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Print version ISSN 0042-9686
Bull World Health Organ vol.81 n.11 Genebra Nov. 2003
BOOKS & ELECTRONIC MEDIA
Shekhar Saxena1; Pratap Sharan
Department of Mental Health and Substance Dependence, World Health Organization, Geneva, Switzerland
Editors: V. Patel & R. Thara
Publisher: New Delhi: Sage Publications India Pvt Ltd; 2003
ISBN: 0-7619-9699-0 (US – hardback);
price: US$ 59.95
81-7820-175-4 (India – hardback);
price: 675 Indian rupees.
Mental disorders and self-inflicted harm contribute immensely to the global burden of disease. In developing countries, while the burden is large, the resources that are deployed for mental health are meagre even in comparison to their own economies. Thus there is an urgent need to develop innovative and cost-effective programmes to respond to mental health problems in these countries. Meeting the mental health needs of developing countries describes some of the possibilities being explored in India.
The book consists of 17 chapters with lucid descriptions of nongovernmental organizations (NGOs) working in various areas of mental health in different parts of India. Each chapter uses the same format: genesis, evolution, current activities, and concerns and future perspectives. This helps to make the content interesting and easily assimilable. It is clear from reading these chapters that Indian NGOs have made useful contributions to clinical care, community outreach, rehabilitation, advocacy, protection of human rights, empowerment, policy change, training and research. It is also evident that the NGOs selected by the editors are driven by high commitment and that they promote active community participation.
In this first systematic effort to document NGO programmes on mental health in India, it is encouraging to note that some organizations have made an initial attempt at self-evaluation. But, it is also evident that the concept of overall programme evaluation has not as yet found its way into their systems. Transparency on professional issues (for instance, the qualifications of staff who administer interventions requiring high levels of skill) would serve to increase the credibility of NGOs. This is in addition to fiscal transparency, which is more often the focus of debate. NGOs should be vigilant about the issue of low salaries for their employees, which has implications not only for retention of staff but also for their possible exploitation in an employer driven market.
In the introductory and concluding chapters, the editors express their opinion on the role of NGOs in mental health care in India, and the extent to which current efforts are succeeding. They feel that the not-for-profit NGO sector, with its deep roots in the community, often gives voice to the needs of users and carers, while the public sector is apathetic about these needs, and the for-profit private sector is sometimes even antipathetic to them. The editors state that from a public health perspective, the strength of "genuine" NGOs lies in their high motivation and social commitment, their sensitivity to the poor, and their flexibility and innovativeness. Their weakness is in lack of accountability, problems of sustainability, and limited scale of operation.
The attempt to delineate the place of NGOs as separate from the state and the market is perhaps too simplistic and narrow. The suggestion seems to be that public health is a state responsibility, and so the main task of NGOs is to set up and run innovative programmes that can be replicated by the public health services. In developing countries, however, the state is often unable to meet many of the needs of the population, such as primary health care or primary education. In those cases, development may call for a large-scale, decentralized but coherent effort to deliver basic services. Since the for-profit private sector does not deal with these needs fully, the not-for-profit nongovernmental sector should take up the welfare function. In a situation where the role of the state is often decreasing, that of NGOs should not be limited to providing models for the public health sector. It should be the much larger one of providing alternative or supplementary services. It is time for NGOs to recognize the magnitude of these responsibilities. They will have to gear themselves up to providing services themselves to significant segments of the population. This would require some introspection on their part, leading to the planning and development of sustainable programmes (for instance by using fees to sustain or improve services).
This publication is an important addition to the literature on mental health from developing countries. It will be relevant beyond the boundaries of India certainly for South-East Asia, and perhaps for all low- and middle-income countries. It will inform users, carers and policy-makers, and should lead to increased thinking and coordination among NGOs as they strive to fulfil their mandate. A less expensive edition would help to get it into the hands of the people who could make the best use of it.