Young Researchers for Social Impact 2023

Revitalising Community Rehabilitation Programs: Mental Health in

India and Beyond

Aadya Kashyap
Pakhi Daswani
Rayhan Shanavas
Sanaa Shaikh
Zurie Aboobakar
Contents

1. Introduction
1.1. What is CBR and Why is it Important?
1.2. Aim and Methodology
1.3. Paper Focus on Depression and Substance Abuse Disorder

2. Community Rehabilitation Programs: An Overview

2.1. Nature, objectives and structure of CBR programs
2.2. Socio-economic and Cultural factors affecting CBRs design and Implementation
2.2.1. Economic and Social Determinants
2.2.2. Cultural Determinants
2.3 Community-Based Rehabilitation Programs in India
2.3.1 Organisations of India Involved in CBR
2.3.2 Learnings and Recommendations from CBR-India Experience

3. International Case Studies

3.1. Case studies -
3.1.1. Thailand
3.1.2. China
3.2. Factors leading to the success of CBR in Thailand and China
3.3. International Best Practices

4. Recommendations
4.1. Policy Recommendations
4.2. Recommendations for CBR Programmes

5. Conclusion

2
 1. Introduction

Mental health is defined by the World Health Organisation (WHO) as an integral part of mental stability
that enables individuals to manage life's pressures, develop their potential and life skills1 such as
effective problem solving, in addition to being able to give back to their communities. Additionally, it is
a crucial element of health and overall well-being that supports both our individual and group capacity
to decide, form connections, and influence the world we live in2. A core human right is access to mental
health3. Furthermore, it is essential for socioeconomic, communitarian, and self development as it works
towards the inclusion, empowerment and integration into society for those with disabilities, both mental
and physical. By recognising access to mental health as our core human right and vital element of health
we acknowledge its profound impacts on our ability to collectively shape the trajectory of our society,
empowering individuals and communities to thrive and foster positive change in the world we live in.

1.1 What is CBR and why is it important?

Community Rehabilitation Programs, also known as CBR, are models of community development that
seek to enhance the standard of life for individuals that have disabilities and their families, as well as
ensure their integration and engagement in society as a whole4. CBR was defined in 2004 by the
International Labour Organization (ILO), United Nations Educational, Scientific and Cultural
Organization (UNESCO) and WHO as “a strategy within general community development for the
rehabilitation, equalisation of opportunities, poverty reduction and social inclusion of all people with
disabilities. CBR is implemented through the combined efforts of people with disabilities themselves,
their families, organisations and communities, and the relevant governmental and non-governmental
health, education, vocational, social and other services.”5

The primary objective of community-based rehabilitation (CBR), which was first established in the
1970s with the intention of providing low-tech rehabilitation services for people with disabilities in
developing nations, has now changed to a focus on community and individual development. The
founding ideology of CBR catered to those with physical disabilities such as mobility-based disabilities
or limb differences as opposed to mental disabilities.

The foundation of CBR is the concept of community-based mental health support, which has evolved
from severely criticised institutionalised asylums that constrained and stigmatised patients to
welfare-focused, support-providing community rehabilitation programs that heavily emphasise syncing
important areas like education, physical and psychological well-being, nutrition, livelihood, and
inclusion.

1
“What are Basic Life Skills? Who Developed Basic Life Skills Curriculum?” UNICEF,
https://www.unicef.org/azerbaijan/media/1541/file/basic%20life%20skills.pdf Accessed 29 July 2023.
2
World Health Organization. “Mental Health.” World Health Organization, World Health Organization, 17 June 2022.
https://apps.who.int/iris/bitstream/handle/10665/204891/B4950.pdf
3
“Human rights.” World Health Organization (WHO), 10 December 2022,
https://www.who.int/news-room/fact-sheets/detail/human-rights-and-health
4
Community-Based Rehabilitation (CBR) Africa Network https://afri-can.org/what-is-cbr/
5
Physiopedia Community Based Rehabilitation (CBR) July 22, 2023 https://www.physio-pedia.com/Community_Based_Rehabilitation_(CBR)

3
As per the National Library of Medicine, “the role of CBR programmes is to promote and protect the
rights of people with mental health problems, support their recovery and facilitate their participation and
inclusion in their families and communities. CBR also contributes to the prevention of mental health
problems and promotes mental health for all community members.”6
For over 25 years7 various studies have depicted that CBR as an approach and as a learning experience
has been accepted into the societal framework of developing countries such as India, Brazil and
Bangladesh8.

1.2 Aim and Methodology

Community rehabilitation programs play a vital role in addressing mental health concerns by providing
essential support and resources within local communities. The aim of this research paper is to explore
the nature and objectives of community rehabilitation programs and the diverse landscape of such
programs in different cultural, social, and economic contexts. It will examine the strengths and
shortcomings of community rehabilitation programs (such as those offered by The Banyan in addressing
mental health disorders such as depression and substance use disorders (SUD). This is followed by a
review of international best practices in community rehabilitation within the context of addressing
mental health disorders in Thailand and China which are countries that are socio-economically similar to
India. It analyses the key factors leading to the success of community-based rehabilitation such as
infrastructure and funding. Based on our research, we have also developed recommendations for India
and identified potential policy changes or advocacy efforts that could support the advancement of such
community rehab programs in India.

This paper has used a comparative analysis as well as case studies of community rehabilitation programs
in Thailand and China with those in India case study to analyse the strengths and shortcomings of these
programs and has used learnings and best practices from these programs to develop our
recommendations. These countries were chosen for their similar socio-economic and cultural features
such as familial structures and familial values9. A comparative analysis is a research method that
primarily aims to bring out the similarities and differences among the various items being considered.
Using this research method is useful to understand the limitations and strong points of community
rehabilitation programs for mental health disorders in India. In addition, this research method can bring
out the best practices that can be recommended to revitalise community-based care for people with
mental health disorders in India. Additionally, stakeholder conversations were conducted with CBR
organisations, people who have benefited from the CBR programs and researchers working in the field.
Thus, firsthand narratives of working in the field of rehabilitation as well as people who have been
impacted by rehabilitation, both, have been incorporated in the paper to make it more comprehensive
and original.

6
“CBR and mental health - Community-Based Rehabilitation: CBR Guidelines.” NCBI, https://www.ncbi.nlm.nih.gov/books/NBK310918/.
Accessed 29 July 2023.
7
Mousavi, Tahmineh. “The Role of Community-Based Rehabilitation in Poverty Reduction.” Researchgate, May 2015,
https://www.researchgate.net/publication/279171983_The_Role_of_Community-Based_Rehabilitation_in_Poverty_Reduction/link/56192df308
ae78721f9cfe43/download
8
CRP BANGLADESH: CRP - Centre for the Rehabilitation of the Paralysed, https://www.crp-bangladesh.org/. Accessed 29 July 2023.
9
Scroope, Chara. “Thai Culture - Family — Cultural Atlas.” Cultural Atlas,
https://culturalatlas.sbs.com.au/thai-culture/thai-culture-family. Accessed 27 July 2023.

4
1.3 Paper focus on Depression and Substance Use Disorders

1.3.1 Depression

Depression and substance abuse disorders often co-occur10, meaning that individuals struggling with one
condition are at a higher risk of developing the other. Addressing both issues simultaneously can
improve treatment outcomes and reduce the likelihood of relapse or recurrence.11

The first mental health disorder this paper focuses on is depression. Also known as major depressive
disorder, is a common and serious medical illness that, according to the WHO (as of 2023), negatively
affects nearly 280 million people worldwide12 on how they feel, the way they think and hence, how they
act. Feelings of sadness and/or a loss of interest in once-enjoyed activities are known symptoms of
depression. It can cause a wide range of emotional and physical issues and hence, reduce one's
functionality in various settings, such as at work or at home.

1.3.2 Substance Use Disorders (SUD)

The second disorder is substance abuse disorder. As per the National Institute of Mental Health,
“Substance use disorder (SUD) is a treatable mental disorder that affects a person’s brain and behaviour,
leading to their inability to control their use of substances like legal or illegal drugs, alcohol, or
medications. Symptoms range from moderate to severe, with addiction being the most severe form of
SUD.” Alcohol, drugs, nicotine and caffeine are commonly misused substances that lead to addiction.
Addiction to these substances can be physical, psychological or both. Recovery from Substance Abuse
disorder requires stringent and regulated medicinal care along with social engagement in facilities for
rehabilitation. The Drug De-Addiction programme introduced by the Ministry of Health and Welfare,
Government of India makes it compulsory to include provisions for treatment of SUDs. Data released by
the Press Information Bureau of India reports that 14.6% of the population from ages 10-75 is addicted
to alcohol, while 2.38% are addicted to Cannabis and 2.1% to Opiates13

Since disorders like depression and Substance-Abuse Disorders are the most prominent and prevalent
disorders among the Indian populace14, they are the primary focus areas of this paper.

10
“Substance Use and Co-Occurring Mental Disorders.” NIMH, https://www.nimh.nih.gov/health/topics/substance-use-and-mental-health.
Accessed 29 July 2023.
11
Chapal Khasnabis, et al. “CBR and Mental Health.” Nih.gov, World Health Organization, 2010,
https://www.ncbi.nlm.nih.gov/books/NBK310918/
12
“Depressive disorder (depression).” World Health Organization (WHO), 31 March 2023,
https://www.who.int/news-room/fact-sheets/detail/depression . Accessed 29 July 2023.
13
“Press Information Bureau.” Press Information Bureau, 19 July 2022,
https://pib.gov.in/PressReleasePage.aspx?PRID=1842697. Accessed 29 July 2023.
14
“First Comprehensive Estimates of Disease Burden due to Mental Disorders and Their Trends in Every State of India - Public Health
Foundation of India.” Phfi.org, 22 Dec. 2019, https://phfi.org/disease-burden-due-to-mental-disorders-and-their-trends-in-every-state-of-india/

5
2. Community Rehabilitation Programs: An Overview

2.1 Nature, Objectives and Structure of CBR Programs

Helander’s (1992) Definition : “A community consists of people living together in some form of social
organisation and cohesion. Its members share in varying degrees political, economic, social and
cultural characteristics, as well as interests and aspirations, including health.15

In the CBR context, community means a group of people with common interests who interact with each
other on a regular basis; and/or a geographical, social or Government administrative unit.16

The concept of "within the community" in the context of Community-Based Rehabilitation (CBR)
represents a collaborative and inclusive approach to addressing mental health challenges within a local
context. It aims to empower the community to take charge of its own well-being and create a more
inclusive environment for individuals with mental illness. This "within community" approach
encourages collaboration between mental health professionals, local health centre staff, and mental
health service users. By working together, they can design and implement more effective and culturally
appropriate mental health services that cater to the specific needs of the community. Mental health
professionals in low-income countries like Nepal, Bhutan and Uganda are advocating for the integration
of mental health services into primary healthcare systems. By aligning CBR programs with this effort,
mental health services become more accessible and integrated into the existing healthcare infrastructure.

A key feature of the "within community" approach is providing mental health care and support within
individuals' homes and communities. For example, Contad Sangath provides home-based care and
council intervention to clients suffering from mental disorders, while also looping the client’s significant
other and involving them as well as counselling them. This ensures that people with mental illness
receive care in familiar surroundings, reducing the sense of isolation and promoting social inclusion. It
emphasises the utilisation of existing community resources and support networks. By tapping into local
resources, such as community centres, social networks, and support groups, the effectiveness and
sustainability of mental health interventions can be enhanced.

Stigma remains a significant barrier to mental health care and social inclusion for individuals with
mental illness. CBR also aims to enable individuals with mental illness to become active and integral
members of their families and communities. By encouraging their participation in social and cultural
activities, these individuals can experience a sense of belonging and acceptance.

Community-Based Rehabilitation programs take a holistic approach to mental health care, considering
the social, economic, and cultural factors that impact individuals' well-being. This approach goes
beyond just treating the symptoms of mental illness and addresses the broader determinants of mental
health.CBR program’s main strength is that it recognizes that mental health is not solely the

15
Helander, Einar (1993): Prejudice and Dignity - An Introduction to CBR, New York: Division of Public Affairs, United Nations Development
Programme, One United Nations Plaza, N. Y. 10017, USA, P. 241 Accessed 29th July
16
II CONCEPT OF CBR https://karnatakaphysio.org/pdf2/CONCEPT_OF_CBR.pdf Accessed 29th July

6
responsibility of mental health professionals but a collective effort involving the entire community. By
leveraging community strengths, reducing stigma, and promoting social inclusion, CBR programs can
effectively address mental health issues and improve the overall well-being of individuals and
communities alike.

Objectives and Structure of CBR Programs for Mental Health Disorder:

Community Based Rehabilitation Programs focus on empowering local communities, local mental
health professionals and healthcare staff to take an active role in promoting the well-being and inclusion
of individuals with mental health conditions. One of the primary goals of CBR is to ensure that mental
health services are accessible and available at the grassroots level. All of this can help reduce the stigma
of mental illness and individuals with mental health conditions can receive the required care and support
in their communities

CBR programs can create linkages between mental health services and other community resources and
support networks through various community workshops that involve the families and educate them
about mental health conditions, their symptoms, and treatment options. Mental health professionals
deliver these workshops, explaining complex concepts in a simple and relatable manner. The program
offers specialized training sessions for family caregivers. These sessions covered topics such as
communication skills, coping strategies, and ways to manage potential crises effectively. Caregivers
learn to provide a supportive and non-judgmental environment for their loved ones. Beyond the families,
the CBR program also conducts awareness campaigns for the wider community like SPARC (School for
Potential Advancement & Restoration of Confidence) India commenced its flagship program in 1997 in
the urban slums of the Lucknow region. After the successful execution of the CBR program in urban
slums, SPARC India expanded the scope of the project by pursuing its rehabilitation projects in the rural
areas of the Barabanki district.17 This holistic approach recognizes that mental health is influenced by
various social determinants, such as employment, housing, and social support. By connecting
individuals with mental health conditions to these resources, CBR programs aim to address the broader
factors that impact their well-being.

CBR recognizes that breaking down barriers to societal inclusion is as crucial to its mission as functional
rehabilitation for individuals with disabilities. Thus, the universal mission of CBR is:

1. Strengthening and empowering the daily lives and activities carried out by individuals suffering
from mental health in order to enhance their capabilities and ensure they learn to lead a more
independent and fulfilling life.
2. Fostering Inclusion and Awareness by promoting awareness in the community to create
barrier-free environments and ensure access to human rights for people struggling with their
mental health.
3. Engaging Community Participation by encouraging active community involvement and
ownership in the social integration of these individuals through various community workshops
that involve the members of the community as well as the individual’s family members that
provide insights into that individual’s needs and preferences so that there is a mutual
understanding between them.

17
Community Based Rehabilitation (CBR) PROGRAM – SPARC India Accessed July 2023
https://sparcindia.in/community-based-rehabilitation-cbr-program/

7
2.2 Socio-Economic Factors Affecting Creation and Implementation of CBRs

Rehabilitation is expected to help 2.4 billion people, living with various health conditions, globally and
the numbers continue to rise.18 Of these, about 1 billion individuals need rehabilitation programs due to
mental health issues and 80% of these individuals are from low- and middle-income countries (LMIC).19

CBR, a strategy specifically designed in the 1970s to provide rehabilitation in the LMIC, is currently
being implemented in more than 100 countries in the world.20 However the program is not “one size fits
all” and very rightly is adopted by each country to suit their socio-economic environment. Given the
interdisciplinary nature of the CBR program and its applicability across conditions, the primary driver
for the design, implementation and outcomes is dictated by the policies, governance and support
provided by the nation including national healthcare policies and financial commitments.21-22 Countries
like China, Bhutan, India, Indonesia, Myanmar, Sri Lanka, Thailand and Timor-Leste have taken an
active interest in integrating CBR into the national policies and bestowed the responsibilities with their
health/social welfare ministries who are accountable for ensuring a healthy life for disabled individuals.
However, the support and efficacy of the current programs are not optimum.23-24. The recent
meta-analysis undertaken by Syed et al. has failed to identify the key drivers of the poor efficacies seen
across CBR programs. The absence of data from robust/well-designed studies and documented evidence
of success and or failures of different CBR initiatives in LMIC indicate the paucity of research in this
area let alone effective outcomes.25

The poor infrastructure, both at policy making and access such as lack of prioritisation, funding,
strategic plans for rehabilitation at a national level as well as lack of available rehabilitation services
outside urban areas, and long waiting times seems to negatively hamper the success of rehabilitation
programs in many LMIC. Most LMICs have high out-of-pocket expenses and non-existent or inadequate
means of funding. The bulk of these limited human and financial resources is historically directed
toward infectious illnesses, and the management of chronic diseases including mental diseases and their
rehabilitation services receives just a tiny portion. However, the diverse utilisation rates of the
rehabilitation services by cohorts across multiple medical conditions when equal access was provided
indicates the impact of factors beyond policies and financial constraints. 26-27

18
Rehabilitation: World Health Organization. Available at: https://www.who.int/news-room/fact-sheets/detail/rehabilitation
19
H;, B.T.S. (2018) A systematic review of access to rehabilitation for people with disabilities in low- and middle-income countries, International
Journal of environmental research and public health. Available at: https://pubmed.ncbi.nlm.nih.gov/30279358/ (Accessed: 29 July 2023).
20
Cayetano, Roi Dennis Adela, and Jennifer Elkins. “Community-Based Rehabilitation Services in Low and Middle-Income Countries in the
Asia-Pacific Region: Successes and Challenges in the Implementation of the CBR Matrix.” Disability, CBR and Inclusive Development, vol. 27,
no. 2, VU e-Publishing, Sept. 2016, p. 112. https://doi.org/10.5463/dcid.v27i2.542.
21
Part 1 Community-Based Rehabilitation. www.dinf.ne.jp/doc/english/resource/cbr_reha_e/cbr_program.html.
22
“Regional Strategic Framework on Community-Based Rehabilitation (‎CBR)‎in the South-East Asia Region 2012-2017.” World Health
Organization, www.who.int/publications-detail-redirect/sea-disability-4. Accessed 29 July 2023.
23
Neill, Rachel, et al. “Prioritizing Rehabilitation in Low- and Middle-income Country National Health Systems: A Qualitative Thematic
Synthesis and Development of a Policy Framework.” International Journal for Equity in Health, vol. 22, no. 1, Springer Science+Business
Media, May 2023, https://doi.org/10.1186/s12939-023-01896-5
24
Magnusson, Dawn, et al. “Provision of Rehabilitation Services for Children With Disabilities Living in Low- and Middle-income Countries: A
Scoping Review.” Disability and Rehabilitation, vol. 41, no. 7, Informa, Dec. 2017, pp. 861–68.
https://doi.org/10.1080/09638288.2017.1411982.
25
Syed, Zarina, et al. “A Rapid Review of the Roles of Community Rehabilitation Workers in Community-based Mental Health Services in Low-
and Middle-Income Countries.” Disability, CBR and Inclusive Development, vol. 33, no. 2, VU e-Publishing, Aug. 2022, p. 108.
https://doi.org/10.47985/dcidj.537.
26
Soltani, Shahin, et al. “Socioeconomic Disparities in Using Rehabilitation Services Among Iranian Adults With Disabilities: A Decomposition
Analysis.” BMC Health Services Research, vol. 22, no. 1, Springer Science+Business Media, Nov. 2022,
https://doi.org/10.1186/s12913-022-08811-8
27
Ding, Ruoxi et al. “Socioeconomic inequality in rehabilitation service utilization for schizophrenia in China: Findings from a 7-year nationwide
longitudinal study.” Frontiers in psychiatry vol. 13 914245. 26 Aug. 2022, doi:10.3389/fpsyt.2022.914245

8
While individual determinants across socio-economic and cultural factors are each responsible in their
own substantial manner, the combined action of multiple determinants has a larger synergistic impact,
both negative and positive. Thus one needs to carefully amalgamate modules, addressing all the drivers
and barriers, into a holistic localised CBR design to achieve desired effects and eventual scale-up.
Accordingly, key determinants are summarised below for understanding of the cause of the mental
health situation, and its aggravation and to a large extent give directional guidance on the determinant
that need to be addressed to implement an effective CBR.

2.2.1 Economic and Social Determinants

There is a clear correlation between the economic inequalities and poor mental health.28-29 Social
determinants such as education, employment, income level, gender, lineage, and community architecture
also have shown a direct correlation on the rate of general illness.30 Studies across multiple geographies
have indicated that lower income-countries bear a higher burden of mental disease or illness, again
indicating that economics play a huge role in health status.31

The key socioeconomic determinants that may specifically have an impact on the success or failure of
the CBR interventions for mental health are listed below:

National Economy, Funds and Infrastructure

Both the evaluation of facilities, social media reports and conversations indicate that it's the absence of
adequate resources at the right time and right place due to economic disadvantages faced by inhabitants
of any place that further deteriorates mental health. Additionally, the deployment of CBR in its current
form involves huge dependencies on medical and social work from diverse disciplines. Poor allocation
of funds by the government and poor economy at the regional level depletes good resources for basic
pharmacotherapy or physiotherapy and hence is a clear deterrent for the CBR program. It's been
observed that the majority of the programs are first deployed at places where individuals have economic
stability, again indicating the impact of the economy on the outcomes.

Socio-economic Status and Healthcare Access

The high prevalence of mental health issues in LMIC is direct evidence of income level impacting
mental health. This economic inequality is seen to extend even within countries where the higher
financial burden of accessing mental healthcare leads to poor utilisation and thereby further aggravates
the mental health status. Social inequity in terms of the inequitable healthcare access for comorbid
conditions also has a direct correlation to the mental health status of the individual. As an example,
women living in poor conditions have poor access to prenatal and postnatal care impacting the mental
health status of both mother and the child. This is evidenced by the higher rates of postpartum

28
“Poverty: Statistics.” Mental Health Foundation, www.mentalhealth.org.uk/explore-mental-health/statistics/poverty-statistics. Accessed 29
July 2023.
29
Sujita Kumar Kar; Eesha Sharma; Vivek Agarwal; Shivendra Kumar Singh; Pronob Kumar Dalal; Gopalkrishna Gururaj; Girish N Rao. "The
socioeconomic burden and disability linked with mental illnesses: findings from the National Mental Health Survey of India 2015-16 in Uttar
Pradesh". GLOBAL PSYCHIATRY ARCHIVES, 4, 2, 2021, 191-200. doi: 10.52095/gp.2021.3586.1024
30
Physiopedia, www.physio-pedia.com/Rehabilitation_Contexts.
31
World Health Organization: WHO. “Social Determinants of Health.” www.who.int, May 2019,
www.who.int/health-topics/social-determinants-of-health#tab=tab_1.

9
depression and also higher rates of mental health conditions among women coming from these
disadvantaged communities. Accordingly, the successful implementation of any CBR program will have
to circumvent the pressure caused by the inequities.

Employment Status and Education

Individuals with poor socioeconomic status have poor confidence, inferior education to a large extent
and hence poor employability index pushing them back to poverty. The out-of-pocket expenses as well
as transportation wages affect the right uptake of the CBR by the affected individuals. Unemployment
and or absence of right employment is forcing individuals to migrate to newer locations. Unless an
ecosystem is established for these individuals and their families, this move creates a deteriorating impact
on the mental state of the migrants. Additionally, this excludes the individuals from accessing local
CBRs deployed at their original home towns and makes them ineligible to the facilities in the newer
location leaving many unattended in spite of localised programs.

2.2.2 Cultural Determinants

Culture has more often than not played a larger role in the aggravation of mental health through its
social norms and traditions. It also determines how much support one can get from the family and
society at large even if organised CBR programs are implemented or a simple psychiatric consult is
provided for psychiatric evaluation and pharmacotherapeutic management.

Social Norms and Traditions

Mental health has been seen as a social stigma for centuries in India. Excluding individuals and in many
cases even families from mainstream activities is still rampant including denying of marriages and
exclusion from the social development programs citing local/regional rules, especially in many rural
communities of the nation. Indian culture does not advocate nuclear families or individualistic attitudes
however it also has gender-based biases in a family /community setup. As an example, men can't cry and
women are expected to endure stress- such norms have prevented early diagnosis and management of
mental health. Unless these stigmas are broken, effective uptake of the CBR in these communities will
be difficult.

Family and Religious Background

Many mental health conditions are genetic in nature and thereby one expects the awareness and
management to be better. There are mixed responses on this as a negative experience of the previous
generation continues to hamper the next generation’s response to the management of these conditions.
As an example, traditionally, any son/daughter of an affluent community with a mental condition was
considered weak and ostracised from all key positions and activities. Even in modern society, children
seeing parents' denial of mental health issues are seemingly scared to accept diagnosis and treatment
even when made available.

Another cultural belief that has deteriorated the mental health management and treatment is the
consideration of mental health as a spiritual disease and hence dependency on the “tantriks” and
“maulas” for treatment rather than mental health professionals. This can be correlated with diverse
religions and religious beliefs but there is a diversity even within each religion. For example, few

10
religions consider mentally disadvantaged individuals to be considered to be “know it all” saints while
another one considers them “ monstrous’’ to be chained and barred from society.

2.3 Community-Based Rehabilitation Programs in India

The scale of rehabilitation needs in the LMIC region is very large but apart from economic determinants,
transferability of the studies/guidance from regulated markets is poor due to the diversity of the social
and cultural determinants, and thus the need of having an ideal CBR in a Low Middle Income country
like India continue to remain unaddressed.32
To address this, Indian forums like IFRA are continuing to work with the Word Health Organization
(WHO) towards defining the local programs and believe that recommendations should be directed
through the national teams for most effective implementation. CBR in essence has to address five core
pillars by looking at the affected individual as a human and not a disease state and these include
restoration of health, livelihood, social protection and empowerment. Paraphrasing the approach taken
by deploying agencies "CBR is implemented through the combined efforts of people with disabilities
themselves, their families, organisations and communities, and the relevant governmental and
non-governmental health, education, vocational, social and other services".33 Thus factors affecting the
utility, access, and adaptability of these tools will impact the efficacy of CBR.
Table 1: Impact of socioeconomic and cultural factors on CBR pillars

CBR Pillar Social Economic Cultural

/Impact

Health (Negative) Poor policies Poor Access to Care Mis or No Diagnosis

Education Taboo and Supply and Demand Gap “No” need belief prevents
(Negative) Discrimination access

Livelihood Taboo and Poor Access to Fear and Care leads to

(Negative) non-recognition Opportunities exclusion

Social Protection Exclusion/Hatred Unequal funds disbursement Art is for elite and its OK to
(Negative) exposes individuals to ignore excludes solutions
crime(s)

Empowerment Very rare Local employment possible Local SHG acceptability

(Positive) with primary sector

2.3.1 Organisations of India Involved in CBR

32
Sanjay. “A Brief Overview of Community Based Rehabilitation for Severe Mentally Ill: An Indian Perspectives &Raquo; the International Journal of
Indian Psychȯlogy.” International Journal of Indian Psychology, Dec. 2021, https://doi.org/10.25215/0904.139.
33
Physiopedia, www.physio-pedia.com/Community_Based_Rehabilitation_(CBR).

11
Multiple organisations in India have been working over decades to navigate these factors while
successfully deploying CBR programs. Some of the pertinent ones are The Banyan, Khushboo, Caritas
India, Paadhai, MHN, Neptune Foundation, CBR Network South Asia Region, Diya Foundation, give,
mSpark, WE care empower, Sahayog and IFRA.34-35-36 But, there have been no “mental health “ directed
CBR programs in India. With heightened need and awareness of mental health, multiple rehabilitation
programs by government centres and NGOs are currently extending their services to mental health
issues. However, most of these modified CBR initiatives are very local and directed towards addressing
an “immediate” identified need to leverage the available infrastructure. Of these programs, the ones
leveraging ASHA workers, that have shown significant success in maternal health and implementation
of other Sustainable Development Goals (SDGs) across India, combating the socio-economic and
cultural barriers of our nation, has emerged as a right model. Randomised studies are currently ongoing
to assess if these self-help groups/ ASHA-supported CBR programs will be more effective and hence
can be transformed into a sustainable approach for the management of mental health for a large
population of India.37

2.3.2 Key take-aways from Indian CBR programs

Multiple CBR programs conducted by local and global organisations have yielded key learnings
to be embraced in the design of new programs. 38-39-40. India is facing a dichotomy where NGOs are
providing education, access, and social integration i.e. one of the pillars of CBR but not a holistic CBr
program. On the other hand, we have agencies doing CBR programs that are not designed for mental
health and hence are more of an adaptation or an extension for mental health. Yet, a combination of
learnings from both these initiatives yields multiple recommendations -which are crucial for Banyan to
understand and embrace as if wishes to be the first mover in this space by establishing CBR for mental
health.

● Mental Health is not a priority: comprehensive mental health CBR program will help 45 Mn
Indians
● Development of strong, sustainable local community structures must: flexibility and adaptability
to ensure institutionalisation/scale
● Family members should receive economic and emotional support to accept and effectively

34
Jaiswal, Atul, and Shikha Gupta. “Implementing a Community-Based Rehabilitation (CBR) Project in India: Learning and Experiences From
The...” ResearchGate, Dec. 2018,
www.researchgate.net/publication/330739215_Implementing_a_Community-Based_Rehabilitation_CBR_Project_in_India_Learning_and_Exp
eriences_from_the_Field_Disability_and_International_Development_Issue_3.
35
Sachdeva, Rhythm. “10 NGOs Helping Mentally Challenged Live Normal Life in India.” Medium, 12 Dec. 2021,
medium.com/giveindia/10-ngos-helping-mentally-challenged-live-normal-life-in-india-5e5b863f9547.
36
Shakti | Community Based Rehabilitation (CBR) Programme.” SANJOG, 22 Oct. 2021, www.sanjogindia.org/programmes/shakti.
37
Sivakumar, Thanapal, et al. “Community-Based Rehabilitation for Persons With Severe Mental Illness in a Rural Community of Karnataka:
Methodology of a Randomized Controlled Study.” Indian Journal of Psychological Medicine, vol. 42, no. 6_suppl, Medknow, Dec. 2020, pp.
S73–79. https://doi.org/10.1177/0253717620971203.
38
“Implementing a Community-Based Rehabilitation (CBR) Project in India: Learning and Experiences From The...” ResearchGate, Dec. 2018,
www.researchgate.net/publication/330739215_Implementing_a_Community-Based_Rehabilitation_CBR_Project_in_India_Learning_and_Exp
eriences_from_the_Field_Disability_and_International_Development_Issue_3.
39
Sustainability: Lessons From a Community-based Rehabilitation Programme in Karnataka, India. | InfoNTD.
www.infontd.org/resource/sustainability-lessons-community-based-rehabilitation-programme-karnataka-india.
40
Djenana Jalovcic, EdD, MPA, MSc, Bente van Oort, MSc. “Towards a Global Knowledge Creation Strategy: Learning From
Community-Based Rehabilitation.” Journal of Humanities in Rehabilitation, 15 May 2023,
www.jhrehab.org/2023/05/02/towards-a-global-knowledge-creation-strategy-learning-from-community-based-rehabilitation.

12
 embrace
● Empowering by “giving back control of their lives to them” by deploying augmented resources
(funds/trainings) created from PPP
● Strong liaisons between all the stakeholders is key from design to implementation and
improvisation for sustainable outcomes
● Role reversal programs and campaign around power of WE helpful
● Additional sensitivity for women, children and senior citizens
● Local workers including ASHA most crucial with amenability to work in low-tech environment
● Poor access to quality healthcare infrastructure and socio-cultural barriers affect treatment

Further we believe these programs also yield some key recommendations for the participating
stakeholders and the same are covered in the next sections divided by the potential action owner.

2.3.2.1 Government

Unit economics and scale will be key to the successful deployment of CBRs across the nation and thus
we recommend that the Indian government bring forward policies to bridge the demand and supply gap.
On the supply side, In India, most of the rehabilitation work is driven by NGOs and unfortunately,
funds for the NGOs are driven not by the need or severity they are addressing but by the execution
capability of the host region. This continues to create economic drift and calls out for action on two
fronts
1. Equitable disbursement of funds per population affected
2. Equip NGOs with the capabilities and capacities needed to deploy holistic CBR programs in
diverse regions
On the demand side, the government has to increase the awareness and knowledge around the mental
health issues and benefits of leveraging CBR. Importantly the demand needs to be created by running
national campaigns of the key determinants which would aid in circumventing CBR execution
challenges primarily those arising from social stigma and cultural beliefs of different regional areas.
Studies are ongoing in countries like China to define the social determinants in a structured manner to
support the development of cause-effect experimental programs at a large scale.41 Similar studies need to
be undertaken by the Indian government as part of the healthcare management surveys and or
digitalization initiatives. This will establish the need gap and tailored solutions for the defined regions
and eventually deliver the content needed for the awareness and marketing campaigns.

2.3.2.2 NGO’s

Our recommendations for the NGOs is to focus on the social integration aspect of the CBR and thereby
reduce the “conversion” factors of mental health status. Since the funds are disbursed to areas that show
higher feasibility index, NGOs such as Banyan can leverage the design thinking model and channelize
funds towards design and deployment of multiple pilot programs following SMART goals. Drawing the
parallel from the work on differently abled individuals and women, two programs for NGOs like Banyan
to consider:

41
Wang, Ruoxi, et al. “Integrated Decision-making Model for Community-based Rehabilitation Service Utilisation Among Persons With Severe
Mental Illness in China: Protocol for a Cross-sectional, Mixed-methods Study.” BMJ Open, vol. 8, no. 12, BMJ, Dec. 2018, p. e021528.
https://doi.org/10.1136/bmjopen-2018-021528.

13
 1. Educate or skill the afflicted individuals as part of CBR program. For example, in rural areas,
one can implement advanced agricultural technologies (water testing/weather testing/yield
matrices etc) and attempt to train individuals with mental health issues and subsequently, deploy
them to support local farmers. If this training is done using the local resources, teachers/ASHA
workers etc, an interdependent sustainable model can be created. One can refer to the Sugarcane
model implemented by the South Indian government to augment productivity.
2. Generate local value-generating “mini employment” programs. This method has been proven to
be effective in women’s empowerment both in rural areas and in the deployment of women
post-pregnancy-based career breaks. Examples., tailoring, condiment making, shoe making etc.

2.3.2.3 CBR Program Deployment Agencies

Many CBR programs for mental health are still focused on solving the infrastructure and access issues.
While the cost is high, the success rates are still low due to the poor initiation and adoption by the
afflicted individuals, immediate and their larger community. The key need here is the ability to identify
the “concerns on time” by local players and provide immediate support in a medically qualified safe
environment. Digitalization of healthcare should be deployed to reduce the burden on the system and on
themselves so the agencies directly or in collaboration with the NGOs can focus on the social inclusion
and empowerment aspects which are more human-centric.

It’s critical for organising groups to accept the mental health status of the individuals involved, and
advocate for their families to refrain from choosing between the continued financial support they can get
from the local governments vs getting their loved ones treated, enabled and empowered. The empathy of
the individuals involved towards the mental status, family members and their religious, traditional
sensitivity while deploying the program is yet another key. Additionally, the program is expected to be
dynamic and for sustainable effect, we recommend the need to manage this a strategic program under a
program management and joint steering committee governance model rather than annual program.

3. International Case Studies

One of the methods of approaching the topic at hand is through case studies of community rehabilitation
programs in countries socio-economically similar to India within the context of addressing mental health
disorders. Two countries have been chosen for this – Thailand and China. Both countries are culturally
similar to India, with social structures that are alike, such as family, religion and gender. They share
demographic and familial dynamics. Like India, Thailand and China have conservative societies which
view mental health as a taboo topic, thus, hampering access to mental health care. However, both these
countries have made considerable progress when it comes to working towards making mental health
care accessible. This section will examine the government-instituted mental health policies and CBR
programs in both countries.

3.1 Case Studies –

3.1.1 Thailand

14
Located in Southeast Asia, Thailand is an upper middle-income country42 with an ever-increasing
number of people suffering from mental health disorders. The numbers there have risen from 1.3 million
people in 2015 to 2.3 million people in 2021.43 Traditional Thai beliefs dictate that mental health
conditions are part of the devil’s design, the stigma hampering access to mental health care in the
community. In recent years, multiple factors have contributed to the increase in mental health disorders,
the most important being the COVID-19 outbreak which led to financial stress among many families.
Another reason is a growing elderly demographic profile, which faces challenges such as isolation,
illness and trouble with family relationships.44

Thailand’s Mental Health Policy was initially formulated in 1995 after the reorganisation of the
“Division of Mental Health in the Department of Medical Services” to the “Department of Mental
Health (DMH)” under the Ministry of Public Health (MoPH).45 The aim of the policy is to promote
positive mental health among citizens and ensure accessibility to mental health care by integrating both
treatment and rehabilitation into the public health service system. Thailand’s mental health policy was
revised in 2008 to include the development of community mental health services, mental health
components in primary health care and quality improvement. The 2018 Mental Health Act Revised
Version focused on community mental health and the need to strengthen infrastructure to cater to the
needs of people with mental health disorders. This entails training more mental health professionals to
work in the rehabilitation facilities and increasing the number of beds available (which is currently at
6.26 beds per 100,000 people and has remained the same in the years 2019-2021).46

Mental health care has been organised and monitored through the public health system to integrate it
into the community at different levels. Today, Thailand’s community mental health system can cover the
prevention, treatment and rehabilitation of mental health disorders for its population. Owing to a
shortage of mental health care personnel, Thailand has tried to train local healthcare workers and
volunteers to provide sustainable care at the community level.47

The community-based rehabilitative services in Thailand have shown to be fairly holistic, with a focus
on many important areas like deinstitutionalisation, vocational rehabilitation, helping people build social
relationships and participation in the community. They also have tried to address employment and social
needs. These services aim to reach out to all people with mental health disorders who cannot access
institutional-based care at hospitals and reach out to therapists. An excellent example of this is that of
The Srithanya Hospital (SH) in Thailand. The SH is a psychiatric tertiary care centre of the Department
of Mental Health. The Srithanya Hospital started the Srithanya Hospital Foundation (SHF) as a charity
organisation to provide care to people with mental health disorders who are economically disadvantaged
and facilitate their return to mainstream society. The SHF made linkages with the five Wats (Buddhist

42
“Thailand Now an Upper Middle Income Economy.” World Bank, 2 August 2011,
https://www.worldbank.org/en/news/press-release/2011/08/02/thailand-now-upper-middle-income-economy. Accessed 17 july, 2023
43
“Mental health as public health in Thailand.” New Mandala, 9 June 2023,
https://www.newmandala.org/mental-health-as-public-health-in-thailand/..
44
“Mental health as public health in Thailand.” New Mandala, 9 June 2023,
https://www.newmandala.org/mental-health-as-public-health-in-thailand/.
45
Community Mental Health: Thailand Country Report 2008. Department of Mental Health, Ministry of Public Health.
https://dmh.go.th/download/Ebooks/CommuMH2551/rptCommunity2008eng.pdf.
46
K., Wannasewok, et al. “Development of Community Mental Health Infrastructure in Thailand: From the Past to the COVID-19 Pandemic.”
Consortium Psychiatricum, vol. 3, no. 3, 2022, pp. 98-109, https://consortium-psy.com/jour/article/view/194.
47
The ASEAN Secretariat. ASEAN Mental Health Systems. [Internet]. ASEAN Secretariat. 2016, pp. 155
https://asean.org/wp-content/uploads/2017/02/55.-December-2016-ASEAN-Mental-Health-System.pdf.

15
Temples) in Nonthaburi Province. The monks here provide shelter and livelihood to former SH patients
who do not have any families to return to. This alliance set up a best practice model for CBR.48

CBR in Thailand has created a positive attitude of society towards people with mental health disorders.
However, the mental health care system is not completely free of weaknesses. First, adequate capital that
is required for the development of a larger number of facilities is still lacking. A major portion of the
financial resources is sent towards psychiatric hospitals instead of residential facilities. Second, the ratio
of human resources available is still unsatisfactory. Human resources available in private practice or in
mental health facilities per 100,000 population is just 7.29. This has pushed the government to involve
laypersons into community based services through training. The access to care is also uneven, directed
more towards areas which are closer to the cities.49

3.1.2 China
The second most populated nation in the world, China is an upper middle income country located in East
Asia. Facing an ever increasing mental health burden, data shows that more than 160 million people
suffer from mental health disorders in China.50 Like many other Asian countries, a significant amount of
stigma exists around the topic of mental health in Chinese society because of deep-rooted cultural
beliefs. Thus, recent laws in the area of mental health in the country have focused on creating
community based services accessible and increasing the funding for improving the quality of services
available.

China has seen two National Mental Health Plans – one from 2002-2010 and the other from 2015-2020.
The former tried to establish an effective mental health care system led by the government, through
community based health facilities and rehabilitation services, while the latter contained more specific
needs to be addressed to improve the system. In 2013, The Mental Health Law was enacted to develop
the field of mental health, and guarantee the legal rights and interests of people with mental disorders.
Rehabilitation is one of the major sections of the law. It specifies the training required for providing
these services like training in life skills and social skills and other skills which will help the patients. It
also addresses the goal of providing employment to people with mental health disorders i.e. providing
‘suitable work for persons with mental disorders based on their actual capabilities,’ emphasising on job
training and proper work environment.

One of the most important components of China’s mental health services is a three-tier hospital
community service which provides inpatient care, outpatient care and rehabilitation. They also
emphasise on health education, vocational rehabilitation and therapy sessions. As there has always been
a lack of adequate trained professionals to provide care, the government has focused on strengthening
human resources to deal with the challenge of mental health. Since Chinese culture promotes the
importance of family, the families of affected people play a vital role in ensuring care and treatment of
people with mental health disorders. Many practices to help in rehabilitation which were adopted from
Western contexts have been adapted to fit the Chinese context. For example, a case study conducted in
An-Ding Hospital in China showed that although social skills training models were adopted from those

48
Norella, Loyd Brendan. Assessment of Best Practice Community-based Mental Health Projects in Thailand.
https://www.asianscholarship.org/asf/ejourn/articles/Loyd%20Norella2.pdf.
49
WHO-AIMS Report on Mental Health System in Thailand,World Health Organization, 2007
https://apps.who.int/iris/bitstream/handle/10665/206157/B0771.pdf Accessed 17 July, 2023
50
Zhang, Wenyi. “Mental health in China:Statistics and facts.” Statista, 2023 https://www.statista.com/topics/9303/mental-health-in-china/
Accessed 17 July, 2023

16
prevalent in the USA, because of the importance of family cohesion and joint decision making in China,
the key family members of patients were involved in some of the training sessions with patients.51

Although years of development and investments have helped improve the state of CBR, China still faces
challenges with implementation of community based rehabilitation of people with mental health
disorders. First is the challenge of an inequitable distribution of services in rural and urban areas in the
country, with rural areas struggling with the burden of fewer services. Currently, only bigger cities like
Beijing and Shanghai are able to offer services like social skills training, vocational rehabilitation and
community support programs, which are integral to help any person with a mental health disorder. In
rural areas, there are mostly underdeveloped clinics which can barely provide continuous services.52
Second, the stigma associated with mental health and lack of awareness still requires work. There is not
much effort being put into mental health education for citizens. Finally, the current community care
services are not linked to other health and welfare services. The lack of integration into the general
mental health care system is a major hindrance to access.

3.2 Factors leading to success of CBR in Thailand and China

The key reasons why CBR for people with mental health disorders has been successful in Thailand
relate to the integration of mental health care with the public health care system. Following the “Health
For All by the Year 2000” policy by WHO in 1978, Thailand added “Mental health” into the original ten
components of the “Basic Primary Health Care” implemented within the health system which resulted in
the major move of mental health concern at the community level. Although there is no legislative
framework around rehabilitation, Thailand has strong policies regarding mental health. The government
has also taken active measures to improve mental health literacy and making education about mental
health disorders readily available. The Social Psychiatric Division of the DMH is responsible for
supervising awareness campaigns for disorders. Government and NGOs have promoted public education
aimed at targeting schoolchildren and adolescents. A psychosocial care system for schools has been
established, and the existence of this care system is a part of the quality assessment criteria for schools
by the Ministry of Education.53

In the case of China, despite the stigma around the topic, mental health services have been identified as
important and the need for its accessibility is acknowledged. The country has shown commitment
towards mental health reform. In 2004, the government launched the “686 Program'', which tried to
integrate mental health care into the community healthcare system and improve rates of recovery and
rehabilitation. It was initiated as a national community‐based model to effectively manage
community‐dwelling patients with psychiatric disorders. The program ensured equal access to a basic
package of community-based mental health care for people with mental health disorders, especially for
those living in poverty. The year 2013 saw China’s first Mental Health Law to protect rights and
improve quality of care. The legislation proved to be an important determiner in ensuring people access
to various mental health services from then on. The law’s focus on rehabilitation and prevention of
mental disorders is something many countries can learn from.

51
Weng, Yong-zhen, et al. “Rehab Rounds: Psychiatric Rehabilitation in a Chinese Psychiatric Hospital.” Psychiatry Online, 1 April 2005,
https://ps.psychiatryonline.org/doi/10.1176/appi.ps.56.4.401. Accessed 27 July 2023.
52
Tse, Samson, et al. “Strengths, Weaknesses, Opportunities and Threats analysis: CMHS in China.” Daa Supplement to “Mental Health Care
Reforms in Asia: The Urgency of Now: Building a Recovery-Oriented, Community Mental Health Service in China.” Psychiatry Online, 1 July
2023, https://ps.psychiatryonline.org/doi/suppl/10.1176/appi.ps.000022013/suppl_file/613_ds001.pdf Accessed 23 July 2023.
53
WHO-AIMS Report on Mental Health System in Thailand,World Health Organization, 2007
https://apps.who.int/iris/bitstream/handle/10665/206157/B0771.pdf Accessed 20 July, 2023

17
3.3 International Best Practices

The international best practices in the field of community rehabilitation for people with mental health
disorders have been compiled as follows:

● Policy support is one of the most important ways to improve CBR. Having comprehensive
mental health laws and rehabilitation provisions is necessary for mental health promotion.
● Using a Bottoms-Up approach rather than a Top-Down approach so that program implementation
strategies by local partners can be based on addressing the needs of unique contexts, instead of
being handed down by generalised CBR practices used in urban areas where resources for
implementation are relatively more.
● Providing linkages to CBR programs with other health and welfare services to ensure better
accessibility. Having collaborations with departments/organizations responsible for healthcare,
reproductive health, child support, education, employment and elderly care.
● Prevention through information and public awareness. Having awareness campaigns and
ensuring easy access to knowledge about mental health in schools and the community.
● Commitment and support to and from community stakeholders is crucial to ensure program
sustainability. The involvement of people who have benefitted from existing programs can help
past patients and future ones.
● Culturally responsive healing methods should be used in rehabilitation interventions. Various
methods like mindfulness training, yoga and meditation can be helpful.
● Training families of people with mental health disorders and the community to provide better
care is necessary to help patients and reduce relapse rates.

4. Recommendations

The widespread aim of CBR is to provide affordable, accessible and socio-economically efficient care
for mental disorders affecting the quality of life in people. The most important component of CBR is to
not only mitigate the risks associated with disorders but also turn patients into well-functioning and
contributing members of society.54

However, studies have shown that mental health care lies at the bottom of priorities in the public health
sphere, a fact that needs urgent attention.55 The needs for CBR differ from one disorder to another, and
after a thorough analysis of CBR programmes in India, socio-economically similar nations like China
and Thailand, and conversations with our stakeholders, we suggest the following practices and systems
be implemented in Community-Based Rehabilitation Programmes:

54
Chawla, Tina, and Mahi Singh. “An Overview of Community Mental Health and Depression in India.”
2020,https://ijpsl.in/wp-content/uploads/2020/12/An-Overview-of-Community-Mental-Health-and-Depression-in-India_Tina-Chawla-Mahi-Singh.
pdf. Accessed 21 July, 2023.
55
Subramaniam, Mythily, et al. “A Qualitative Exploration of the Views of Policymakers and Policy Advisors on the Impact of Mental Health
Stigma on the Development and Implementation of Mental Health Policy in Singapore.” NCBI, 29 September 2021,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9005417/. Accessed 22 July 2023.

18
4.1 Policy Recommendations

● The National government must mandate a Mental Health Review Board set up in each state.56 As
an institution running under India’s National Mental Health Program (NMHP), the Mental
Health Review Board could work at the state level with district centres and act as the reporting
authority that carries out regular audits, monetary checks on spending and inflow of funds,
quality control operations to ensure the safety and welfare of patients, and review internal
workings of the non-governmental organisations working in the mental healthcare sphere.

● The National Government must allocate funds transparently and draw clear boundaries as to
what scheme/policy constitutes national funding and what requires funding at the state level. A
large part of the Health and Family Welfare budget is allocated to Tele-Mental Health
Assistance and Nationally Actionable Plans through States (T-MANAS).57 As useful as the
T-MANAS programme is, it cannot be a long-term mental health programme. Hence, the
government must focus on increasing funding for community-based rehabilitation and contribute
more to the District Mental Health Programme.

● The overall budget for the Tertiary Care Programme in the Union Budget has dropped from INR
500 crores in 2022-23 to 290 crore in 2023-24.58 This would probably have led to a decrease in
mental tertiary care programmes as well. The Government would benefit from increasing the
budget allocation to the Tertiary Care Programme and the NMHP too.

● Social inclusion of people with mental disorders, and the issue of unemployment and loss of
wages for people seeking mental health care can be further strengthened by creating reservations
at jobs and educational institutions. Along the lines of the Rights of Persons with Disabilities Act
2016, which mandates 4% reservation for People with Disorders (including mental disorders),
more reservation policies can be created or reformed to include mental disorders as well.

● The number of insurance policies covering mental health clauses must be increased and the
scope of these policies must be expanded to include mental disorders across all spectrums. These
policies would proliferate the number of people seeking mental health services. Patients with
chronic mental illnesses and those from low-income, socially backward backgrounds would
stand to gain the most from insurance policies that cover their expenditures on receiving mental
healthcare.

● Mental health schemes and policies addressing substance abuse disorders can be included under
social and economic development objectives and programmes, in order to create awareness,
reduce stigma and ensure treatment stemming from national-level authorities. There must be an
increase in the implementation of social justice and development schemes as social issues like
unemployment, food insecurity, poverty etc have a direct impact on the mental health of people
and consequently their ability and willingness to seek treatment for the same.

56
Sagar, Rajesh. “National Mental Health Policy, India (2014): Where Have We Reached?” NCBI, 25 October 2021,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9460016/. Accessed 29 July 2023.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9460016/
57
“Budget Brief 2023 v3.” cmhlp, 4 February 2023, https://cmhlp.org/wp-content/uploads/2023/02/Budget-Brief-2023-v3.pdf. Accessed 29 July
2023.
58
“Budget Brief 2023 v3.” cmhlp, 4 February 2023, https://cmhlp.org/wp-content/uploads/2023/02/Budget-Brief-2023-v3.pdf. Accessed 29 July
2023.

19
 ● The National government must increase funding given to non-governmental institutions working
in the sphere of mental health. It must also work towards contributing more to CBR programmes
by increasing schemes like the Deendayal Disabled Rehabilitation scheme, which allows
grants-in-aid to home-based and CBR facilities.59

4.2 Recommendations for CBR programs

● The treatment of any mental disorder must begin with the humane treatment of those possessing
the disorder. Following up on incidents like the Erwadi Fire in Kerala, India, where 28 ‘in-mates’
perished to death when a fire broke out and they were unable to escape as they were chained
within the Erwadi Mental Health Hospital, we must realise the threat these cases pose to the
system of mental healthcare in India.60 Extremely oppressive measures like chaining can not only
be damaging to a person’s self-esteem but become a physical hazard and impinges on their right
to live freely. Dehumanising practices like chaining patients, referring to them as ‘in-mates’ thus
branding them criminals, and taking away personal possessions are infringements on their
freedom and can be the biggest roadblocks to their mental, physical and emotional development.

● Healthcare workers must be empathetic to patients’ struggles and demands, as well as respect
their personal beliefs and act with sensitivity, professionalism and confidentiality to preserve
patients’ trust. Psychological first-aid courses, sensitization to gender-based issues, cultural
differences, shortcomings and restrictions at home, monetary factors and social standing of
patients must be a quintessential part of volunteer and caregiver training.

● The above-mentioned recommendation can be done at scale using the Bellary Model, formulated
by the National Institute of Mental Health and Neurosciences, which supports those in need of
mental healthcare by providing laypersons, members of the community and willing volunteers a
short 9-day training on basic mental help. 61 The model should be adopted in CBR centres over
the country to mobilise labour and financial resources in order to successfully treat the gap
between affordable care and lack of manpower.

● Therapists, trained volunteers and psychiatrists must be available as part of organisational

networks for patients to access and confide in. The Mental Health Survey of 2016 highlighted the
shortage of mental health programs and medical officers equipped to provide mental healthcare
at the grassroots level.62 This can also be remedied slowly by adopting the NMHP Bellary model
of Karnataka, formulated by NIMHANS, Bangalore.

● For any CBR programme to be successful, special consideration must be given to the patient’s
social and economic background. Familial issues, informed consent of the patient, and financial
concerns must be addressed. The Mental Healthcare (Rights of Persons with Mental Illness)
Rules, 2018, written as part of the NMHP, can be referred to achieve this goal.

59
“DDRS.” Department of Empowerment of Persons with Disabilities, 13 July 2021, https://disabilityaffairs.gov.in/content/page/ddrs.php.
Accessed 29 July 2023.
60
“Erwadi Tragedy was gruesome, Do you know about it? - GR.” Ground Report, 11 August 2021,
https://groundreport.in/erwadi-tragedy-was-gruesome-do-you-know-about-it/. Accessed 22 July 2023.
61
“NATIONAL MENTAL HEALTH PROGRAMME.” Ministry of Health and Family Welfare,
https://main.mohfw.gov.in/sites/default/files/ComprehensiveReport%20Part%202-83145794_1.pdf. Accessed 29 July 2023.
62
“NATIONAL MENTAL HEALTH PROGRAMME.” Ministry of Health and Family Welfare,
https://main.mohfw.gov.in/sites/default/files/ComprehensiveReport%20Part%202-83145794_1.pdf. Accessed 29 July 2023.

20
 ● The Mental Healthcare Act 2017 can also serve as a helpful source to structure CBR
programmes and run a mental health non-governmental organisation in accordance with
government-mandated laws.63

● Care for hygiene, timely eating, physical movement and hobby cultivation must be emphasised
for treating a disorder like Depression. Token economy, rewarding systems and positive
reinforcement can also be used to incentivise and appreciate the efforts of the patients. The
effects of positive psychology are longer lasting and often more efficient than traditional
therapies.64

● For Substance-Abuse Disorder, healthcare workers need to understand in-depth the level and
nature of dependence on the substance and personal tendencies of the patient and inform the
primary caregivers as well as the family of the patient of the true and correct treatment paths for
the concerned patient.65 A ‘one-size fits all’ approach cannot and must not be employed for every
patient.

● A biopsychosocial model, like the Minnesota Model of Residential Chemical Dependency

Treatment which aims to develop ‘abstinence’ as the primary goal of treatment, along with a
12-Step Program meant to prevent relapse, can be employed largely to provide substance-abuse
treatment. For various Severe Mental Disorders, Indian mental healthcare schemes often
overlook the psychosocial components.66A biopsychosocial model incorporates biological or
medicinal care for detoxifying, with counselling, psychological tests and therapies useful in
mitigating the psychological need and dependence on the substance abused, and the social
component which involves group exposure, peer interaction and enriching activities to foster
unity, belonging and agency in the patient.67

● For a country like India, keeping in mind the social and cultural diversity, as per the World
Health Organisation’s recommendation, the ‘Manual on Minimum Standards of Services for the
Programmes under the Scheme for Prevention of Alcoholism and Substance (Drugs) Abuse’ can
be referred to as it lays down specific guidelines for ethics, nature of the treatment, the minimum
infrastructure required for the treatment, the activities to be involved, etc68.
5. Conclusion

63
Gupta S, Sagar R. Where Have We Reached? Indian Journal of Psychological Medicine. National Mental Health Policy, India
(2014):2022;44(5):510-515. doi:10.1177/02537176211048335
64
Chowdhury, Madhuleena Roy, and Jo Nash. “The Connections Between Positive Psychology & Mental Health.” Positive Psychology, 13
March 2019, https://positivepsychology.com/positive-psychology-and-mental-health/. Accessed 22 July 2023.
65
“Chapter 5—Specialised Substance Abuse Treatment Programs - A Guide to Substance Abuse Services for Primary Care Clinicians.” NCBI,
https://www.ncbi.nlm.nih.gov/books/NBK64815/. Accessed 22 July 2023.
66
Saha, Somen et al. “Psychosocial rehabilitation of people living with mental illness: Lessons learned from community-based psychiatric
rehabilitation centres in Gujarat.” Journal of family medicine and primary care vol. 9,2 892-897. 28 Feb.
2020,https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7114046/#:~:text=Introduction%3A,improving%20their%20quality%20of%20life.
67
“Chapter 5—Specialised Substance Abuse Treatment Programs - A Guide to Substance Abuse Services for Primary Care Clinicians.” NCBI,
https://www.ncbi.nlm.nih.gov/books/NBK64815/. Accessed 22 July 2023.
68
“Drug Abuse Treatment and Rehabilitation: a Practical Planning and Implementation Guide.” Unodc,
https://www.unodc.org/docs/treatment/Guide_E.pdf. Accessed 22 July 2023.

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Community plays an indispensable role in alleviating mental disorders. While mental health is gaining
traction in today’s world, there is still a long way to go in fighting the stigma, misconceptions and
malpractices associated with mental healthcare worldwide. The social component of mental disorder
treatment comes to life with CBR programmes. These programmes must succeed at not only treating the
disorder but also engaging patients physically, mentally, and emotionally and equipping them with the
skills, confidence and ability to find their footing in the world. Positivity, safety and optimism must be
fostered through an array of activities, interactions and efforts from stakeholders, governments,
volunteers, and professionals alike.

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