SNEHA – A community-based health model that delivers

Public health in urban areas is one of the most persistent, yet neglected, issues facing the developing world. Cities present an especially challenging canvas given the many different factors – migration, inadequate housing, lack of infrastructure, crime, political corruption, pollution, and dysfunctional health systems – that are in play.

Over 50% of the world’s population lives in cities and this number will rise in the next few decades. Due to migration, India’s cities are growing more than three times as fast as the rural areas, and it is likely that more than half of the country’s population will live in urban areas by 2050.

The factors that affect human health are many, ranging from climate change and greenhouse gas emissions to reproductive health and rights. Meeting them is key to India’s success in achieving universal health coverage and improved national health indicators.  96-of-109

The National Urban Health Mission in India aims to enable rightful access to quality health care. This is by setting up an improved public health system, partnerships, and community-based mechanisms. This is to be done with the help of secondary and tertiary institutions, urban health centres, and community outreach. The positive outcomes of such a partnership in Mumbai’s urban settlements, demonstrated by SNEHA, is the subject of a paper recently published in the prestigious medical journal The Lancet.

The interventions of the Society for Nutrition, Education and Health Action, SNEHA, interventions are born out of 16 years of work with women and children in informal settlements. They range from maternal and neonatal health, sexual and reproductive health, childhood nutrition, and prevention of violence against women and children. What makes SNEHA’s model unique and effective is that it integrates these activities, and the model can be replicated in urban settlements across India, perhaps in many developing countries as well, with some tweaks for local, cultural specifics.

SNEHA’s adoption of an integrated approach came after a large neonatal trial conducted in Mumbai. It was felt that this would be an effective method given the multiple health issues faced by women and children, and the belief that communities would be more responsive to an intervention that had both, physical presence and service delivery.

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Every SNEHA centre is equipped with three full-time community organizers with backgrounds similar to the people they reach out to. They are trained to bring together the themes of reproductive, maternal, and neonatal health, child health and nutrition, and prevention of violence against women and children into the community services. They are responsible for home visits, group meetings, organizing day care for malnourished children, and community events, in close association with existing systems.

A survey was done before, and two years after SNEHA’s intervention on three main outcomes – family planning in women (15–49 years), immunization of children, and wasting among children less than five years. The survey looked at secondary outcomes as well, like violence against women or children, number of home births, pregnancies in women younger than 20 years, to name just a few.

There were significant improvements in the met need for family planning, and full immunization. Compared to the NFHS 2015-16 figures of 14% unmet need in Mumbai, the results in the areas of intervention was 22%. Again the NFHS-4 findings showed that 46% of children between 12–23 months in Mumbai were fully immunized. Contrast that with the intervention area rates of 69%. The findings were similar when it came to wasting in children, and diet among children.

There were other positive fallouts seen as well like the use of sturdier material to build homes, building of private toilets and use of safe, drinking water.

The challenges of meeting the health needs of settlements in an urban milieu are many. The shifting nature of the population and specific cultural beliefs can often slow down rates of progress. However, the overwhelmingly positive outcomes demonstrated by SNEHA’s model shows a way forward to city governments across developing countries who are grappling with ways to improve health in informal settlements.

Link to The Lancet paper – http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(16)30363-1/abstract

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Build a conversation on mental health

The recent countrywide survey by the reputed National Institute of Mental Health & Neurosciences, Nimhans, is a wake up call to how lifestyle changes are having an impact on the mental health of Indians.

The report says that a shocking 13.7% of India’s general population suffers from some form of mental illness. A majority of them, over 10% are in need of urgent medical intervention, which translates to about 150 million Indians.

Nearly one in 20 people suffer from depression. Women between 40-49 years are especially vulnerable and report high rates.

Despite being among the first countries to develop a national mental health policy, this is the first time that a proper, in depth study has been done to understand the spread of mental illness in India. Earlier studies at the state levels had several loopholes.

The incidence of mental illness is especially high in urban areas, which is perhaps only too obvious given that is here that the impact of lifestyle changes, changes in family support structures and issues related to job stress are most apparent.

The report raises red flags on many fronts. One is the sheer scale. The other is the huge gap in terms of treatment. This extends to both mental health specialists as well as institutions.

A 2013 government of India study said that there are 3,800 qualified psychiatrists in the country as against the required 11,500. When it comes to clinical psychologists, the requirement is 23,000. The availability is 850. The figures for psychiatric nurses are equally dismal.

The other alert is the widespread stigma attached with mental disorders. The Nimhans report says that 80% of people suffering from mental disorders had not received any treatment despite suffering for over a year.

A major step towards ending the stigma is to build a conversation around mental health. In this regard, it is encouraging to see celebrities like Deepika Padukone come forward to talk about their struggles with depression. It’s a small step, however, given the sheer scale of the mental health crisis India faces. There is a need to look initiatives by NGOs like Sangath that train workers at primary health centres to counsel patients in the community on dementia, depression and schizophrenia.

Rather than just a top down approach, the government needs to encourage and incorporate community level initiatives to help end the stigma and heal.

Child marriages & impact on mental health

The impact of early marriage on the reproductive health of women has been well documented, but the effect on mental health often gets overlooked. Child brides often find themselves struggling to cope with anxiety and depression and find little sympathy or support in their marital home.

A sociological study done by the University of Calicut among 600 women who had married before the legal age found that most of them were in conflict with their husbands and other members of the marital home. They were under pressure to take over the household chores and produce a child early.

Any assertion of right or voicing an opinion was treated as a challenge and often met with ridicule, even physical abuse.

A new India wide study by the Delhi-based SAMA Resource Group for Women and Health is also examining the wider impact of early marriage on a woman’s health. Early findings of the report say that when girls are forced to leave school and marry, they experience a loss of mobility. The immediate result is a loss of companionship as they are no longer free to meet their friends. This is a major cause for distress.

Every aspect of their lives comes under close watch – from what they wear to whom they speak to – so there is a constant feeling of apprehension that they might break the rules.

Any sign of sadness or unduly quiet behaviour is regarded as proper and hence gets ignored. It is only when the signs of mental health become very obvious that outside help is sought and this is not professional help, but from traditional faith healers.

“Whenever there is physical violence, it shows up in scars”, says Praful Kamble, Program Officer of SNEHA’s Little Sisters program which has been working towards bringing addressing domestic violence issues in Mumbai’s Dharavi area. “But the impact on the mind is 25% more. There is depression and a sense of shock. And when there is negative support from the family, the woman feels even more isolated.”

Geeta (name changed) experienced verbal violence from her in laws and husband, as her son was constantly ill. Even her sisters-in-law did not support her. One day she threw kerosene on herself and set herself on fire.

“I did it out of despair”, she says. “Caring for a sick child was stressful as it is and then to be constantly blamed for it was a miserable feeling. I was worried for my child and had no idea where to seek help.”

There are multiple linkages between early marriage and health. Mental health is a key one, and needs greater focus in India’s programs and policies.

 

New Mental Health Bill is a much welcome step

The Mental Health Care Bill 2013, is welcome as it a step towards acknowledging the huge shortage of infrastructure and psychiatrists in the country. The bill aims to protect and promote the of rights of people with mental illness and offer better support and facilities to people suffering from various types of mental illnesses.

In India, mental health problems are more common than cancer and heart diseases. There is a high prevalence of mental disorders, from 58.2 to 73 per 1000 population.

However, research says that over 80% of people suffering are not getting the required treatment due to shortage of mental health experts, stigma, inadequate facilities and the high treatment costs. At present, there is only one psychiatrist for every 343000 people.

The new Bill is progressive because it acknowledges these glaring shortfalls and also calls for greater support for caregivers who are largely neglected. The move to decriminalize attempted suicides also recognizes the rights of the mentally ill. The focus on compassion and responsibility is also a welcome shift away from socially stigmatizing those who suffer from mental illnesses.

However, how effective this Bill will be depends on the implementation and this is a big question mark. Since health is a state subject, different states are left to their own devices when it comes to bringing the various provisions into force and this could undermine many of its positives.