PMI at the centers varied from Rs. 7000 to Rs. 60,000.[33] The estimated monthly expenditure is assumed to be Rs. 10,000/month per PMI as per consensus among the authors.

The total costs for providing rehabilitation care for PMI will be Rs. 10,000 × 22.5 Lakhs PMI × 12 months = Rs. 27,000 crores/year.

Long-term sheltered homes for homeless persons with mental illness

The NMHS estimates the homeless mentally ill to be 1% of serious mental disorder,[12] which translates into one million people are homeless and suffering from mental illness. Majority of the States do not have any specific policies for the care of the homeless mentally ill. However, MHCA, 2017 casts an obligation on the State for providing care for a homeless PMI.

The census has estimated that 0.15% of India's total population is homeless. This translates into 19.5 lakh people.[34] The studies have shown beyond doubt that 70%–80% of the homeless have the mental illness.[35363738] On estimation, approximately 13 lakh people are homeless and suffer from mental illness in India. It is reasonable to assume that Rs. 20,000/month would be needed for treatment, food, shelter, the salary of the staffs and rehabilitation of the homeless mentally ill.

13 lakh population with mental illness are homeless × 20,000 Rs. per month × 12 months = Rs. 31,200 crore/year.

Economic cost of suicide and attempted suicide

According to the report brought out by the National Crime Records Bureau, New Delhi, 130,000 people completed suicides in India in 2015.[39] However, the World Health Organization (WHO) estimates that about 170,000 deaths by suicide occur in India every year.[40] For every death by suicide, on an average, 15–20 people attempt to die by suicide but fail.[4142] On estimation, approximately 5.75 million people attempted to die by suicide in India (2015). The suicide attempts can be classified into (i) lethal and severe attempt and (ii) nonsevere, nonlethal attempt with full recovery in the short term. As per the WHO Sustainable Development Goal Statistics,[43] in 2016, 17% of the persons who attempted to die by suicide belonged to the severe category, i.e., 977,500 persons; and the remaining 83%, i.e., 47.7 lakh persons, belonged to the nonsevere category.

Section 115 of the MHCA, 2017 “decriminalizes the suicidal attempt” by articulating that notwithstanding anything contained in Section 309 of the Indian Penal Code, any person who attempts to die by suicide shall be presumed, unless proved otherwise, to have severe stress and shall not be tried and punished under the said Code. Further, the legislation takes a proactive step in Section 115(3), by casting an obligation on the government. It articulates that government shall have a duty to provide care, treatment, and rehabilitation to a person, having severe stress and who attempted to die by suicide, to reduce the risk of recurrence of an attempt to die by suicide.

Lethal and nonlethal attempted suicides incur both direct costs, which are directly related to injury treatment and indirect economic costs, which are mainly productivity losses from lost time from injuries and disability. Direct cost includes the costs for medical care (especially emergency departments and inpatient hospitalization), ambulance transport, investigations by medical examiners, forensic medicine cost, nursing home care, general and specialty physicians’ care, rehabilitation, and follow-up care.[4244] The reasonable estimate of costs for one nonlethal attempted suicide may be Rs. 10000 per person and Rs. 100,000 for one lethal attempted suicide.[4244] The reasonable estimate of grand total for lethal and nonlethal attempted suicides 14,545 crore rupees [Table 5].

Table 5

Approximate cost of suicide and attempted suicide

Variable	Numbers per year	Cost per unit in rupees	Total cost in crore rupees per year
Lethal severe attempted suicide	977,500	100,000	9775
Nonlethal attempted suicide	4770,000	10,000	4770

Grand total for Suicide and attempted suicide is Rs. 14, 545 crores per year

Strengths and Limitations of the study

The strengths of our study include that this is the first study to use the mental health statistics to estimate the approximate cost for implementing the “rights-based” MHCA, 2017. The estimated total cost on government is 94,073 crore rupees. We did not estimate the cost of infrastructure for implementing agencies and rehabilitation centers and the cost of human resources to run those rehabilitation centers, which escalates the cost on government many folds [Table 6].

Table 6

Conservative estimate of cost on the government to implement rights-based MHCA 2017

The recurring annual cost that the government should invest in for implementation of MHCA 2017		The cost in Rs. (crores)
Statutory agencies	MHA and MHRB	271
Human resources	Workforce Development over a period of 10 years is Rs. 30,000 crores. MHCA, 2017 Section 31 (3). For 1 year is Rs. 3000 Crore	3000
Mental health care	Outpatient treatment cost	15,600
	Inpatient cost	2457
	Mental health rehabilitation services cost	27,000
	Cost for providing sheltered home for a homeless person with mental illness	31,200
	Lethal and nonlethal attempted suicide survivor	14,545
Total recurring costs on the government for service delivery in crore rupees (this does not include infrastructure cost)		94,073 crores

MHRB – Mental Health Review Board; MHA – Mental Health Authority; MHCA – Mental Healthcare Act

The findings of the study need to be interpreted in the background of certain limitations. We might have underestimated the cost of mental health-care service delivery, particularly in those States which have a severe shortage of mental health human resources. The data were rounded to the nearest approximate number for ease of calculation, and the exact number was not used. The study estimates the cost of providing treatment under modern medicine only, and it does not include the cost of providing AYUSH system-based mental health care (section 18[10]). The study does not differentiate the cost to be borne by the central government and the State government separately. Further, this study did not estimate the cost for the following: (a) mental health promotion and primary prevention (Section 29); (b) eradication of stigma and discrimination (Section 21); (c) making alterations in the public mental health establishments to fulfill the minimum norms; (d) supporting family members of PMI (Section 18(4c); (e) emergency mental health and ambulance services (Section 21); (f) registering all public mental health establishments (Section 65); (g) prison mental health services (Section 103); (h) perinatal services, child mental health services, and old age mental health services (Section 18(4e); (i) modified electroconvulsive therapy (Section 95(1a); (j) creating awareness of mental health and mental illness (Section 30); (k) two assessments before admission, periodic capacity assessments, documentation, maintaining of outpatient department records, informing the statutory bodies, litigation cost, and defensive practice; (l) Registration, updating and maintenance of online digital registry of MHE, MHP, and advance directive; (m) infrastructure for implementing agencies and rehabilitation centers; (n) setting-up of deficit 6 lakh public psychiatric beds in establishments; (o) training psychiatrists, psychiatric nurses, psychiatric social workers, and clinical psychologists; and (p) disability-adjusted life years.

ESTIMATED LOSS INCURRED BY THE GOVERNMENT FOR NOT INVESTING IN MENTAL HEALTH

The estimated number of people suffering from mental morbidity is around 13 crores. The provisions for care and treatment are lacking, and the resulting mental morbidity would result in significant disability and unemployment. A lack of treatment and care could also increase the rates of suicides, violence, and homelessness. The treatment gap as per NMHS is 7%–92% across all diagnoses.[12] Despite all the interventions that are currently in place, three out of the four PMI remain untreated. With such high treatment gaps, there could be a very high rate of unemployment. Since there is a lack of data in terms of unemployment rates in mentally ill in India, the researchers came to a consensus that half of the PMI are unemployed and unable to earn their livelihood. Thus, 6.5 crores PMI could be estimated to be unemployed. As per the Minimum Wages Act of 1948, the government has fixed the national floor level minimum wages to be Rs. 176/day from 2017.[45] This would result in a monthly loss of Rs. 176 × 25 days/person = Rs. 4400/Person.

The annual loss because of unemployment can be estimated to be Rs. 4400 × 12 months × 6.5 Crores = Rs. 343,200 Crores.

If the government does not invest in providing access to mental health care as per Section 18 of the MHCA 2017, the PMI will have to spenf from their pocket for the treatment from the private health sector. The treatment costs to be borne by the PMI just for the outpatient care can be estimated as the total number of persons who have mental illness as per the NMHS data multiplied by the minimum amount spent on consultations for illness (direct and indirect cost). The direct cost includes consultation charges, assessments, investigations, medication and psychosocial intervention, which is estimated to be Rs. 1000/month per patient. The indirect expenses include travel, loss of 1-day wages for two persons, food and time, which is estimated to be Rs. 500/month per patient. Total cost (including both direct and indirect) will be 1500 Rs. per month. This amount needs to be reimbursed as per section 18 (5f). Monthly estimated costs on PMI for outpatient treatment is the total number of persons suffering from mental illness × Rs. 1500/month, i.e., 13 Crores × Rs. 1500 = Rs. 19,500 Crores/month.

Annual estimated cost just for outpatient treatment would be Rs. 19,500 Crores × 12 months = Rs. 234,000 crores/year.

The annual estimated cost for inpatient treatment for 7.8 lakhs PMI × 31500 rs = Rs. 2457 Crores does not change between private and public mental health sector for inpatient services.

Disability pension

The WHO estimates that 10% of the world's population has some form of disability.[46] However, a study conducted to determine the prevalence and pattern of disability in all age groups in a rural community of Karnataka reported that the overall prevalence of disability was 6.3% (60/954).[47] The most common type of disability among disabled persons was a mental disability, at 2.3% (22/954). From this study, one can easily estimate that 2.5 crore people in the population will have a mental disability in India.[4849] The disability pension that the government provides for severe mental illness currently is Rs. 1000/month.

The total costs for providing disability pension will be 2.5 crore PMI × Rs. 1000 per month × 12 months = Rs. 30,000 crores/year.

The total direct and indirect costs incurred by Government for not providing comprehensive mental health care, (which is one of the factors that could minimize the losses incurred by losing productivity due to disability resulting from mental illness) will be 343,200 (unemployment) +234,000 (outpatient) +2457 (inpatient) +30000 (disability pension) = Rs. 609,657 Crores/year. However, the conservative estimated total cost on government is 94,073 crore rupees to invest in the implementation of MHCA, 2017. The total loss incurred comes to be around 6.5 times higher than the investment that the government must make, to provide comprehensive mental health care. A study of global return on investment analysis for a scaled-up response to the public health and economic burden of depression and anxiety disorders across 36 countries reported substantial economic returns (3.5-5.7-1) benefits on investment in mental health-care services.[50] In other words, the present study also depicts that investing in implementation of MHCA, 2017 by the government will yield 6.5 times the return on investment analysis benefit.

As per NHMS, approximately 50% of the PMI access public mental health-care sector.[12] Considering that 50% of them seek help in the public health sector, the government need to invest at least Rs. 47,036 Crores per annum. On the other hand, the government can also argue that there is an 80% treatment gap, then also they must invest Rs18,814 Crores per annum immediately from this financial year. However, keeping the spirit of the MHCA, 2017, the government needs to implement the Act because it is “Rights Based” legislation. It would be prudent to increase the allocation of funds for mental health-care services in India not only because we now have a rights-based legislation but also from the economic perspective.

CONCLUSION

MHCA 2017 is a step in the right direction. The approximate conservative estimated total cost on government to implement the act is 94,073 crore rupees. The loss incurred by the government for non-investment on mental health care is estimated to be 6.5 times more per annum than the investment that the government must make, to implement MHCA, 2017. However, one must be cautious to consider the limitation of the study before interpreting the results of the study. When the decision is to overhaul an entire system, we must also consider the political will, available funds, infrastructure, and trained human resources available for providing rights-based mental health-care services. Ultimately, the implementation of any rights-based legislation largely depends on the proactive measures taken by the respective governments.

Financial support and sponsorship

Nil.

Conflicts of interest

Dr. Suresh Bada Math is a Member of ‘the Committee of Experts’ constituted by the Ministry of Health and Family Welfare, Nirman Bhavan, New Delhi dated 23rd May, 2017 for framing Rules and Regulations under the MHCA 2017.