MYTHS AND REALIZATIONS; EXPLORING THENEED TO EMPLOY PSYCHOLOGISTS IN NONGOVERNMENTAL

ORGANISATIONS

AN EXPLORATORY STUDY

A

THESIS SUBMITTED TO

MANAV RACHANA INTERNATIONAL UNIVERSITY,FARIDABAD

FOR THE DEGREE OF

MASTER OF ARTS

IN

PSYCHOLOGY

Supervisor: Submitted by:

(Dr. Chavi Bhargav Sharma) (Swati Sharma)

(Manav Rachna International University)

(2014)

Declaration

This is to certify that the material embodied in the

present work entitled “(Myths and realizations; exploring the need to

employ psychologist in nongovernmental organisations, an exploratory

study)”is based on my original research work. It has not been

submitted in part or full for any other diploma or degree of

any University. My indebtness to other works has been duly

acknowledged at the relevant places.

(Swati Sharma)

(Dr. Chavi BhargavSharma)

(Dr. Chavi Bhargav Sharma)

(Manav Rachna International University)

Acknowledgment

I want to express my gratitude to faculty of management

studies, Manav Rachna International University, for their

constant support, motivation and guidance throughout this

incredible journey. Two years ago after my father’s accident

and the damage of his right foot and the family going through

a major crises, I had no idea about how will I even be able to

pay the fees for my Masters program at the university, until,

I met the director of FMS, Manav Rachna International

university. Without Chavi ma’am and my parents, I don’t see

myself taking a single step forward to my dream of becoming a

psychologist. I want to thank Chavi ma’am for her belief,

support, encouragement, guidance, warmth and strictness in my

ups and lows during my journey. From the bottom of heart, I

want to thank you ma’am most importantly for the most precious

gift that I am taking from you and that is of having a vision

and realization that psychologists are very different from

other people, it may be unfair sometimes on ourselves but to

serve others we have to constantly introspect within

ourselves. I want to thank my mother for her firm belief in my

dreams and for all the hard work she puts in everyday so that,

I can keep going on carrying out my journey to pursue my

dreams. I want to thank my father for the heritage of will

power and determination which commands me to stand up and walk

again, whenever I have a low moment and sit down,

disheartened. I want to thank my sister, Stuti, for bearing

the lights on for the nights when I have been working. I

want to take this opportunity and thank Stuti ma’am who had

made the first call from the university to guide me about the

course, when I was sitting disheartened for the mere reason of

not being able to crack other institutions, where I applied

for my masters. It was only for me to realize today that our

own vision, thoughts and potential makes us who we are. I want

to thank my mentor, Shilpa ma’am, without whom attending a

single class was also not possible. I want to thank her for

all her hard work and the effort that she took, even in the

most casual tasks that we have been a part of in these two

years. I want to thank Manisha ma’am for never getting tired

in answering even my most stupid questions in our research

lectures, which has made me capable of conducting this study

today. I want to thank Anita ma’am for being like a mother

figure to me, someone whom I have shared laughter, joy and

happiness and even sorrow through our unbelievable discussions

on life and psychology and for taking along such beautiful

teachings from her. I want to thank Jayant sir, for all his

scolding’s and questions, and for reminding me of my own

potential and intellect on every stage in these two years. He

has been my best critic all through my journey.

Lastly, I am in debt to all my friends, Shikha Singh Chauhan,

Pooja Atual Kumar, Chainika Sharma and Reva sexana who spared

their time off for discussions and feedback during my research

work.

Swati

Sharma

CONTENTS

PAGE NO.

List of Tables (in Roman no.)

List of Figures (in Roman no.)

Synopsis (in Roman no.)

CHAPTER 1 INTRODUCTION (in no.)

CHAPTER 2 LITERATURE REVIEW (in no.)

CHAPTER 3 GENERAL METHODOLOGY (in no.)

CHAPTER 4 RESULTS AND INTERPRETATION (in no.)

CHAPTER 5 DISCUSSION (in no.)

CHAPTER 6 CONCLUSION AND RECOMMENDATIONS (in no.)

REFERENCES (in no.)

APPENDICES (in Roman no.)

(QUESTIONNAIRES, CERTIFICATES ETC.)

LIST OF TABLES

Table No. Page

No.

LIST OF FIGURES

Figures No. Page No.

Synopsis

Over and over again, many at times it has been said, “health

is wealth. But have we given this a thought ever, that health

is not merely related to our physiological fitness or physical

well being, but a healthy individual is a physically and

mentally healthy. Various researches suggest that mental well

being plays a significant role in the life of any individual.

Issues concerning health problems in India have always been on

hype. In order to address this problem various nongovernmental

organizations working for societal welfare have come into

action, with focus on addressing health problems , by

providing free medical care and by creating awareness among

the community members, for instance, awareness regarding life

threatening diseases such HIV and cancer. But it is vital

here, to understand that, physical health and mental health

are not two separate entities; both physical health and mental

health are two components of an individual’s health, which

work together to comprise a healthy human being. According to

this, if professionals working for societal welfare are merely

focusing on undertaking programs that are addressing issues

concerning only biological health of any individual in our

society, then a very significant component, psychological and

mental wellbeing is constantly being missed out. And this

makes the goal of achieving a society of ‘healthy’

individuals, incomplete. This brings into account a very

serious problem which highlights the execution of incomplete

strategies , adopted by certain nongovernmental organizations

to approach societal development, because without a mental

health care professional or a psychologist, the execution of

these strategies remain incomplete.

“Myths and realizations” is an essential study i) exploring

the need to employ mental health care professionals in

nongovernmental organizations to address issues concerning

individual’s health , and ii) secondly, to highlight the

significance of psychologists in nongovernmental

organizations, in order to progress towards social

development. In order to do so a qualitative research for a

period of 1 month was conducted in a nongovernmental

organization, Smile foundation under swabhiman department.

This program was established in 2005, which aimed at both

collective self esteem and inner strengths for marginalized

and socially excluded women and adolescent girls through

innovative community practices. The research methodology used

to come to any conclusions and interpretations in the

research, was participant observation conducted in training

programs, slum and field visits and at the head office itself,

which was done during the volunteer ship in the

organization, under the program officer of Swabhiman

department to explore and have an in-depth understanding of

the research problem. Based on the findings of the research it

was found that, i) certain myths prevail, in context to mental

health care professionals and psychologists which were a

mental health care professional or psychologists are essential

only for the treatment of psychological illness or mental

illness; furthermore this view suggests, that, the need to

hire mental care professionals in organizations, which are not

focusing on mental illness do not need to hire psychologists,

ii)The second finding of the study enlightens the realization

and drags attention towards the fact that, any form of

deviance or psychopathology, in the context of the study, ill

health has more internal or psychological factors behind it ,

rather than external. Considering this, if individuals in our

society or beneficiaries of nongovernmental organizations are

provided with mental health care facilities, there can be a

significant change in lives of these individuals, particularly

making them efficient enough to deal with day-day life

problems, which may be a reason of ill health, deviance or

pathology in the future. iii) It was also realized during the

research study that, the execution of strategies adopted by

any nongovernmental organization, in context of, social

welfare and development will remain incomplete without a

mental health care professional or a psychologist, as mental

health is as vital as physical health for any individual.iii)

moreover it was found that, despite of various strategies and

development programs for the marginalized groups and

underprivileged community members, mental health , which

largely contributes in the overall functioning of

individuals, is been consistently missed out and neglected by

policy makers and professionals involved in the process of

social development. The need of the hour is to employ

psychologists and other mental health care professionals for

early detection, identification and rectification of any

deviance in the community members or the beneficiaries of

nongovernmental organizations as mental health care

professionals and psychologists will play a vital role as they

are well equipped with the understanding of human behavior.

Keywords- nongovernmental organization, psychologists,

development, society

Chapter 1 Introduction

Introduction to the study

Social and human development has been serious concern for the Indian society ever since our freedom. To a great extent our society has passed the test of time and has progressed in various sectors, but despite of this, there is a great imbalance of availability and accessibility of resources between privileged and the underprivileged society of our country. This study attempts to highlight the fact that for development to take place, it is essential that all the institutions, who are in action to work for social development, ranging from policy makers to nongovernmental organizations, must understand that, ensuring mental health and wellbeing, of each and every individual of our society, isof prime importance, in order to progress towards development.Urban sections and the privileged society, who have had accessto mental health care services in our country have been fortunate enough to get services which are essential for theirpsychological mental well being, but it is now high time that we realize that, the dream of development will remain incomplete if a vast majority of population (underprivileged section of the society) has diminutive or nil opportunity to avail mental health care. The need of the hour is to realize and accept the importance of mental health care professionals in order to ensure psychological well-being of individuals, inthe process of social development. Moreover, also to understand that there must be equal opportunity of availability and accessibility of mental health care services to all sections of our society. Considering this, the study attempts to specially focus on the need of psychologists and mental health care professionals, for certain underprivileged sections of the society, who approach various nongovernmental organizations for help, in face of their beneficiaries. This study, which was conducted in the period of one month

internship at a nongovernmental organization named Smile foundation, under a women empowerment program, providing various facilities to its beneficiaries except of any mental health care services, was the best suited place to have an in-depth understanding of the research problem, which is “what isthe significance of a mental health professional in a nongovernmental organization, in context to social development”?. The study was conducted by participant observation for a period of 30 days at various locations, which were essential to have an in-depth understanding of the research problem. The objective of the study is to i) explore the need to employ mental health care professionals and psychologists in nongovernmental organizations, to address issues concerning individual’s health. ii) And secondly, to highlight the significance of mental health care professionalsand psychologists in nongovernmental organizations to progresstowards social development.

Participant observation as a research method

In order to have an in-depth understanding of the research problem, it was essential to be a part of a nongovernmental organization that would have no mental health care facility inits action program for its beneficiaries. This enabled me to understand, the significance of mental health care professionals in the process of execution of action plans. Being a volunteer and thinking like a mental health care professional gave a great insight also to the limitations and shortcomings for a mental health care professional in context to employment in a nongovernmental organization and the stereotypes that various people from the organization as well as the beneficiaries of the organization hold about mental health care professionals. To conclude participant observationwas an essential tool to have an in depth understanding of theproblem, which also enabled exploration of certain myths and realizations related to the nongovernmental organization, its beneficiaries (underprivileged section of the society) and finally mental health care professionals to a great extent.

Focus of the study- Mental health, Social development, Nongovernmental organizations, and the current scenario

The primary objective of any nongovernment organization is to ensure social progress and development. It aims to target those sections of the society who are experiencing lack of monitory, social, personal, physical, occupational and mental resources. It works towards the progress of these individuals,who come from a variety of backgrounds, are underprivileged and have no opportunity to avail and access assistance of varied services. Statistics suggests that more than half of the population in our country is rural population, which is under poverty line. Mental illness constitutes nearly one sixth of all health-related disorders. With the population in-crease, changing values, life-style, frequent disruptions in income, crop failure, natural calamity (drought and flood), economic crisis, unemployment, lack of social support and increasing insecurity, it is fearfully expected that there would be a substantial increase in the number of people suffering from mental illness in rural areas. Among priority non-communicable diseases in India, mental illness constitutes26 percent share in the burden of disease and available data suggest that there would be a sharp increase in this in comingyears. Projections suggest that the health burden due to mental disorders will increase to 15% by 2020. (Anant kumar, 2011. Mental health services in rural India, Challenges and prospects). It is interesting to note that due to various reasons, some families have started migrating from their villages to cities, in search of employment and to earn their livelihood. These families, who are auto drivers, rag pickers,maid servants etc, constitute a vast majority of people who approach various nongovernmental organizations, in face of beneficiaries and look forward to their help, support and assistance. The job done by nongovernmental organizations in order to work for societal developmental has been commendable.But despite of their various efforts, mental health has alwaystaken a back seat in being their major focus area. The blame

of course should not be on the strategies and policies of nongovernmental organizations, who neglect the significance ofmental health in the process of development, but the responsibility equally lies in the hands of policy makers, whohave failed to establish a rule or a compulsory law regarding the employment of a mental health care professional in nongovernmental organizations to address social issues. The problem lies in not being able to understand the fact that anyform of development or progress cannot take place unless all individuals in the society are given equal opportunity to avail and access mental health care services. Moreover to equalize the pace of development, in context to mental health,between the privileged and underprivileged sections of the society, there must be a special and an immediate focus on making mental health care services available for the underprivileged. Considering that mental well being for all individuals is as essential as physical health the study has attempted to explore and highlight the significance of mental health care professionals to be employed in nongovernmental organizations, so that mental care services along with other health and occupational assistance reaches the beneficiaries or the underprivileged society, as assurance to progress towards development in a complete sense.

The holistic view of development and its relation with mental health

Development is a process of advancement, betterment, change, enlargement, evolution, expansion, extension, furtherance, gain, growth, improvement, progress, promotion, regeneration and reinforcement in a society. It is vital to understand thatthe process of development has various elements, which must ensure mental health at each element, in order to progress towards social development. Development is not a single concept; rather it consists of various other perspectives thatneed consideration and attention which in totality comprise ofdevelopment.

Development means

Advancement- in the society where individuals become capable enough to be able to predict and evaluate both the positive and negative impact of their decisions and actions- which would denote an advancement in their thinking. By development in terms of advancement in the psyche of individuals of our nation, this shall include all individuals of our society irrespective of their age,creed, caste, ethnicity, religion and gender.

Betterment- of all sections of the society where individuals of both urban and rural society have the ability to work for a meaningful life and are able to maximize their psychological potential through which theyare constantly able to achieve betterment in their lives at least, by finding practical solutions to their day to day problems.

Change- to encompass a range of typical societal outcomesfrom increased awareness, modernization and understanding, to attitudinal change, to increased civic participation, the building of individual's will for acceptance of all mankind, to policy change that correctsinjustice. Social change must start with the individual, as its impact happens at a broader institutional, group, or community level. This change in society may also include to make psychological services available at, eventhe most lower levels such as at villages for instance sothat development occurs from the most basic levels of oursociety to the uppermost level where these services are available today.

Enlargement- that will be in terms of enlargement and establishment and equal distribution of these health carecenters at even the most remote areas of India.

Evolution and extension- by which services of the mental care sector are extended to rural and underprivileged society so that they no longer are deprived from mental

care facilities and can access them at any point of time whenever the need arises.

furtherance and growth- that has a vision of working bothat rural and urban level with an integrated approach

Improvement: - development means improvement of policies that need reconsideration and attention of the Indian government so that there is improvement in the mental health care facilities at all levels and spheres of our society.

Regeneration and reinforcement: - apart from all these factors that may consider those processes in our society that need to be rectified or be worked upon for development to occur at all spheres of the society, it isalso vital that we also work on areas that will help us retain this development by constantly regenerating new and innovative ways, and by also reinforcing them to maintain balance, both at rural and urban level.

Only when we are able to integrate various elements of development mentioned above and are able to distribute mental health care services at all levels of our society, balancing both the urban and rural sector of our nation, we can move forward towards upliftment of weaker sections and rural sectorand the development of our country.These elements when integrated will be helpful in providing the psychologist with a blueprint for working towards development and upliftment of rural and underprivileged sections of our society.

Overview of Thesis

India is a nation having its roots deep within its cultural heritage and acceptance of diverse cultures, along which comesindividual's from various groups .class, communities, religions, cultural backgrounds, ethnicity, beliefs, values and norms. In such a society it is vital that we understand the needs of these various diverse groups that come up with their own societal issues and expectations. In spite of being

so united our nation, with its roots deep within its collectivist culture is extremely diversified in terms of its social issues, which makes it difficult to come up with solutions that may apply for all societies, classes and cultures in India at large. This brings into light a very serious problem that may affect development of the Indian society and cause disruptions for overall development. Development is an advancement,betterment,change,enlargement,evolution,expansion,extension,furtherance,gain,growth,improvement ,progress, promotion ,regeneration and reinforcement, so why should the weaker and underprivileged sections of our society be kept ignored while considering a larger perspective of development. And for this to happen, psychologist have a significant rolein the context to break all barriers and reach within the roots of these societal problems and understand that development in any society cannot take place if all the spheres of the society are not uplifted, especially in a developing nation like ours where majority of the population is either agricultural or under poverty line. For developmentto happen in true terms it is essential that we as psychologist understand the needs of ' today' and extent our arms to those remote areas that have still never been touched upon and provide our services in the best interest of our society in order to understand the societal problems of todayand construct an integrated approach that has a vision of making psychology accessible in every sphere of the Indian society so that we are able to create an independent and a developed society. Moreover, the size of India’s population has made progress in solving other problems very slow. And this can be said because problems of our earlier generations are not problems of our generations and our problems will alsonot be problems of the coming generations .So it would not be really justified to say that our nation has been stagnant in terms of development, research indicates that our society has significantly moved forward towards development and by that itmeans , various domains have been considered in order to make

our society more developed from economic development, entrepreneurship development and rural development to Nationalfilm development and many others, but despite the development on spheres of employment, economy, health, cinema, science, and educational front , mental health, even after 67 years of independence has not been given prime importance. The questionthat now arises here is that, will it be appropriate to consider development as, only external phenomenon and not psychological?

The study emphasis on the overall understanding of the processof development which occurs both internally and externally in individual units in human beings primarily, which further drives the society members to become more advanced and developed externally. Moreover the finding of the study suggests the role of any mental health care professional or psychologists as significant in the process of development. This can be said because if nongovernmental organizations are executing strategies for societal upliftment and development, their strategies are incomplete without the consideration of the psychological well being of the community members and their beneficiaries. The idea is to understand that the concept of development is not restricted to economic, social or just in terms of maximizing, utilization and availability of resources, but, also to the acceptance of the fact that ,development also indicates the significance in the , i) efficiency of mental skill and ability , ii) to constantly strive for a meaningful life , iii)and to maintain a positive sense of self, so that the beneficiaries of nongovernmental organizations become independent products of appropriate self esteem, mental abilities, established sense of self and a healthy self image, and , most importantly are able to withstand societal pressures and be able to resolve their own conflicts. And this can only be possible if all individuals inour society are given equal opportunity to access psychological help at any point of time, and want to approach psychological services through various nongovernmental

organizations. All individuals have the right to strive towards betterment and growth but, due to the imbalance of mental health services, and the prevailing unemployment of psychologists in nongovernmental organizations, there is greatdisparity among the under privileged and privileged sections, in context of accessibility of mental health care services in our country.

Diverse research indicates that there is a significant gap inservice availability of mental health care services in nongovernmental organizations in comparison to the availability of other professionals, varying from social workers, teachers to doctors. It must be understood that any nongovernmental organization aims at societal development, but, development is not a single concept; rather it consists of various other perspectives that need consideration and attention, which in totality comprise of development. It is now high time that we begin to look at development from a psychological perspective, where we will constantly be striving towards positive living style and the mental well being of our complete society, which is inclusive of mental health care services and policies that are made for the betterment of both rural and urban sectors of our country. Moreover, the fact that, development cannot take place unless all spheres of our society are given equal opportunity to access mental health care services so that all communities andgroups in our country have equal access and availability of psychological resources, that will help them develop mental strength for constantly sustaining a positive state of mind, mental wellbeing and a healthy living style. With this vision we are enabling mental health care services at all levels of our society and working towards integrating various mental health professionals to work towards mental well being of individuals from all communities, classes and groups uniformly. Considering this, the study attempts to highlight the significance of a psychologist or any mental health care professional to a nongovernmental organization in the process

of social development and encountering societal issues. It attempts to draw attention of nongovernmental organizations tounderstand the significance of employing psychologists in their organizations along with, other professionals, like, social workers, and doctors in order to address societal issues. Moreover, this study has attempted to answer the question of ‘how’ and in what ways, a mental health care professional can contribute by being a part of nongovernmentaland other organizations which are working for social development. Furthermore, study aims at bringing into light the significance, and, much needed awareness for having makingpsychologists and other mental health care professionals employed in nongovernmental organizations in context to address social issues. The work done by many non-governmental organizations over these years is commendable, but in spite ofvarious policies made by our government and health care services being provided at the village level we are unable to distribute our limited psychological resources equally at all levels. The study stresses the importance of integration of all the resources together which will help in sustain appropriate balance in the execution of the policies and management plans, framed by nongovernmental organizations for social development. If we are considering the concept of development, it is essential that we understand that, development cannot take place unless all spheres of the society are not kept in mind. The concepts of development is not restricted to economic, social or just in terms of maximizing, utilization and availability of resources but alsothe development of mental skill and ability to constantly strive for a meaningful life and maintain a positive sense of self so that individuals are able to withstand societal pressures and be able to resolve their own conflicts. And thiscan only be possible if all individuals in our society, particularly the underprivileged section is given equal opportunity to access psychological help and avail psychological services by the medium of nongovernmental organizations.

Considering that mental health is a fundamental requirement for social development to occur, the study attempts to explorethe significance of a psychologist and mental health care professionals to nongovernment organizations. The study initially, attempts to explain a holistic view of development,which explains development as a process which functions at both internal; psychological level in its most basic form and manifests into external; social development in a society. It attempts to draw attention of nongovernmental organizations towards the execution of incomplete strategies, adopted by them, in order to encounter the issue of social development, which is a result of various factors such as, less or nil availability of resources in mental health care sector which, results in incomplete execution of strategies, adopted by nongovernmental organizations, for the development of the underprivileged society. The latter section of the study addresses various myths and realizations, in the context with the working of a nongovernmental organization and its beneficiaries based on the research findings of the study. Finally, the study suggests a manual for mental health care professionals, psychologists and nongovernmental organizations, explaining the work arena of a mental health care professional or a psychologist in nongovernmental organizations, to highlight the role of a psychologist in order to address societal issues, in coordination with other professionals, like social workers, who are a part of the sameorganization and working for the same goal of, social development. Discussing and analyzing the research findings ofthe study, it attempts to suggest an integrated approach for development at a larger scale for the process of societal development.

The size of India’s population has made progress in solving other problems very slow. And this can be said because problems of our earlier generations are not problems of present generations and, our problems will also not be problems of the coming generations, because societal

development takes place as the times change and the members ofthe society keep transforming into even more complex and advanced agents of the society with different underlying needsof the time. It would not be really justified to say that our nation has been stagnant in terms of development, of course ithas moved forward towards development and by that it means, various domains have been considered in order to make our society more developed from economic development, entrepreneurship development and rural development to Nationalfilm development and many others. But despite this, mental health has been neglected to some extent in consideration of social development as studies indicate. The need of the hour is to come to terms with the fact that, development, in a society, cannot take place, unless all the sections of the society are not given equal opportunity to avail and access varied services available in a society, especially mental health care services, as physical health and mental health both are components of well being of an organism. Considering the notion, that well being constitutes of both physical and psychological wellness of any living being and, the fact that for development to occur, there must be equal and uniform distribution of mental health care and all available resources, it must be stressed here that, all spheres of our society must be given equal opportunity to access mental health care services so that, all communities and groups in our country have equal access and availability of psychological resources, that will help them develop mental strength for constantly sustaining a positive state of mind, mental wellbeing and a healthy living style. With this vision we are enabling mental health care services at all levels of our society and working towards integrating various mental health professionals to work towards mental well being of individuals from all communities, classes and groups uniformly.

This study aims at bringing into light the much needed awareness for making mental health care services available

even at the grass root level, especially to the underprivileged sections of our society that can be helped through a medium of nongovernmental organizations. The work done by many non-governmental organizations over these years is commendable, but in spite of various policies made by our government and health care services being provided at the village level we are unable to distribute our limited psychological resources equally at all levels which is disturbing the balance of mental health and coping abilities of a majority of underprivileged section of the Indian society. If we are considering the concept of development, it is essential that we understand that, development cannot take place unless all spheres of the society are not kept in mind. The concepts of development is not restricted to economic, social or just in terms of maximizing, utilization and availability of resources but also the development of mental skill and ability to constantly strive for a meaningful life and maintain a positive sense of self so that individuals are able to withstand societal pressures and be able to resolve their own conflicts. And this can only be possible if all individuals in our society are given equal opportunity to access psychological help at any point of time they require its need and feel the need to avail psychological services. All individuals have the right to strive towards betterment and growth so why is it that there is imbalance of mental careservices in our society...?. In comparison to the urban sectoror the privileged society of India in terms, of availability and access of mental care, the underprivileged section of the society, who are beneficiaries of various nongovernmental organizations, are lagging far behind. This is indicative of avery serious problem, and that is, that all spheres of development are not been worked upon efficiently. There aspectof mental health care for the underprivileged majority of our society is not been considered in a larger picture of development. Therefore it will be appropriate to say that the underprivileged and rural sections of the Indian society todayare still deprived from mental health care and other

psychological services that could contribute in making lives of those individual a lot more meaningful and healthier. To counter the concern, for highlighting the mental care needs ofthe underprivileged society and draw the attention of nongovernmental organizations to this issue, this study is significant in terms of i) highlighting the need to understandthe significance of mental health in the process of social development. ii) It attempts to draw attention of all those nongovernmental organizations, functioning without or with least accessibility of mental health care resources, to the significance of mental health care professionals and psychologists in the process of social development and in the functioning of their organization. iii) The study aims to benefit the underprivileged society who have least or no access to mental health care services and addresses the concern of providing mental health care services and increasing the availability of mental care resources for the underprivileged sections of the society, who are beneficiariesof nongovernmental organizations, to strive towards a healthy life and mental well being of the underprivileged society. iv)The study is a helpful intermediate between nongovernmental organizations, and mental health care professionals and psychologists, demonstrating an agenda for working of a mentalhealth care professional, which will contribute in facilitating the overall functioning of the organization for the process of social development and will ultimately benefit its beneficiaries psychologically, who are belonging to the underprivileged sections of our society.

Chapter 2

Literature Review

Understanding Social development, Nongovernmental organizations and Mental Health

Social Development Theory-by Garry Jacobs and Harlan Cleveland(November, 1999)

We define social development in its broadest social terms as an upward directional movement of society from lesser to greater levels of energy, efficiency, quality, productivity, complexity, comprehension, creativity, choice, mastery, enjoyment and accomplishment. Development of individuals and societies results in increasing freedom of choice and increasing capacity to fulfill its choices by its own capacityand initiative. Social development is driven by the subconscious aspirations/will of society for advancement. The social will seeks progressive fulfillment of a prioritized hierarchy of needs – security of borders, law and order, self-sufficiency in food and shelter, organization for peace and prosperity, expression of excess energy in entertainment, leisure and enjoyment, knowledge, and artistic creativity.Social development can be summarily described as the process of organizing human energies and activities at higher levels to achieve greater results. Development increases the utilization of human potential.In the absence ofvalid theory, social development remains largely a process of trial and error experimentation, with a high failure rate and very uneven progress. The dismal consequences of transition strategies in most Eastern Europe countries, the very halting progress of many African and Asian countries, the increasing income gap between the most and least developed societies, andthe distressing linkage between rising incomes, environmental depletion, crime and violence reflect the fact that humanity

is vigorously pursuing a process without the full knowledge needed to guide and govern it effectively.

Hierarchy of learning

Social development consists of two interrelated aspects – learning and application. Society discovers better ways to fulfill its aspirations and it develops organizational mechanisms to express that knowledge to achieve its social andeconomic goals. The process of discovery expands human consciousness. The process of application enhances social organization.

Society develops in response to the contact and interaction between human beings and their material, social and intellectual environment. The incursion of external threats, the pressure of physical and social conditions, the mysteries of physical nature and complexities of human behavior prompt humanity to experiment, create and innovate.

The experience resulting from these contacts leads to learningon three different levels of our existence. At the physical level, it enhances our control over material processes. At thesocial level, it enhances our capacity for effective interaction between people at greater and greater speeds and distances. At the mental level, it enhances our knowledge.

While the learning process takes place simultaneously on all these planes, there is a natural progression from physical experience to mental understanding. Historically, society has developed by a trial and error process of physical experimentation, not unlike the way children learn through a constant process of physical exploration, testing and even tasting. Physically, this process leads to the acquisition of new physical skills that enable individuals to utilize their energies more efficiently and effectively. Socially, it leads to the learning and mastery of organizational skills, vital attitudes, systems and institutions that enable people to manage their interactions with other people and other

societies more effectively. Mentally, it leads to organizationof facts as information and interpretation of information as thought.

The outcome of this learning process is the organization of physical skills, social systems, and information, which are then utilized to improve the efficiency and effectiveness of human activities. It is a cyclical process in which people arecontinuously learning from past experiences and then applying that learning in new activities.

This learning process culminates in a higher level of mental effort to extract the essence and common principles or ideas from society’s organized physical experiences, social interactions and accumulated information and to synthesize them as conceptual knowledge. This abstract conceptual knowledge has the greatest capacity for generalization and application in other fields, times and places. The conceptual mind is the highest, most conscious human faculty. Conceptual knowledge is the organization of ideas by the power of mind. That conceptual knowledge becomes most powerful when it is organized into a system. Theory is a systematic organization of knowledge.

A comprehensive theory of social development would provide a conceptual framework for discovering the underlying principlescommon to the development process in different fields of activity, countries and periods. It would also provide a framework for understanding the relationships between the accumulated knowledge generated by many different disciplines.If pursued to its logical conclusions, it would lead to not just a theory of social development, but a unifying theory of knowledge—which does not yet exist in any field of science or art. In most discussions, development was conceived in terms of a set of desirable results—higher incomes, longer life expectancy, lower infant mortality, more education. Recently emphasis has shifted from the results to the enabling conditions, strategies and public policies for achieving those

results—peace, democracy, social freedoms, equal access, laws,institutions, markets, infrastructure, education and technology. But still little attention has been placed on the underlying social process of development that determines how society formulates, adopts, initiates, and organizes, and few attempts have been made to formulate such a framework.

Second, a very large number of factors and conditions influence the process. In addition to all the variables that influence material and biological processes, social processes involve the interaction of political, social, economic cultural, technological and environmental factors as well. Development theorists have not only to cope with atoms, molecules, material energy and various life forms. They must also cope with the near infinite variety and complexity of human beliefs, opinions, attitudes, values, behaviors, customs, prejudices, laws, social institutions, etc.

Third, the timeframe for social development theory cannot be confined to the modern day or even the past few centuries. Human development has been occurring for millennia. The basic principles of development theory must be as applicable to the development of early tribal societies as they are to the emergence of the post-modern global village. Development theory must be a theory of how human society advances through space and time.

Development as a spherical whole

A theory of social development should generate a framework around which all knowledge of the factors, instruments, conditions, agencies and processes of development can be integrated. Rather than singling out a specific set of determinants or giving primacy to a limited set of instruments, it would reveal the nature of the relationships and processes that govern the interaction of all these elements to generate developmental results. Rather than generate a linear formula or ‘right’ perspective, it would make it possible to view the whole field and phenomenon of

development from multiple perspectives that are integrated andunified ways of knowing the whole, rather than divided and separate ways of viewing the parts.

The modern tendency to divide scientific inquiry into an increasing number of specialized fields of study has made the emergence of an integrated perspective very difficult. Philosopher Stephen Toulmin mourns the absence of broader conceptual thinking in physics over the past few centuries andargues the need for grand cosmological visions of the universeto unify and integrate the discoveries of many different disciplines.

Comparatively, the need for synthesis is even greater for the study of human social development than for understanding the physical and chemical evolution of the universe. For in human development, we must not only grapple with four material dimensions in space and time that preoccupy the physicist and chemist, but also integrate the dimensions of life and mind—including physical, genetic and biological determinants; social behaviors, skills, attitudes, customs, traditions, systems, formal organizations, non-formal institutions, and cultural values; and linguistic determinants, data, facts, information, beliefs, opinions, systems of thought, ideas, theories, and spiritual values—all of which interact and influence each other to impact the course of human development.

The quest for theory in social development cannot lead to any linear or logarithmic equation that adequately explains and predicts human progress. The reality we seek to understand is not of that type. It is not linear or uni-dimensional or even a combination of several dimensions. It is a complex, many-dimensional whole that evolves in many interrelated directionssimultaneously. The development of society is best representedto our minds as an expansion from a point to a sphere, rather than as movement along a single line or along multiple lines of progress. Social development is the gradual discovery and

unfolding of the potential of a complex, integrated whole, a living organization, a living social organism.

From unconscious experience to conscious knowledge

Finally, social development theory remains elusive because thevery nature of social learning is a subconscious seeking by the collective that leads ultimately to conscious knowledge. We experience first and understand later. Our mental comprehension perpetually lags behind physical experience and struggles to catch up with it.

Our view is that the very intensive, concentrated global experience of the past five decades provides fertile soil for the formulation of a more synthetic conceptual framework for social development. Such a framework can vastly accelerate thetransfer and replication of developmental achievements around the world and make possible more conscious and rapid progress even for the most advanced societies in the world.

Development as self-conception

The hypothesis on which our attempt at theory is based is thatsocial development is determined by human beings, not externalconditions. External conditions certainly can and do influencethe process. People may even act and react in predictable waysto a given set of external conditions. But the results of any development equation cannot be reliably predicted on the basisof external factors. Human development is determined by human responses based on choices made by people. To our knowledge, external forces alone have never unleashed a process of socialdevelopment, but there are countless instances in which external agents have failed to do so.

Human development is a function of human awareness, aspirations, attitudes and values. Like all human creative processes, it is a process of self-conception. As the writer, artist, composer, political visionary and businessman conceiveof unrealized possibilities and pour forth their creative energies to give expression to them, the social collective

evolves a conception of what it wants to become and by expressing its creative energies through myriad forms of activity seeks to transform its conception into social reality. The only major difference is that while the individual sometimes (but not always) is conscious of the conception he or she is trying to express, the society is usually (not always) unconscious of the idea and the urge thatmove it to create something more out of its own latent potential.

Society is a subconscious living organism which strives to survive, grow and develop. Individual members of society express conscious intention in their words and acts, but theseare only surface expressions of deeper subconscious drives that move the society-at-large. The consciousness of a true collective organism is not merely the sum of its individual parts, but acquires its own identifiable character and personality. This is why the USA has been able to assimilate such large numbers of immigrants, yet retain its distinctive (but constantly changing) national character. Immigrants are moved by the values of the collective to share in the nationalaspiration for greater individual freedom, practical organization and material progress. In a similar vein, the feverish collective behavior of the stock market, fashions andpop culture are subconscious social collectives that acquire their own distinct personalities.

Role of the Individual

Society has no direct means to give conscious expression to its subconscious collective aspirations and urges. That essential role is played by pioneering conscious individuals–visionary intellectuals, political leaders, entrepreneurs, artists and spiritual seekers who are inspired to express and achieve what the collective subconsciously aspires and is prepared for. Where the aspiration and action of the leader donot reflect the will of the collective, it is ignored or rejected. Where it gives expression to a deeply felt

collective urge, it is endorsed, imitated, supported, and systematically propagated. This is most evident at times of war, social revolution or communal conflict.

India’s early freedom fighters consciously advocated the goal of freedom from British rule long before that goal had become a felt aspiration of the masses. The leaders spent decades urging a reluctant population to conceive of itself as a free nation and to aspire to achieve that dream. When finally the collective endorsed this conception, no foreign nation had thepower to impose its will on the Indian people.

Determinants of Development

We have described social development as the release and channeling of social energies through more complex social organization to enhance productive capacity and achieve greater results. This process depends upon mechanisms to direct and channel the collective energies of the society intonew and more productive forms of activity. We can identify four distinctly different levels or types of mechanism that serve this function—social aspirations, government authority, social-cultural structure, and social know-how in the form of science, technology and productive skills.

Social aspirations

Economically, development occurs when productivity rises, enabling people to produce more, earn more and consume more. To do so, they have to be motivated to learn new skills, adaptto new work processes, and adopt new technology, changes whichin past ages have met with considerable resistance.

The driving force behind the whole movement is psychological. At the deepest level the energies of society are directed by the collective’s subconscious aspirations. Society’s self-conception of what it wants to become releases an aspiration of the collective for accomplishment. That aspiration exerts apowerful influence on the activities of the society. India’s twin revolutions were spurred by a growing aspiration of

Indian society for security, prosperity and enjoyment. A similar aspiration spurs middle class Americans today to invest their savings in the stock market.

evolution of social aspirations in India has been traced from pre-Independence to the present day. The earliest expression was an aspiration for political freedom and self-determination. After Independence this aspiration evolved intoan urge for self-sufficiency, a willingness to try new things and take risks. More recently it has matured into a movement of rising expectations permeating all levels of Indian society.

Motives for development

Societies throughout the world are presently preoccupied with achieving the material results of social development. But it is interesting to note that the process itself does not appearto be driven exclusively or perhaps even primarily by materialmotives, although these are uppermost in the social consciousness at the present time. Even in instances where material needs and wants have approached saturation, the process shows no signs of abating in speed or intensity. On the contrary, the momentum that has led to such incredible achievements over the past century continues to accelerate. Inour search for the fundamental motive that drives the process,we have to look beyond the material preoccupations by which itis currently characterized.

While it is difficult to document at the social level, at the individual level it is readily apparent that physical securityand comfort are important but by no means the only or even the

most powerful motives for human action. Once these needs are met, there is still the seeking for social prestige and influence, the impulse of curiosity, the thirst for understanding, the drive for accomplishment, the urge for invention and creativity, the attraction of complexity and rich variety of experience—and the irrepressible and inexhaustible quest for enjoyment that all of these activitiesengender.

The process of development, even the limited sphere of social development, is not driven exclusively by material motives or confined to material achievements. The goals societies and individuals seek are determined by their needs and their values. In the hierarchy of needs, physical survival, security, and comfort are primary. Vital, social and mental needs gain prominence when the basic physical needs are met. As society prospers, the vital urge for intensity, excitement,enjoyment, adventure, changing experience and self-expression become more important determinants. Beyond these lie the mental urge for curiosity, knowledge, creativity and imagination, and the aspiration for spiritual realization.

This concept of development holds very important implications for the future of humanity and the prospects for progress in the next century. Its suggests that there are no inherent limits either to the speed or to the extent of the developmentprocess, other than those imposed by the limitations of our thought, knowledge and aspirations. If we change our view, thecharacter of this process can be transformed from the slow, trial and error subconscious process we have known in the pastto a swift, sure leaping progress from height to greater height.

Motives for development

Societies throughout the world are presently preoccupied with achieving the material results of social development. But it is interesting to note that the process itself does not appearto be driven exclusively or perhaps even primarily by material

motives, although these are uppermost in the social consciousness at the present time. Even in instances where material needs and wants have approached saturation, the process shows no signs of abating in speed or intensity. On the contrary, the momentum that has led to such incredible achievements over the past century continues to accelerate. Inour search for the fundamental motive that drives the process,we have to look beyond the material preoccupations by which itis currently characterized.

While it is difficult to document at the social level, at the individual level it is readily apparent that physical securityand comfort are important but by no means the only or even themost powerful motives for human action. Once these needs are met, there is still the seeking for social prestige and influence, the impulse of curiosity, the thirst for understanding, the drive for accomplishment, the urge for invention and creativity, the attraction of complexity and rich variety of experience—and the irrepressible and inexhaustible quest for enjoyment that all of these activitiesengender.

The process of development, even the limited sphere of social development, is not driven exclusively by material motives or confined to material achievements. The goals societies and individuals seek are determined by their needs and their values. In the hierarchy of needs, physical survival, security, and comfort are primary. Vital, social and mental needs gain prominence when the basic physical needs are met. As society prospers, the vital urge for intensity, excitement,enjoyment, adventure, changing experience and self-expression become more important determinants. Beyond these lie the mental urge for curiosity, knowledge, creativity and imagination, and the aspiration for spiritual realization.

This concept of development holds very important implications for the future of humanity and the prospects for progress in the next century. Its suggests that there are no inherent

limits either to the speed or to the extent of the developmentprocess, other than those imposed by the limitations of our thought, knowledge and aspirations. If we change our view, thecharacter of this process can be transformed from the slow, trial and error subconscious process we have known in the pastto a swift, sure leaping progress from height to greater height.

Development of the collective is subconscious. It starts with physical experience which eventually leads to conscious comprehension of the process. Conscious development based on conceptual knowledge of the social process accelerates development and minimizes errors and imbalances.

Society is the field of organized relationships and interactions between individuals. Only a small portion ofhuman activity is organized for utilization by society, so only a small portion of development potential (of technology, knowledge, information, skills, systems) is tapped.

Every society possesses a huge reservoir of potential human energy that is absorbed and held static in its organized foundations—its cultural values, physical security, social beliefs and political structures. At times of transition, crises and opportunities, those energies are released and expressed in action. Policies, strategies and programs that tap this latent energy and channel it into constructive activities can stir an entire nation to action and rapid advancement.

The act is the basic unit of social organization. The evolution of more complex and productive activities woventogether by people to form systems, organizations, institutions and cultural values constitute the fabric orweb of social organization.

The essential nature of the development process is the progressive development of social organizations and

institutions that harness and direct the society’s energies for higher levels of accomplishment. Society develops by organizing all the knowledge, human energies and material resources at its disposal to fulfill its aspirations.

The process of formation of organization takes place simultaneously at several levels: the organization of peace and physical security in society, the organization of physical activities and infrastructure, the organization of productive processes through the application of skills and technology in agriculture, industry and services, the organization of social processes we call systems, laws, institutions and administrative agencies, the organization of data as useful information, the organization of knowledge througheducation and science, and the organization of higher social and cultural values that channel human energy intohigher forms of expression.

Each of these levels of organization admits of unlimited development. Each of these levels of organization dependsupon and interacts with the others. Elevating the organization at any of these levels increases the utilization of resources and opportunities and accelerates development.

Development requires an enormous investment of energy to break existing patterns of social behavior and form new ones. Development takes place when surplus social energies accumulate beyond the level required for functioning at the present level. The social energy may be released in response to the opening up of a new opportunity or confrontation by a severe challenge. Wheredifferent cultures meet and blend, explosive energies forsocial evolution are released.

Expression of surplus energy through existing forms of activity may result in growth—a quantitative expansion ofsociety at the existing level of organization. Channelingthe surplus energy into more complex and effective forms

of organized activity leads to development—a qualitative enhancement in the capabilities of the society. The freshinitiatives that lead to this qualitative enhancement usually occur first in the unorganized activities of society that are not constrained and encumbered by the inertia of the status quo.. The rate and extent of development is determined by prevalent social attitudes which control the flow of social energies. Where attitudes are not conducive, development strategies will not yield results. In this case the emphasis should be placed on strategies to bringabout a change in social attitudes—such as public education, demonstration and encouragement of successful pioneers.

The social gradient between people at different levels ofpower and accomplishment in society represents a ‘voltagedifferential’ that stimulates less accomplished sections of the population to seek what the more accomplished haveachieved. The urge to maintain this voltage gap compels those at the top to seek further accomplishments. At the same time, the overall development of society is determined by its ability to make accessible the privileges and benefits achieved by those at the top to the rest of its members.

Development proceeds rapidly in those areas where the society becomes aware of opportunities and challenges andhas the will to respond to them. Increasing awareness accelerates the process.

Social progress is stimulated by pioneering individuals who first become conscious of new opportunities and initiate new behaviors and activities to take advantage of them. Pioneers are the lever or spearhead for collective advancement. Pioneers give conscious expression to the subconscious urges and readiness of thecollective.

Development occurs when pioneering individual initiativesare imitated by others, multiplied and actively supported

by the society. Society then actively organizes the new activity by establishing supportive laws, systems and institutions. At the next stage it integrates the new activity with other fields of activity and assimilates itinto its educational system. The activity has become fully assimilated as part of the culture when it is passed on to the next generation as values through the family.

Development is a process, not a program. Development is an activity of the society as a whole. It can be stimulated, directed or assisted by government policies, laws and special programs, but it cannot be compelled or carried out by administrative or external agencies on behalf of the population. Development strategy should aimto release people’s initiative, not to substitute for it.

All resources are the creation of the human mind. Something becomes a resource when human beings recognize a productive or more productive use for it. Since there are no inherent limits to human inventiveness and resourcefulness, the potential productivity of any resource is unlimited.

. Human beings are the ultimate resource and ultimate determinant of the development process. It is a process of people becoming more aware of their own creative potentials and taking initiative to realize those potentials. Human awareness, aspiration and attitudes determine society’s response to circumstances. Development occurs only at the points where humanity recognizes its power to determine results.

The development of social organization takes place withina larger evolutionary context in which the consciousness of humanity is evolving along a continuum from physical to vital to mental. This evolution expresses as a progressive shift in emphasis from material resources to technological and information resources; from the social importance of land to the importance of money and knowledge; from hereditary rights of the elite to

fundamental rights for all human beings; from reliance onphysical forms of authority to laws and shared values. Associety advances along this continuum, development becomes more conscious and more rapid.

Infinity is a practical concept. Human potential is unlimited. Development potential is infinite.

The same principles and process govern development in different fields of social life political, economic, technological, scientific, cultural, etc.

The same principles and process govern development at thelevel of the individual, the organization and the society.

To conclude the study it will be appropriate to say that,development of society occurs only in fields where that collective will is sufficiently strong and seeking expression. Development strategies will be most effectivewhen they focus on identifying areas where the social will is mature and provide better means for the awakened social energy to express itself. Only those initiatives that are in concordance with this subconscious urge will gain momentum and multiply.

Exploring social development

Social development is about putting people at the centre of development. This means a commitment that development processes need to benefit people, particularly but not only the poor, but also a recognition that people, and the way theyinteract in groups and society, and the norms that facilitatessuch interaction, shape development processes. While the role of formal institutions and policies has become central to the development debate, the role of informal social institutions has received less attention. Debates on growth and poverty reduction have paid relatively little attention to the impact of, for example, norms of cooperation in villages and neighborhoods, community oversight in the management of projects, or non-discrimination against women and minorities

in education and health. Of course, micro-studies invariably highlight their importance, but can we measure such informal social institutions? What exactly are these social institutions? We understand these as the behaviors, norms and conventions that pattern human interaction. Participation in local organizations, demonstrations, petitions, and elections are examples of such behaviors. Norms and conventions, often unwritten, govern human interaction, and are they lived relations between people. Norms of non-discrimination against groups based on ethnicity, language, or gender are examples ofsocial institutions, as are norms of criminal behavior and about civic activism. Social development thus implies the change in social institutions. Progress toward an inclusive society, for example, implies that individuals treat each other (more) fairly in their daily lives, whether in the family, workplace, or in public office. Social cohesion is enhanced when peaceful and safe environment within neighborhoods’ and communities are created. Social accountability exists to the extent that citizens’ voices are expressed, and heard by the authorities. Formal institutional reform – for example, the provision of legally enshrined rights, better law enforcement, or more participatory governance – are part of the process by which institutional change is achieved, changing the way people relate to people is an equally important part of this. The Indices of Social Development focus on measuring the informal social institutions, how they compare across countries, and how thesechanges over time. It does this by using existing databases, around the world, and combining these to find the best possible match with our definition of social development. Through an on-going process of expert discussion, and review of existing databases, we have organized the Indices of SocialDevelopment into five groupings:

Civic activism refers to the social norms, organizations, and practices which facilitate greater citizen involvement in public policies and decisions. These include use of media,

access to civic associations, and involvement in activities such as nonviolent demonstration or petition.

Clubs and associations uses data on levels of engagement in local community groups, time spent socializing in voluntary associations, and membership of developmental organizations, to identify the extent to which people are part of social networks and potentially supported by community ties.

Inter-group cohesion refers to relations of cooperation and respect between groups in a society; where this cooperation breaks down, there is the potential for conflict and acts of terror and riots.

Interpersonal safety and trust measures the level of trust andconfidence between individuals that do not know each other personally, specifically with regard to the likelihood of criminal violence and other forms of trust violation, and combines this with measures of rates of violence.

Gender equality estimates the extent of discrimination againstwomen, whether in the labour market, education, healthcare, orin the home.

Mental health and social development

Relationship between Mental health and societal development

Persons with mental and psychosocial disabilities represent a significant proportion of the world’s population. Millions of people worldwide have mental health conditions and an estimated one in four people globally will experience a mentalhealth condition in their lifetime. Almost one million people die due to suicide every year, and it is the third leading cause of death among young people. Depression is the leading cause of years lost due to disability worldwide. Mental healthproblems, including alcohol abuse, are among the ten leading causes of disability in both developed and developing countries. In particular, depression is ranked third in the global burden of disease, and is projected to rank first in

2030. Persons with mental and psychosocial disabilities often face stigma and discrimination, as well as experience high levels of physical and sexual abuse, which can occur in a range of settings, including prisons, hospitals and homes. Theeconomic cost of mental health problems is vast, while reasonable investment in mental health can contribute to better mental health for people. Poor mental health is both a cause and a consequence of poverty, compromised education, gender inequality, ill-health, violence and other global challenges. It impedes the individual's capacity to work productively, realize their potential and make a contribution to their community. Including mental health as an integral part of development is relatively new to the United Nations and its development partners. There is growing recognition within the international community that mental health is one of the most neglected yet essential development issues in achieving the Millennium Development Goals (MDGs). In order tohighlight the urgent need to pay attention to mental health indevelopment, this WHO publication highlights the urgent need to redress the current situation. It presents compelling evidence that people with mental health conditions meet major criteria for vulnerability and yet fall through the cracks of development aid and government attention. It makes the case for reaching out to this vulnerable group through the design and implementation of appropriate policies and programmes and through the inclusion of mental health interventions into broader poverty reduction and development strategies. It also describes a number of key interventions which can provide a starting point for these efforts. This report is a call to action to all development stakeholders — multilateral agencies, bilateral agencies, global partnerships, private foundations, academic and research institutions, governments and civil society — to focus their attention on mental health.By investing in people with mental health conditions, development outcomes can be improved.

Connection between Mental and Physical Health

Mental and physical health is fundamentally linked. There are multiple associations between mental health and chronic physical conditions that significantly impact people’s quality

of life, demands on health care and other publicly funded services, and generate consequences to society. The World Health Organization (WHO) defines: health as a state of complete physical, mental and social well-being and not merelythe absence of disease or infirmity. The WHO states that “there is no health without mental health.”

Nowhere is the relationship between mental and physical healthmore evident than in the area of chronic conditions. The associations between mental and physical health are:

Poor mental health is a risk factor for chronic physical conditions.

People with serious mental health conditions are at high risk of experiencing chronic physical conditions.

People with chronic physical conditions are at risk of developing poor mental health.

The social determinants of health impact both chronic physicalconditions and mental health. Key aspects of prevention include increasing physical activity, access to nutritious foods, ensuring adequate income and fostering social inclusionand social support. This creates opportunities to enhance protective factors and reduce risk factors related to aspects of mental and physical health. Understanding the links betweenmind and body is the first step in developing strategies to reduce the incidence of co-existing conditions and support those already living with mental illnesses and chronic physical conditions.

Definitions

The Definition of Health

The World Health Organization defines health as "a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity’’. It is the extent to which an individual or group is able, on the one hand, to realize aspirations and satisfy needs and, on the other hand

to change or cope with the environment." (Health Promotion Glossary, p. 1) Achieving Health For All, a discussion document released by Health and Welfare Canada in 1986, reflects a growing awareness that health must be viewed in terms of our personal and social resources for action. It speaks of health as "a resource which gives people the abilityto manage and even to change their surroundings...a basic and dynamic force in our daily lives, influenced by our circumstances, our beliefs, our culture and our social, economic and physical environments." (Achieving Health For All, p. 3)

This active concept of health a accords greater prominence than ever to the mental and social determinants of health. It also requires us to think of health as something experienced not only individually, but also collectively. Most significantly, this new understanding of health dwells less onpeople's traits as individuals and more on the nature of theirinteraction with the wider environment. "Environment" in this context is interpreted in its broadest sense, and includes notonly our physical surroundings, both natural and artificial, but also the social, cultural, regulatory and economic conditions and influences that impinge on our everyday lives.

In the past few decades there have been significant developments in our understanding of mental health. They have arisen from a growing community mental health movement and a body of social science research that places increasing importance on the ability of external forces and events to influence individual mental health. Social and economic situations, family and other relationships, the physical and organizational environment - all are plainly recognized as contributing factors. As a result, current concepts of mental health reflect a number of themes:

• Psychological and social harmony and integration;

• Quality of life and general well-being;

• Self-actualization and growth;

• Effective personal adaptation; and

• The mutual influences of the individual, the group and the environment

The essential role of physiological processes (and, in particular, brain function) in all mental life has become moreand more evident. We now know that human biology and human experience interact continually in shaping mental life.

Mental life embraces both inner experience and interpersonal group experience. Our interactions with others take place within a framework of societal values; therefore, any definition of mental health must necessarily reflect the kind of people we think we should be, the goals we consider desirable, and the type of society we aspire to live in. Social workers do not isolate ideas about mental health from such wider social values as the desire for equality among people, the free pursuit of legitimate individual and collective goals, and equitable distribution and exercise of power.

The Definition of Mental Health

It is from this perspective that the following dynamic and interactive definition of mental health has been developed: Mental health is the capacity of the individual, the group andthe environment to interact with one another in ways that promote subjective well-being, the optimal development and useof mental abilities (cognitive, affective and relational), theachievement of individual and collective goals consistent withjustice and the attainment and preservation of conditions of fundamental equality.

In this definition, mental health moves into the realm of the relationship between the individual, the group and the environment. Mental health is no longer conceived of as an individual trait, such as physical fitness; rather it is

regarded as a resource consisting of the energy, strengths andabilities of the individual interacting effectively with thoseof the group and with opportunities and influences in the environment. This conceptualization leads to certain conclusions about the factors that can enhance or weaken mental health. Whatever makes it difficult for the individual,the group and the environment to interact effectively and justly (for example, poverty, prejudice, discrimination, disadvantage, marginality or poor coordination of or access toresources) is a threat or barrier to mental health key featureof this new definition is that it does not define mental health in terms of the presence or absence of mental disorder,nor does it imply that mental health and mental disorder are simply opposite poles on a single continuum.

Promoting mental health as an essential aspect of health promotion

It is of great concern that mental health promotion is frequently overlooked as an integral part of health promotion (Desjarlais et al., 1995;WHO, 2001; Lavikainen et al., 2000).This is surprising because, in theory, mental health is accepted as an essential component of health (WHO, 2001), the close relationship between physical and mental health is recognized (WFMH, 2004) and it is generally known that physical and mental health share many of the same social, environmental and economic determinants (WHO, 2004). We know that facilities for those with mental health problems are morepoorly resourced than those for physical illness in many partsof the world (Desjarlais et al., 1995; WHO, 2001) and it is important that mental health promotion does not get similarly affected.

The relationship between health promotion and mental health promotion

Health is defined by the World Health Organization (WHO) as ‘astate of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ [(WHO, 2001a),

p. 1] and health promotion is understood as ‘actions that support people to adopt and maintain healthy lifestyles and which create supportive living conditions or environments for health’ [(WHO, 2004), p. 5].In these definitions it is clearlyrecognized that mental health promotion is an integral component of health promotion. Not only are there complex interconnections between physical and mental health, they share many of the same determinants (Raphael et al., 2005). Therefore, while mental health promotion will focus more specifically on the determinants of mental health and the creation of conditions that enable optimum psychological and psycho-physiological development, these efforts will impact positively on physical health (Herrman et al., 2005).Two of the five strategies set out in the Ottawa Charter for Health Promotion ‘strengthen community action’ and ‘develop personal skills’ (WHO, 1986)—essentially refer to mental health promotion activities: for example, programmes aimed at reducing social inequality and building social capital (WHO 2004). It is also recognized that strategies that maximize theactive ownership and participation of people in health promotion initiatives contribute positively to the sustainability of the programmes (WHO, 1997). In this sense health promotion is facilitated by mental health promotion. Conversely, when the focus of the intervention is more directly on the promotion of mental health, physical health issues must not be ignored.Mental health can be understood as:a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her own community [(WHO, 2001b),p. 1].Other definitions of mental health refer to the individual's subjective feelings of well-being, optimism and mastery, the concepts of ‘resilience’, or the ability to deal with adversity, and the capacity to be able to form and maintain meaningful relationships (Lavikainen et al., 2000). Although the expression of these qualities will differ

contextually and individually from culture to culture, the basic qualities remain the same.

The relationship between physical and mental health

The artificial division of ‘physical health’ from ‘mental health’ common in the western developed world is not shared bymany traditional cultures in which physical conditions have long been considered as being closely related to the emotional, social or spiritual health of the person (Swartz, 1998).The reciprocal relationship between physical and mental health now is widely recognized (Raphael et al., 2005). It is known that mental well-being, social support and social networks are protective factors for physical health. Positive mental health significantly assists people to deal with physical conditions. Conversely, the promotion of physical health impacts positively on mental health, for example, in older people (Li et al., 2002; WFMH, 2004). It is recognized that diabetes, cancer, cardiovascular disease and HIV/AIDS affect and are affected by the mental state of individuals, and particularly by depression (Raphael et al., 2005). Heart disease is found to double in people with depression and approximately one-half of people with heart disease suffer an episode of major depression (WFMH, 2004).Clearly, to be effective, promotion and prevention programmes addressing health conditions should take mental health factors into account, and mental health and health programmes are best implemented together.

The burden of mental ill health

Apart from aiming to increase positive mental health, mental health promotion has an important role to play in relation to mental disorders, in that positive mental health is a strong protective factor against mental disorders (WHO, 2004a). Mental health promotion includes ‘strategies to promote the mental well-being of those who are not at risk, those who are at increased risk and those who are suffering or recovering from mental health problems’ (WHO 2004a).The size and cost of

the burden of mental and behavioural disorders is perhaps not fully appreciated. Mental and behavioural disorders (expressedin disability adjusted life years, or DALY'S) represented 11% of the total disease burden in 1990, and this is expected to rise to 15% by 2020 (WHO, 2001c). Five of the 10 leading causes of disability worldwide in 1990 were mental or behavioural disorders. Depression was the fourth largest contributor to the disease burden in 1990 and is expected to rank second after ischaemic heart disease by 2020. It is estimated that one in four people will develop one or more mental or behavioural disorders in their life-time and that one in four families has one member suffering from a mental orbehavioural disorder (Murray et al., 1996; WHO, 2001c).The social and economic costs of only attempting to deal with these issues through individual and treatment paradigms is notonly prohibitive, but impossible in many parts of the world where there are few mental health professionals (Desjarlais etal., 1995). A public health approach to mental health promotion is imperative, in which, in addition to treatment, efforts are made to support the factors that have been shown to promote mental health and address the factors that constitute risk factors for mental disorders (VicHealth, 1999;Herrman et al., 2005). Unless this is done, the burden of mental illness will continue to grow (Desjarlais et al., 1995).

The way forward

As many determinants of health, and particularly mental health, largely lie outside the health sector, addressing promotion requires an understanding and commitment from stakeholders from many constituencies. In a public health approach, the health sector requires the knowledge, attitudes and skills to advocate, persuade and collaborate with these other sectors to engage in activities that enhance mental health.The activities of mental health promotion are mainly socio-political: reducing unemployment, improving schooling and housing, working to reduce stigma and discrimination of

various types… The key agents are politicians, educators, and members of nongovernment organizations (WHO, 2004), p. 26].Themain motivation for these other sectors to engage in promotionprogrammes may not be their impact on health or mental health per se, but outcomes of the programmes more closely connected to their own disciplines and interests. If they are carrying the cost, this is understandable and acceptable. They need to be convinced that these programs would address their own needs. In order to persuade other sectors to adopt policies and programs conducive to mental health promotion, the health sector needs to be able to communicate with them in their own language and to see the policies and programs from their perspective. This applies whether engaging in policy development at the national level, encouraging non-governmental organizations to initiate programs or engaging with service user groups. In addition, the mental health outcomes of programs not primarily aimed at mental health promotion need to be evaluated. Working with other sectors is particularly important in developing countries where a wide range of initiatives, including community and social development programs, are needed to address the multiple factors associated with poverty that impact negatively on health and mental health. The process followed in addressing these multiple factors is guided by the principles of advocacy, participation and empowerment, which are intrinsic to the promotion of mental health (Patel, 2001; WHO, 2004). The positive mental health outcomes of these programs suggeststhat maximum use of these partnerships will further the cause of mental health promotion. Finally, it is advocated that mental health assume its rightful place in health promotion. The significant number of evidence-based mental health programs concerned with well-being from early childhood to oldage, aimed at individuals, groups or at community structural issues demonstrate that well designed interventions contributesignificantly to the well-being of populations. Efforts need to be made to strengthen this evidence, particularly in developing countries. A further challenge is for mental health

professionals to become more skilled in the process of advocacy in order that such evidence is used to maximum effectin ensuring that mental health promotion is recognized as an integral and central component of health promotion.

The Impact of Mental Illness on Society

"...the burden of psychiatric conditions has been heavily underestimated..."

The burden of mental illness on health and productivity in the United States and throughout the world has long been underestimated. Data developed by the massive Global Burden of Disease study conducted by the World Health Organization, the World Bank, and Harvard University, reveal that mental illness, including suicide, accounts for over 15% of the burden of disease in established market economies, such as the United States. This is more than the disease burden caused by all cancers. This Global Burden of Disease study developed a single measure to allow comparison of the burden of disease across many different disease conditions by including both death and disability. This measure was called Disability Adjusted Life Years (DALYs). DALYs measure lost years of healthy life regardless of whether the years were lost to premature death or disability. The disability component of this measure is weighted for severity of the disability. For example, disability caused by major depression was found to be equivalent to blindness or paraplegia whereas active psychosis seen in schizophrenia produces disability equal to quadriplegia.Using the DALYs measure, major depression ranked second only to ischemic heart disease in magnitude of disease burden in established market economies. Schizophrenia, bipolar disorder, obsessive-compulsive disorder, panic disorder, and post-traumatic stress disorder also contributed significantly to the total burden of illness attributable to mental disorders.The projections show that with the aging of the world population and the conquest of infectious diseases, psychiatric and

neurological conditions could increase their share of the total global disease burden by almost half, from 10.5 percentof the total burden to almost 15 percent in 2020.

Facts

Depression is the leading cause of disability worldwide among persons age five and older.

For women throughout the world as well as those in established market economies, depression is the leading cause of DALYs. In established market economies, schizophrenia and bipolar disorder are also among the top ten causes of DALYs for women.

Negligence to mental health care to underprivileged and marginalized communities in India; major challenge for social development

Mental health services in rural India: challenges and prospects- By Anant Kumar 2011

Introduction

Health is “a state of complete physical, social, and mental well being and not merely the absence of disease or infirmity”. Nevertheless, our health system is pre-occupied with curative health care services and disease prevention, with little attention on social and mental well being. Among these, mental health and well being is the most neglected one,particularly in rural areas. Silence on mental health servicesin rural India in the National Rural Health Mission (NRHM) is a serious matter of concern. The omission of mental health in the NRHM mission document becomes even more serious in the backdrop of the uneven performance of the National Mental Health Program (NMHP, 1982 and District Mental Health Program (DMHP) which is operational in only 125 districts out of 626

districts of India. With various flaws and implementation constrains in the NMHP and DMHP, there has been a very little effort so far to improve the rural mental health services.

Issues and concerns

Mental illness constitutes nearly one sixth of all health-related disorders. With the population in- crease, changing values, life-style, frequent disruptions in income, crop failure], natural calamity (drought and flood), economic crisis, unemployment, lack of social support and increasing insecurity, it is fearfully expected that there would be a substantial increase in the number of people suffering from mental illness in rural areas. Among priority non-communicablediseases in India, mental illness constitutes 26 percent sharein the burden of disease and available data suggest that therewould be a sharp increase in this in coming years. Projectionssuggest that the health burden due to mental disorders will increase to 15% of DALY by 2020 .The study by the National Commission on Macroeconomics and Health (NCMH) shows that at least 6.5% of the Indian population has some form of serious mental disorders, with no discernible rural–urban differences.Epidemiological studies done in last two decades shows that the prevalence of mental disorders range from 18 to 207 per 1000 population with the median 65.4 per 1000 at any given time. Most of these patients live in rural areas, far away from any modern mental health facilities. The overall individual bur- den for rural areas cannot be estimated with the available studies. Nevertheless, considering the fact that72.2 per- cent of population lives in rural areas, with only about 25 percent of the health infrastructure, medical man- power and other health resources, it may be surmised that the number of people affected with any mental and behavioral disorder would be higher in rural areas. Despite NRHM initiatives and improvements, general health services in ruralareas are not adequate and are struggling with infrastructural, human resources and other problems. Only 31.9percent of all government hospital beds are available in rural

areas as compared to 68.1 percent for the urban population. Atthe national level the current bed-population ratio for Government hospital beds for urban areas (1.1 beds/1000 population) is almost five times the ratio in rural areas (0.2beds/ 1000 population) [27-29]. There is a shortfall of 8% of doctors in Primary Health Centres (PHC), 65% of specialist at Community Health Centres (CHC), 55.3% of male health workers, and 12.6% of female health workers.

Challenges

The epidemiological situation and available health service system shows that providing mental health services in rural areas is a challenging task, which needs infrastructural, architectural, and programmatic correction in the existing National Mental Health programme and District Mental Health programme. Lack of trained human resource for mental health care and treatment is another challenge, considering few institutions available for mental health professional training. Besides these, major challenge is lack of political commitment and realization that mental health is an important aspect of our health system which has far reaching implicationfor the development of the country.

Needs and treatment Gap

Considering the limited or no service availability; the treatment gap is huge in rural areas. According to one estimate, even if all 3000 psychiatrists available in the country are involved in face to face patient contact and treatment for 8 hours a day, five days a week, and see a single patient for a total of 15 - 30 minutes over a 12 month period, they would altogether provide care for about 10% - 20%of the total burden of serious mental disorders. Surprisingly,it is almost similar to the estimated ‘treatment gap’ of ninety percent.

Barriers in seeking help

Barriers in seeking help in rural area are many. Major barriers in seeking help are unavailability of mental health services, low literacy, socio-cultural barriers, traditional and religious beliefs, and stigma and discrimination associated with mental illness. unavailability of mental health services and lack of resources, particularly in terms of human resources, financial constraints, and infrastructure are one of major barriers which makes access to mental health services in rural areas more difficult. The services availablein urban areas are far and costly; and difficult to utilize and access due to various reasons. Lack of awareness and recognition of CMD (common mental diseases) with prevailing stigma and discrimination is an important issue and barrier which is closely associated with low literacy in rural areas. Other barriers are low political will of Central and state governments and unclear plan of action and policy. Another barrier is resistance to decentralization, and resistance by mental health professionals and workers, whose interests are served by large hospitals. Above all, major barrier is difficulties in integrating mental health in Primary Health Care. Primary health care workers are overburdened with lack of supervision and specialist support. Other barrier is that medical students and psychiatric residents are often trained only in mental hospital settings with inadequate training of general health work- force and lack of infrastructure for supervision in the community. Another important barrier is mental health leadership of the country which often lacks public health skills. Those who are in leadership positions are psychiatrists, trained in clinical management, without formal Public health training. Besides, the major barrier and challenge is resistance by psychiatrists to accept others as leaders.

Human resource and infrastructure gap

The people in rural areas are unable to access the services ofthe qualified doctors and other mental health professionals, where just 0.2 psychiatrists, 0.05 psychiatric nurses, 0.03

psychologists per 100,000 people, and 0.26 mental health beds per 10,000 populations, 0.2 in mental hospital and 0.05 in general hospitals are available for the whole country . Interestingly, the number of availability of psychiatrist has gone down during 2001 and 2005. To make the resources equitable, India needs about 140,000 psychiatrists whereas we have about 3000 psychiatrists and 75% of them are working in urban areas where less than 28% of the population lives. The government expenditure on mental health is another concern where it spends just 0.83 percent of its total health budget on mental health.

Future prospects

Proposed decentralization and synchronization of National Mental Health Programme (under 11th Five Year Plan, 2007-2012)with National Rural Health Mission is a good opportunity and has a wider prospect [41]. We can hope that this will ensure Primary Health Centre (PHC) based mental health services to the rural population. Involving and training village level Accredited Social Health Activists (ASHA) is another opportunity. Adding a module on community mental health and training ASHAs will definitely help in early detection, treatment, and rehabilitation of patients in the community in the rural areas. Presently, most of the rural people approach traditional healers (religious saints, tantric (black magicians), unregistered medical practitioners, and quacks) for treating mental health problems. Considering people’s faith in them and lack of trained professional, training thesetraditional healers could help in alleviating mental illness in rural areas. Developing short-term special curriculum basedtraining for medical officers is another prospect which will help in providing clinical services at block level.

Presently, the Government of India is providing mental health services in 125 districts through District Mental Health Programme under NMHP. There is need to integrate NMHP and DMHP

with NRHM Programme to provide mental health care, services and support to each and every individual in rural areas.

Development and mental health in India

Developments in the fields of science and technology have revolutionized Human Life at material level. But in actuality,this progress is only superficial: underneath modern men and women are living in conditions of great mental and emotional stress, even in developed and affluent countries. People from all over the world irrespective of culture and economic background suffer from mental illness and though a number of researches are carried out worldwide but till date it has not been possible to resolve the problem. The most neglected invisible problem of the society in a developing country like India is the burden of mental problem, its effects and its outcome in the coming years. The World Health Organization haswarned that many countries will be unable to cope with a predicted boom in Mental Illness over the next decade. According to Dr. Gro Brundtland, the former head of WHO, “If we don’t deal with Mental Illness, there is a burden not only on Mentally Ill, on their families, their communities, there is an economic burden if we don’t take care of people who needour care and treatment.”

Few Facts

In India over 125 million people suffer from Mental Illness.

Prevalence rates have increased due to poverty, illiteracy, urbanization, industrialization, discrimination,

Better diagnostic methods, increased public awareness. After all drug treatment 33% of patients do not improve. Estimated population of chronic psychotic patients in

India will be 50 millions by 2020.

But even then the government had no other option but to allocate funds on physical illness or disabilities like cancer, AIDS or any other problem than on Mental Illness. Lackof economic resources along with lack of professionals in the field has made the scenario even bleaker and worse. In India till date a person suffering from mental illness fails to receive any support either from Government or from any organization. Disability Card, which is issued for all other disabilities except mental illness have remained a dream for us those who are living in West Bengal. Even the support of Disability Commissioner in this issue failed to provide any needed solution. The mental problem is an invisible problem and so people cannot feel it or visualize the impact of the problem. Neither can they understand the impact it can create on the individual who is affected and his family members. The society is apprehending them as a burden and not putting efforts to utilize their potentialities or putting adequate efforts to change them again in to a productive member of the society. The problem with illness like Schizophrenia is even more. They often remain a burden to the society. Some live their whole lives within the four walls of their dark room, remaining secluded and accepting a sedentary lifestyle where they spend the day and night without doing any effective work.They live their life on the mercy of other family members. It is really difficult for the family members too, to make arrangement for a non-productive family member’s food, clothing, shelter and ever increasing cost of pharmacy-therapy. So these people, who are suffering through no fault of t heir own, are sent to homes or government hospitals, which are even worse than jails. Little attention is paid to their human rights, their feelings or their emotions –althougha large part of their problem centers on feelings and emotions. Some start believing that they are not members of this world anymore – they are here by mistake or by chance notby choice. For some the agony is unbearable and they commit

suicide. – Some dare not as they are too weak physically and mentally to take a bold steps like that.

To improve the quality of life of these persons rehabilitationcenters are needed. These can provide them with vocational training to give them hope: to work on bringing back motivation, to remove their apathy and lack of drive and to make them capable to start earning. It is seen that in urban populations the most important need for a person suffering from mental illness like schizophrenia is work and economic independence. So vocational training has the possibility of making them productive and is a method to reach more people.

Vocational training-

People from both western & eastern world can overcome the burden of the disease if they can successfully employ themselves in creative productive works. Even in India, where a person gets too much support & does not need to earn money due to over protectiveness of parents, -the prognosis & functional level remains below others who are actively participating in rehabilitation process.

Selection of Vocational Training

Selection of Vocational training depends on the individual aptitude ability & interest of the candidate. Often the parents who accompany the patient have a preconceived idea about their child’s capabilities. They often try to guide us &discourage us about some Vocational training which they think cannot be suitable for their child. It has been seen so far that almost everyone has some creative abilities and if this can be successfully utilized it can help them in the long run to overcome their problems and help them towards becoming a productive member of society. They can utilize skills learned to help them reduce their anxiety and in some cases to earn their livelihood.

A Few Simple Methods of Vocational training-

Collage works often help people to reduce their anger & aggression, water colours & works with plaster of paris helps them to overcome compulsive tendencies in them.To unfold the hidden capabilities of these person we always encourage them to explore their capabilities starting from simple drawing, fabric works, glass painting, Block printing with vegetables, colourful earthen pots, colourful earthen wall hangings, jute works, jute decorative folders, bead work, bead ornaments, animals made of beads, mobile cover, embroidery etc.

The role of Parents in Vocational Training-

Parents have a very important role to play in the rehabilitation of persons suffering from mental illness. It has been seen that supportive parents who are not overprotective can help their child to gain adequate confidence & functional level & on the other hand too much overprotective parents creates a hindrance towards the growth & development of their affected child. Vocational training along with learning few basic life skills for their proper functioning like going to the bank, depositing electricity bills, marketing the day to day products, taking a few responsibilities at home, looking after their parents, helps to improve their functional level and make them self-dependent. We also have some fixed responsibilities for all the clients at the centre: e.g. some setting the mat on the floor; some is distributing the tea, some selling the productsduring exhibition; elder clients helping the younger ones to learn the training programs. As we have to run the center without any monetary support from government or any organization we try to utilize the human resources of our clients. This not only reduces the running cost but also helpsto regain the lost confidence of our clients.

Social rehabilitation

This is the most important need for the people suffering from these disorders. Whenever, any human being suffers from any disease or crisis it is human to want the support, the comfort

of family members, friends and community. This culture still now prevails in India – though there is a breakdown of extended family, due to the impact of Western influence on Indian society – but till now there is a huge difference between the lifestyle of Indians and that of the western world. Till now people care for their family members; parents support their children till their death and siblings take careof their affected family member. Till now the Rehabilitation centers run by the self-support groups of India are more effective than those run by professionals. In this background where the bondage of love and understanding is important, social rehabilitation of the sufferers is important. Due to stigma, due to hopelessness, due to fear of rejection – the sufferers often try to avoid interacting with the society. This creates a barrier. Self Support groups help them to firstget the social acceptance. “I am still loved & cared by so many group members” help them to get the needed support & guidance. It is really surprising to see how they help their fellow friends during the annual tours from our center A few important things for proper rehabilitation are developing the feeling of togetherness, the bondage, the love, the “family feeling” – that we all belong to the same family / community. This helps a lot to overcome their deep-rooted insecurities & anxieties.

The Indian case

Among the events marking World Mental Health Day was a parade through the Indian capital, Delhi. Campaigners described the neglect of people with psychiatric disability in the country as a national emergency. The head of India's Institute of Human Behavior and Allied Sciences said women faced the greatest problems, including being abandoned by their familiesfollowing psychiatric illness. He said that in his own institute, there were people who had been cured up to 20 yearsago, but had nowhere to go. Many of the issues surrounding mental illness in India are common to the developing world. But the BBC's South Asia correspondent Mike Wooldridge says

problems in India can be particularly acute because of its ever-growing population and limited public resources. Nearly 25 million people in India are in need of mental health services. Of these at least a third need help to cope with disability resulting from various psychiatric disorders. Some experts have calculated that mental health problems contributeto an even greater reduction in the quality of life in India than tuberculosis or cancer. (Article Taken from UNI .DI 59 , 4 October 2001)

Health- WHO- mental disorders

A staggering 450 million people suffer from mental and behavioral disorders, which is among the leading cause of ill-health and disability worldwide while one in four people are affected by mental or neurological disorders at some point of time in their lives .This has been highlighted in the World Health Report 2001 titled 'Mental Health: New Understanding, New Hope', which was released simultaneously worldwide today.Releasing the report here, WHO Regional Director for South East Asia Region Uton Muchtar Rafei said that in the South East Asian region 27 per cent or nearly one third of disability is due to neuropsychiatric disorders. The mortalitystatistics however, does not reflect the burden of mental and neurological disorders, which cause untold sufferings. He saidstigma and discrimination faced by persons with mental disorder and misconceptions about them was the major challengein dealing with the problem. Moreover, the region faces great scarcity of trained manpower as there is only one psychiatristin Bhutan, 65 psychiatrists for 115 million people of Bangladesh, 420 for 200 million people of Indonesia and only 3500 for one billion Indian population.He called for urgent upgradation of services and trained manpower to deal with increasing mental and neuro- psychiatric illnesses in the countries of the region.Dr Uton said that member countries should develop Community-based mental health programmes shifting from traditional practice of hospital based psychiatry. Through proper programmes and projects a lot could

be done to reduce the enormous burden on mankind, he added.Presenting a synopsis of the report, WHO Deputy RegionalDirector for the region Dr.Poonam Khetrapal Singh said that every year one million people commit suicide while 20 million attempt to kill themselves. These diseases are the leading cause of disability, particularly in the most productive yearsbetween 14 to 44 years.The report underlines the importance ofcountries to have appropriate mental health policies, proper financing of mental health care and a thorough revamping of laws and practices in dealing with mental ill. The report includes ten recommendations which if implemented properly could go a long way in meeting the mental health needs of the population, she added. ( Article Taken from UNI AJ MS , BK1906, 4 October 2001, ZCZC, DI 68 )

Health-WHO-Mental disorders; New Delhi

Dr Vijay Chandra, WHO regional advisor, Health and Behaviour, said that with greater life expectancy, the number of patientswith neuropsychiatric disorders is likely to increase. This will have a social and economic impact with people facing rejection, isolation and a high risk of human rights violations. Moreover, in the absence of economic safety nets, few people have access to health or disability insurance, which further increases their vulnerability.Listing the steps to be taken by the coutries, Dr Chandra said that mental and neuropsychiatric disorders must be treated at the primary health care level with the support of the community. Human resources need to be developed urgently with an increase in the number of psychiatrists and neurologists. General practioners, nurses and lay health professionals must be trained in identifying and managing patients and appropriate medicine must be made available at an affordable price. He stressed the need for creating greater awareness in the community about such disorders. The national policies should be established and upgraded, programmes formulated and legislations must be strengthened to protect the human rights of these patients.Dr D S Goel, National Consultant on Mental

Health to the Indian Government, describing the situation in the country said major mental illnesses like schizophrenia, bipolar disorder and major depression affect a significant number of people and other psychiatric disorders are also quite common in the country and added that suicides and its attempts are growing particularly among women, children and adolescents.Rapid urbanisation, breakdown of the joint family system and migration of young adults from villages to towns insearch of employment has led to erosion of the traditional social security network and this has significantly contributedto the burden of mental illness in the country, he pointed out.According to Dr Goel, future strategies include a ten-foldincrease in the budget allocation for mental health in the tenth five year plan to Rs 150-220 crore. India would focus ondistrict mental health programmes, strengthening departments of psychiatry in medical colleges, upgradation of mental hospitals, energising central/state mental health authorities and promotion of reliable community based research, he informed.

Role of Ngo’s in the process of social development and promoting health issues

Understanding Nongovernmental organizations and their role inIndia

Non-governmental organization (NGO) is a legally constituted international organization created by private persons or organizations with no participation or representation of any government. In the cases in which NGOs are funded totally or partially by governments, the NGO maintains its non-governmental status insofar as it excludes government representatives from membership in the organization. India is estimated to have between 1 and 2 million NGOs.

Types

Apart from 'NGO' often alternative terms are used as for example independent sector, volunteer sector, civil society, grassroots organizations, transnational social movement organizations, private voluntary organizations, self-help organizations and non-state actors (NSAs).Nongovernmental organizations are a heterogeneous group. A long list of acronyms has developed around the term 'NGO'.

These include:

INGO stands for international NGO; BINGO is short for business-oriented international NGO,

or big international NGO; ENGO, short for environmental NGO, such as Global 2000; GONGOs are government-operated NGOs, which may have been

set up by governments to look like NGOs in order to qualify for outside aid or promote the interests of the government in question;

QUANGOs are quasi-autonomous non-governmental organizations, such as the International Organization forStandardization (ISO). (The ISO is actually not purely anNGO, since its membership is by nation, and each nation is represented by what the ISO Council determines to be the 'most broadly representative' standardization body ofa nation. That body might itself be a nongovernmental organization; for example, the United States is represented in ISO by the American National Standards Institute, which is independent of the federal government. However, other countries can be represented by national governmental agencies; this is the trend in Europe.)

TANGO, short for technical assistance NGO

There are also numerous classifications of NGOs. The typology the World Bank uses divides them into Operational and Advocacy. The primary purpose of an operational NGO is the design and implementation of development-related projects. Onefrequently used categorization is the division into 'relief-oriented' or 'development-oriented' organizations; they can also be classified according to whether they stress service delivery or participation; or whether they are religious or

secular; and whether they are more public or private-oriented.Operational NGOs can be community-based, national or international.

The primary purpose of an Advocacy NGO is to defend or promotea specific cause. As opposed to operational project management, these organizations typically try to raise awareness, acceptance and knowledge by lobbying, press work and activist events. USAID refers to NGOs as private voluntaryorganizations. However many scholars have argued that this definition is highly problematic as many NGOs are in fact state and corporate funded and managed projects with professional staff NGOs exist for a variety of reasons, usually to further the political or social goals of their members or funders. Examples include improving the state of the natural environment, encouraging the observance of human rights, improving the welfare of the disadvantaged, or representing a corporate agenda. However, there are a huge number of such organizations and their goals cover a broad range of political and philosophical positions. This can also easily be applied to private schools and athletic organizations.

Role of nongovernmental organizations in mental health in India

The paucity of treatment facilities and psychiatrists in the Government sector has widened the treatment gap in mental health. Non-governmental organizations (NGOs) have played a significant role in the last few decades in not only helping bridge this gap, but also by creating low cost replicable models of care. NGOs are active in a wide array of areas such as child mental health, schizophrenia and psychotic conditions, drug and alcohol abuse, dementia etc. Their activities have included treatment, rehabilitation, community care, research, training and capacity building, awareness and lobbying. Mental health has for decades been low in the priority of health planners at state and central levels and

this is well reflected in the quantity and quality of mental health services in India. The needs of patients and families far outstrip the availability and accessibility of services for those with mental disorders. India's scarce mental health resources, such as mental health specialists, are largely concentrated in some states (mainly in the south) and in urbanareas and a large proportion are solely in the private sector.Over half of all inpatient beds are located in 40 odd mental hospitals, most of which were built during the colonial years.It is not surprising, then, that the 'treatment gap' for mental disorders is large all over the country, but especiallyso in rural areas, northern states and amongst the socially disadvantaged.

Historical Aspects

Non-Governmental Organizations (NGOs) are institutions, recognized by governments as non-profit or welfare oriented, which play a key role as advocates, service providers, activists and researchers on a range of issues pertaining to human and social development. Historically, NGOs have played acritical role in promoting and facilitating health and educational activities in India. Prior to independence, religious bodies set up a number of educational institutions, health facilities and other charities. These movements were often led by charismatic individuals, driven by a sense of missionary zeal. Many NGOs were born in response to major disasters and crises with the aim of providing emergency relief and rehabilitation. Since independence, there has been a meteoric rise in the profile, breadth and range of NGOs in the country. Three key changes have occurred in the evolution of the NGO- first, the greater degree of professionalization of NGO activities; second, the widening of sources of funds for NGO activities to include major national and internationaldonor agencies; and third, the secular origins of NGOs. The growing professionalization of NGOs led to the evolution, in the 1960s, of NGOs which focused on health issues. These NGOs increasingly filled gaps in healthcare provision, focusing on

under-served populations. Some of these NGOs have now become large institutions in their own right, providing primary care services and strengthening community action for change. The activities of, now internationally acclaimed, NGOs such as theSelf Employed Women's Association (SEWA), the Karuna Trust andthe Aravind Eye Care group, have become models for wider adoption by the government in its own program development. Much has already been written and documented on the work of NGOs in a variety of sectors of community development issues, including health (Pachauri 1994). [1] However, there had been no such initiative in the specific area of mental health untilthe recent documentation of a number of NGO programs in mentalhealth in India by the authors (Patel and Thara, 2003).

Diversity of Mental Health Non-Governmental Organizations

Despite the considerable challenges faced in developing mentalhealth programs, it is gratifying to note the achievements made by many MHNGOs are distributed throughout the country, although there are a greater number in urban areas, and in states where there are relatively lesser pressing problems posed by poverty and communicable diseases (for example, southern states). In part, this is because these areas alreadyhave the mental health specialist resources that are often critically important in leading the development of NGO-based services. Another reason is that these are the areas of the country where the epidemiological transition is more advanced and where mental disorders account for a larger proportion of the burden of disease. Although MHNGOs are predominantly urbanin location, many have begun to extend services into rural areas. Most MHNGOs serve a defined community; however, the work of some has spread to more than one center or geographical region. Examples of such NGOs are the Alzheimer and Related Disorders Society of India (ARDSI), which was started in Cochin, and has now spread to more than a dozen centers in India. Similarly, the Richmond Fellowship Society has three centers. The oldest MHNGOs in India are probably

those working in the field of child mental health, and in particular, mental retardation. This may not be surprising given the close nature of the relationship between mental retardation and the concept of childhood disabilities which has been one of the bedrocks of the NGO movement for several decades. The concept of child mental health has broadened fromits earlier focus on mental retardation to include the far commoner mental health problems seen in children, such as autism, hyperactivity and conduct disorders. MHNGOs such as Sangath Society (Goa) and Umeed and the Research Society (Mumbai) provide outpatient and school based services for suchproblems.

Other than mental retardation, the other early MHNGOs had careand treatment and rehabilitation as their priorities and developed appropriate models of rehabilitation in diverse settings and for diverse clinical populations. Their primary focus was on severe mental disorders and many of these MHNGOs (such as the Schizophrenia Research Foundation (SCARF) in Chennai, Manas in West Bengal, the Medico-Pastoral Association(MPA) in Bangalore, and Shristi in Madurai were started by psychiatrists who already held full-time faculty positions in the local medical school. These MHNGOs were started to fulfillthe need for a broader, holistic approach to the management ofsevere mental disorders. Thus, activities ranging from family counseling to vocational rehabilitation, which were rarely provided in psychiatric out-patient clinics, were given greater attention. Another area of mental health which attracted considerable interest and attention was substance abuse. Alcohol abuse and, in particular, drug abuse captured the public imagination and received considerable media interest in the 1970s and 80s. This public attention and the obvious need for community-based rehabilitation services for persons affected by substance abuse led to the development of numerous MHNGOs working in this area. The TTK Hospital in Chennai, the TRADA in Karalla and Karnataka, Parivarthan in Maharashtra, Kripa Foundation, Alcoholics Anonymous and the

Samaritans in many parts of the country and the National Addiction Research Center in Mumbai are examples of MHNGOs focusing on substance abuse problems. National programs on alcohol and drug abuse are increasingly being implemented through grants-in-aid to such NGOs. More recently, the scope of activities of MHNGOs has broadened further, with a better understanding of the range and nature of mental health problems. Thus, stress-related disorders such as anxiety and depression are increasingly recognized as major causes of sickness and disability. MHNGOs providing community based counseling and suicide prevention activities have mushroomed. Reports highlighting the rising rates of suicide in India, in particular amongst young people, have alerted health professionals and the community about this serious mental health problem. Sneha (Chennai), MPA (Bangalore) and Saarthak (Delhi) work on suicide prevention activities; many NGOs now run help-lines for distressed persons. Some MHNGOs focus on women's mental health; common mental disorders, which are often linked to stress and oppression, are not surprisingly, more frequent in women. The activities of the Bapu Trust (Pune) demonstrate how the feminist theory can contribute to the discourse on the linkages between women's lives in a gender-biased society and their mental health. Banyan (Chennai) provides shelter and care for women living with mental disorders.

Two welcome developments in the NGO sector are the growth in user/family NGOs and the inclusion of mental health by NGOs whose original mandate was in other areas of health. Some MHNGOs, such as ACMI (Bangalore) and Aasha in Chennai are entirely run by, and focus on, families of those affected by severe mental disorders. ARDSI works with families who have a member affected by dementia. The growth of these, non-professional, family oriented MHNGO sector is to be welcomed for it is very likely that the needs of the mentally ill may be expressed and met in different ways by families and by mental health professionals. Basic Needs is an NGO which

combines both service, delivery with an emphasis on livelihoodskills development to empower people with mental disorders. Adolescent health interventions based on the life skills model, have become very popular in secondary schools around the country; many such programs are run in collaboration with local NGOs focusing on reproductive and sexual health issues. Targeted interventions for injectable drug users are also supported though national programs for HIV/AIDS (NACO) and implemented through NGOs focusing on HIV/AIDS (for e.g. Positive People in Goa). Many disability-focused NGOs now include mental health as a core element. An example of such anMHNGO is Ashagram in Madhya Pradesh whose primary focus was physical disabilities, especially persons affected by leprosy but which expanded it community based rehabilitation program to include severe mental disorders which also produce a profound disability in some persons. Other examples of broad-based NGOs which are integrating mental health in their agendainclude the Voluntary Health Associations of India and the Community Health Cell (Bangalore). These are healthy trends facilitating the view of mental health as an integral component of the broader rubric of public health.

Despite considerable diversity in the range of objectives and types of MHNGOs as described above there are several common features shared by many of the MHNGOs. The perceived need of the community appears to have been a major catalyzing factor for the initiation and sustainability of all the MHNGOs. In some cases, personal tragedies and first hand experiences havebeen inspirational factors. Scepticizm and cynicism, especially of the medical community, and lack of cooperation and sensitivity of government officials and donor agencies have been uniform experiences, especially in the founding years. Not unexpectedly, a high premium is placed on involvement of families and other stakeholders in the activities and programs of all the MHNGOs. For many MHNGOs, government funding support is minimal; and most are dependent

on general public or donor agencies for financial resources. Afew have been able to mobilize research funds, by virtue of having established research credentials. Many MHNGOs charge fees for services. Let us now consider the kinds of activitieswhich MHNGOs are engaged in working towards their objectives towards improving the health of those affected by mental disorders.

Mental Health Non-Governmental Organizations Activities and Programs

The activities of the MHNGOs were grouped in the following broad categories for the sake of discussion; however, there are obvious overlaps between some of these activities: Treatment care and rehabilitation, Community-based activities and prevention, Research and training, Advocacy and empowerment. It was natural for many MHNGOs to identify treatment and rehabilitation as their priorities, based on thefelt and largely unmet needs of the populations they wished toserve. Models of care and rehabilitation have been developed, many of which are replicable in diverse settings. While most state-run organizations focus on medical treatment, psycho-social rehabilitation (PSR) is sadly a neglected though major aspect of MHNGO programs. The absence of trained staff to carry out PSR activities has, however, kept it away from mainstream psychiatric services. Hence, many NGOs have taken it upon themselves to develop modules of PSR in both urban andrural areas. The programs include a spectrum of activities such as individual and group counseling, vocational rehabilitation and livelihood skills training, cognitive retraining, family support and counseling, self-help groups, recreation and leisure activities. The range of care facilities depends on the conditions which are the focus and the resources of individual NGOs. Out-patient clinics, in-patient care, day care programs and long term residential careform the spectrum of services provided by MHNGOs, especially the ones dealing with chronic psychotic conditions. Within this spectrum of services, a range of treatments including

drug and psychological treatments are offered. Many persons require long-term care to minimize the disability associated with some mental disorders such as schizophrenia and dementia.Typically, about a third of patients with schizophrenia will show signs of long-term disability associated with a variety of factors such as chronic symptoms, stigma and the side effects of medication. Most MHNGOs working in this area have comprehensive services focusing both on the control of symptoms of the acute phase of the illness, as well as rehabilitation to ensure optimal functioning in the longer-term. Providing vocational training in skilled professions such as carpentry and printing, social skills training and family therapy are some examples of the kind of activities undertaken. MHNGOs provide linkages with potential employment by sensitizing employers to the needs of those suffering from chronic mental disorders. Specific interventions targeted to groups such as children or the elderly are also being offered by some MHNGOs. In the case of child mental health, for example, interventions targeted at children, their parents andclass room interventions are offered. Childhood mental disorders also require a range of rehabilitation interventions, particularly in the educational field. MHNGOs working in other areas, such as substance abuse, also provide a range of rehabilitation services.

Community programs and prevention

Although the National Mental Health Program was initiated in 1983 to ensure minimum standards of mental health care by integration with existing primary healthcare services, this still remains a utopian dream in almost all parts of the country. A major reason for this is the almost complete biomedical emphasis of the program with an outpatient clinic where medicines are doled out in a health centre being the principal and, indeed in most places, the only form of care which is provided. On the other hand, NGOs have initiated a number of community-based mental health programs emphasizing on services in a variety of community, including home-based,

settings and offer a range of PSR activities. These programs range from primary prevention activities such as suicide prevention (see below) to provision of treatment in community clinics, increasing awareness and providing community based rehabilitation (CBR). NGOs are arguably better placed to approach and win the trust of local communities, establish ties with them and locate their programs in and for the community. Examples of primary prevention programs are the telephone help lines for depressed and suicidal persons, earlyintervention for babies born at risk for developmental delay and education programs in schools and workplaces for prevention of substance abuse.

Secondary prevention focuses on minimizing the handicaps associated with an existing mental disorder. Examples of such programs include CBR programs for child and adult mental disabilities and school programs to help children with hyperactivity and dyslexia stay in school. CBR is an essentialingredient of community care programs. SCARF, as part of vocational support activities, has distributed livestock, cowsand helped expansion of petty shops in rural areas to help persons with schizophrenia. This is not just a means of livelihood, but has also improved their functioning and involvement in many ways. Empowerment of the local community is equally important and involvement of key and influential persons in the community such as teachers, religious heads, and local administrators has yielded good results. Basic Needsis another MHNGO which emphasizes on such CBR activities as the core component of its mental health program. Community programs gained much significance when the tsunami left in itswake a number of psycho-social problems which required intensive counseling, support and sometimes medication to allay anxiety and depression. NGOs like SNEHA (Chennai) provided a range of community based counseling and mental health interventions in the aftermath of this disaster. In keeping with latest advances in technology and communications,SCARF has started using telemedicine to expand access to

specialist mental health services in rural areas. Homelessnessand the destitute mentally ill have also received growing attention in the last decade or so. NGOs such as Banyan and Anbagam in Chennai, Ashadeep in Guwahati and Samarpan in Indore, and a few others, have developed comprehensive services for the "wandering" mentally ill. However, to sustainthese programs, a national plan is required for the provision of care to the homeless and wandering mentally ill, whose plight is borne out of a combination of health, socio-economicand human rights issues.In the 1970s and 80s, there was a mushrooming of NGOs to deal with substance abuse, but few of these organizations have sustained themselves. The TTK hospital/TT Ranganathan Clinical Research Foundation started in 1980 in Chennai is an organization which has expanded itself in various activities and become a referral center for training and awareness building in substance abuse. This NGO has been active in the various fields of out-patient and in-patient care, extending care to those who need it through community outreach programs and CBR activities. The Indian Alcohol Policy Alliance, a network of centers and individuals working in de-addiction have released an" "Alcohol Atlas of India" as a reference guide for policy makers and professionals The National Addiction Research Centre (NARC), established in 1985, is another example of an NGO focusing on substance abuse who have sustained their activities, in part due to the growing emphasis on drug users as a target population for HIV/AIDS control.

Research and training

Until relatively recently, MHNGOs were primarily concerned with service provision and advocacy related activities. Research was considered as an academic exercise, best reservedfor the ivory towers of universities and teaching hospitals. This has changed so much in recent years that today MHNGOs areat the forefront of ground-breaking health research in India. Major research programs in health areas as diverse as infectious diseases to nutrition are now conducted under the

aegis of NGOs. MHNGOs are no exception to this trend. The SCARF studies on schizophrenia are the most widely-cited research on the subject from any developing countries (Thara and McCreadie 1998). [3] All three published studies of dementia in the community in India are from work done by MHNGOs (REF). Sangath's studies on the treatment of depressionare amongst the largest such studies from India (Patel et al. 2003), [4] Sangath's Manas project is the largest trial for a mental health treatment from any developing country. Ashagram's community program for schizophrenia has generated the first scientific evidence of the use of the CBR approach for rehabilitation of a mental disorder (Chatterjee et al. 2003). [5] The experience of CBR in Ashagram has led to the initiation of the first randomized controlled trial of this approach in three sites in India. These are just some examplesof innovative, action-oriented research emanating from MHNGOs.Many MHNGOs actively invest in the development of skills of their staff and of other stakeholder groups. Participation in workshops, conferences and seminars, and formal training in courses such as rehabilitation are often offered as opportunities for career development. Most of the MHNGOs provide opportunities for training other professionals and health workers in specific areas of mental health, such as counseling skills. Many colleges, for example, send their students to MHNGOs for field placements. Workshops with healthworkers, teachers and other key groups are a standard feature of the activities of many MHNGOs. Many of these organizations regularly conduct local, national or international conferences, seminars, workshops and symposia to discuss current issues in this field (Kalyanasundaram and Varghese, 2000).

The Richmond Fellowship has successfully established a full two-year MSc program in psychosocial rehabilitation. Two NGOs (Sangath and SCARF) launched a new course ("Leadership in Mental Health") in 2008 to strengthen skills on scaling up

services for people living with mental disorders. The course attracts students from around the world.

Advocacy and building awareness

Advocating for the needs of under-served and underprivileged sections of the population has been the raison d’être for mostMHNGOs. At present, there is very low awareness of the considerable advances in our knowledge of the causes and treatment of mental disorders in India This low awareness, coupled with the enormous stigma attached to mental illness, means that the needs and rights of mentally ill persons are largely ignored. MHNGOs have made raising awareness in different sectors of the community, such as health workers, teachers and lay persons, a priority area. Documentation and dissemination of relevant facts and research, and lobbying policy makers for changes in the law are vital instruments forimproving mental healthcare. A prominent example of the success of efforts of MHNGOs is the inclusion of mental disabilities in the disability legislation of the country. Thefilm festival organized by SCARF called the "Frame of Mind," which features several films portraying mental illness and an international competition for short films on mental health andstigma, is a huge success and has had three editions so far. Similar festivals have since been held in other cities like Kolkata. Many NGOs use short films to spread awareness about their work/cause. Many publish regular newsletters and host web sites marking the close affinity of MHNGOs with contemporary technological advances. Many MHNGOs adopt methodsto enhance the effectiveness of care through empowerment of affected persons and their families. Support groups are widelyused as a way to ensure that persons recovering from substanceabuse can remain sober. The globally recognized organization, Alcoholics Anonymous, is an example of the kind of support group philosophy which becomes the core to the process of treatment of alcohol dependence. Support groups are also evident in the residential and day care facilities geared to those with severe mental disorders. Some MHNGOs run support

groups not for those directly affected by a particular disorder, but for their families. Thus, families of elders with Alzheimer's disease, adults with schizophrenia and children with autism, meet regularly to discuss common problems, support each other and provide practical solutions to everyday difficulties. Advocacy led by such user and familyNGOs may have particularly important impact on government policies. The All India Federation for Mental Health, an umbrella organization of many NGOs working in the field of mental health, and the National Association of the Mentally Ill (NAMI- India) are examples of coalitions of NGOs and consumers respectively which are actively advocating for mental health policy and care reforms in India.

Mental Health Non-Governmental Organizations Strengths andLimitations

Why is it that the MHNGO movement has continued to survive despite the lack of resources and other barriers? This is probably because MHNGOs have some inherent and intrinsic advantages. We can consider the advantages of MHNGOs under three broad categories: Working in Partnership, Innovations inPractice and Transparency in Administration.

• Working in partnerships: One of the great strengths of MHNGOs is their ability to strike up collaborations and partnerships with other agencies or individuals with ease; unlike the public health sector where layers of permissions stifle the scope for collaboration and unlike the private health sector where collaborations may be perceived as a threat to the practice. Most MHGNO activities are provided by multidisciplinary teams of doctors, therapists, health workers, other professionals and volunteers. Partnerships are built not only between medical and non-medical professionals, but also between professionals and families. The close collaboration between academics, clinicians, social workers, rehabilitation workers, remedial teachers, clinical and

educational psychologists are a distinct feature which marks MHNGOs as being a very different breed of animal from traditional psychiatric clinics in hospitals or private psychiatry.

• Innovations in practice: MHNGOs are, typically, closer tothe community they serve and hence in a better position to be more sensitive to changing needs and perceptions. Further, MHNGO services may be attached with much less stigma than formal psychiatric services, and may thus attract a much widerrange of clients. Clinical support, involving diagnosis and treatment of specific mental disorders, is the key to many MHNGO activities. The success of MHNGOs lies in providing services which are accessible, such as through outreach camps,which rely on available human resources, such as the communityparticipatory model of rehabilitation. Many MHNGOs provide a wide range of services which are especially suited for severe and childhood mental health problems. By taking up the processof promoting attitudinal changes in the community and amongst policy makers, MHNGOs also play a key role in advocacy for changes which can benefit all persons with mental illness.

• Transparency in administration: The activities of MHNGOs are driven not by profit but by the desire to achieve a basic quality of care for all clients, irrespective of their abilityto pay. They are governed by a relative flexible set of regulations. Employment and promotional avenues can be based on merit as opposed to the traditional governmental holy grailof seniority. Because they are dependent on external funding, MHNGOs are constantly kept on their toes in achieving program objectives and ensuring fiscal accountability. MHNGOs can explore, with remarkable entrepreneurial dynamism, collaborations with any other organization or individual to achieve their objectives.

However, MHNGOs have their fair share of limitations and problems. We can consider these under the broad themes of Sustainability, Accountability and Scope.

• Sustainability: A key problem facing most MHNGOs is the source of their funding, which is largely project-based. The periodic fund raising required to augment resources can take up a good deal of time and energy. Staff members have no guarantee of employment beyond a defined project period. As a consequence, some MHNGOs suffer a high turn over of staff. This is partly because staffs are appointed on specific fundedprojects and their continuity depends on the funding available. There might be a temptation to dilute goals and objectives as a response to availability of funding. Donor funding is notoriously fickle; priorities change over time, and MHNGOs often reinvent their objectives to keep afloat. Therecent trend for massive investment in HIV/AIDS related work, though important in its objectives, is concentrating the bulk of donor money to this one-disease issue. Many MHNGOs and, indeed, some MHNGOs are adding HIV/AIDS as core priorities to secure these funds. While this may broaden the scope of MHNGOsby enabling an integration of existing priorities with new ones, there is equally a need not to allow the focus on mentalhealth to be diluted to the point that it becomes irrelevant

• Accountability: Some MHNGOs have poorly established mechanisms for evaluation and monitoring. Although networking is actively sought for project collaboration, there is no similar zeal for review and monitoring from external assessors. There has been considerable public concern regarding the misuse of funds and lack of financial accountability of NGOs in general. Although this may not be assignificant an issue in the context of MHNGOs where funds are scarce, MHNGOs would be well advised to ensure transparency inaccounting for their funds. As MHNGOs become larger and more professionalized, there is a danger of increasing bureaucratization with increasing administrative costs. MHNGOsshould be wary of this from the beginning since it could well dampen creativity and flexibility, two elements which give MHNGOs their unique flavor.

• Scope: Finally, and perhaps the most important limitationis the limited scope of individual MHNGOs. The world of most MHNGOs is confined to a city or a few villages. There is, however, a need to transplant the wide experience of these onto a larger canvas, ideally through influencing policies andprograms for the entire state and country. For changes to occur on this wider canvas there is little doubt that the public or government health sector must play a key and leadingrole. MHNGOs can, in this context, be seen as innovators who develop locally relevant models which can then be implemented on a national scale.

Hence it will be appropriate to say that, MHNGOs have made tremendous strides in mental health promotion and care, against massive odds ranging from low awareness about mental illness to lack of motivation donors. Although there can be little dispute whether the MHNGOs have a definite role to playin meeting mental health needs in India, there is also little doubt that their impact on mental health care at the national level has been marginal. For example, there are very few MHNGOs working in rural or impoverished areas. The strength ofMHNGOs does not lie in their ability to reach out to the millions of persons with mental disorders, but in evolving andperfecting quality programs and models which have the character of replicability. Through innovation and accountability, MHNGOs can provide models for the public healthcare system to emulate and partner. However, they cannotentirely meet the needs of the under-served and underprivileged sectors of our population. That responsibility, was, is, and must rest principally with the public health sector. We believe that the time and setting is right not only for the emergence of new MHNGOs, but also for the consolidation and strengthening of existing ones.There is need to call for the inclusion of MHNGOs as full partners of the government services in the National Mental Health Program.Such a partnership could take several forms.

Participation in intersectional committees to monitor andimplement the NMHP in each district, involving government, NGO and psychiatric stakeholder representation. These committees can be empowered to takeon roles of combating stigma, supporting user groups, monitoring rights, and capacity building.

NGOs running DMHP following the model of NGOs adopting primary health centers in some districts; here NGOs become providers of the DMHP services, especially in districts where government mental health services are weak.

NGOs developing niche community based services including day care centers and residential facilities for chronically disabled patients or children or mental health promotion activities, help lines for distressed suicidal patients, facilitating user and family support groups and assisting with livelihoods and employment generation and so on.

NGO placements becoming mandatory for psychiatric training for doctors and nurses whose current training programs are mainly hospital based, thereby missing out on the entire range of community-based and PSR experiences.

NGO representation should be sought in all committees, task forces involved with planning of mental health activities and program implementations at the state and national levels.

Government agencies must take note of the huge public health implications of mental disorder and the lack of organized services for the mentally ill, and provide support for MHNGOs in the ways proposed above. Given a favorable climate, we are sure that the MHNGO movement in Mental Health will not be a sporadic or isolated phenomenon as it is now, but a more enduring and unified force in the realm of Mental Health in India. While the government or public services are the key providers of care for these populations, and therefore need strengthening, the NGO movement in the country has seen a steady upswing in the last two decades to fill the large gaps.NGOs are driven by a passion towards a certain cause and back it up with commitment and drive. While the reach of their work

cannot parallel that of government agencies, the quality of care and their efforts in reaching out to the various stakeholders, particularly those who are discriminated againstsuch as persons with mental disorders, gives them a distinct advantage.

Inclusion of people with mental illness in Community Based Rehabilitation: need of the day- by Dr. N. Janardhana and D.M. Naidu (2012

Throughout the world people with mental illness are denied their basic human rights, especially the right to access treatment, rehabilitation and appropriate mental health care (UN 2006, UN 1999). People with mental illness (PWMI) and their families experience discrimination and exclusion from economic and social activities. Due to stigma, PWMI and theirfamilies are often ridiculed and isolated, trapping them in acycle of poverty. A lack of access to information about theirrights and support to exercise these rights perpetuates and deepens this marginalization. People with disabilities also do experience stigma, discrimination and social exclusion. However, the situation, in the case of people with disabilities has improved in many countries through CBR initiatives. Including PWMI having psychosocial disabilities in CBR programme seems an ideal answer to address the needs and rights of PWMI along with other people with disabilities.Mental illness is not a personal failure, it happens to most of us at one time or the other in life. Mental, behavioural and social health problems are an increasing part of health problems in the world. The WHO estimates that mental and behavioural disorders constitute 12% of the global burden of disease. Worldwide, nearly 450 million people have mental orbehavioural disorder (WHO 2001). The number of PWMI will increase substantially in the coming decades for the following reasons. Firstly the number of people living in theage groups of risk for certain illness is increasing because of the changes in the demographic features. Thus there has

been increase in the number of person with mental illness in the age group of 15- 45 years. Secondly, there has been substantial increase in the geriatric population having mental health problems, as the life expectancy is increasing.Thirdly, there is an overall increase in the rate of depression seen in all age groups as an effect of the changing socio- cultural-economic and political situation of the modern world (Janardhan and Naidu, 2006; Janardhan and Naidu 2007).Mental illness in certain cases leads to psychosocial disability (Tally and Murali 2001). Advances in behavioural science have proven that mental and behavioural disorders are treatable like any other physical illness (WHO 2001). Unfortunately, in most countries mental health and disorders are low priority, with no services in the communityfor treatment and well-being. Though the burden resulting from psychiatric, psychosocial, and behavioural disorders areenormous; it is grossly under represented by conventional public health statistics. Nearly 10% of Disability Adjusted Life Years (DALYs) across all age groups are due to depressive disorders, suicides and alcohol related problems. It is estimated by WHO that in 2020 the burden of mental disorders would increases to 15% and mental disorders will beamong the leading cause of global disease burden by 2020, at which time, depression alone is expected to become the secondhighest cause of death and disability world wide (WHO 2001). If a person is unable to perform an activity because of disease/illness or due to bodily impairment, the person is considered as disabled. Though psychiatric disorders do not cause any physical impairment, they can stop a person from doing many activities that are expected of them. The disability in psychiatric illnesses is dynamic being influenced by the nature of illness, phase of the illness, treatment status and social support network available to them. PWMI are treated as second-class citizens with no adequate facilities or provision from the government. As a result, they face chronic ill health and the families

experience economic and social burden. In certain cases this leads to social destitution.

Goal of Inclusion of people with mental illness in the CBR programme

PWMI participate in societal activities, having access to generic services as well as appropriate support and which they consent to. The Purpose of inclusion will be to enable development practitioners to include mental health issues in the existing CBR programs through increased understanding of PWMI, recognizing psychosocial disabilities, appreciating thesimilarity in approaches, cost effectiveness etc.

Mental health is a development issue

Basic Needs India (BNI), a resource group in mental health and development believes that mental health is a development issue; hence it can be included in the development activitiesof the organizations. BNI provides technical support to the CBOs and NGOs to include mental health issues in their existing programs. BNI has been successful in including PWMI in 50 CBOs and NGOs, carrying out CBR work and other development activities. In the process, awareness has been created about the needs of PWMI in the communities and among local and district level government authorities. Many people recovering from mental illness and their family members have joined self- help groups of people with disabilities. While working with the CBR organizations in following activities PWMI can be included.

CBR and people with mental illness

Development and changes in the concept of CBR over the last two decades has influenced the thought of inclusion of mentalhealth in CBR programs. The CBR strategy shifts rehabilitation interventions to homes and communities of people with disabilities. Basic services are provided or

facilitated by CBR workers who are minimally qualified non professionals but who are highly qualified change agents. Themain goal of rehabilitation has become broader and focuses beyond the individual, to the family and communities in whichpeople live. CBR recognizes that breaking down barriers to inclusion in society is as important to the mission of the CBR programme as is the functional rehabilitation of individuals with disabilities. Thus the universal mission of CBR is:

To enhance activities of daily life of disabled persons To create awareness in disabled person’s environment to

achieve barrier free situations around him and help him in meeting all human rights.

To create a situation in which the community of the disabled persons, participates fully and assimilate ownership of their integration in to the society. The ownership lies with the affected persons. Maya Thomas and M.J Thomas 2003, Pritivish 2006).

The above mission is no exception for PWMI. CBR programs can link with mental health professionals, users of mental health services, DPOs and SHGs to broaden its scope to include people with psycho social disabilities and to promote community mental health services

Promote community mental health servicesMental health professionals in several low-income countries are actively promoting Community Mental Health(CMH) and are attempting to influence their governments to initiate measures to bring mental health into the primary health care system. CBR programs can work with mental health professionals, local health centre staff and users of mental health services to promote communitymental health services. Many mental health problems can be effectively resolved by working together with people who experience mental illness in their own homes and communities, using resources and support networks that are available to them. Awareness raising campaigns and large-scale dissemination of knowledge and skills would

help in reducing the stigma attached to illness. Building knowledge and awareness among families can makethe real difference, in ensuring that PWMI are integral members of the family and community, participating in all social and cultural activities. 

Role of non-governmental organizations in mental health in India- by R.Thara and Vikram Patel

Mental health has for decades been low in the priority of health planners at state and central levels and this is well reflected in the quantity and quality of mental health services in India. The needs of patients and families far outstrip the availability and accessibility of services for those with mental disorders. India’s scarce mental health resources, such as mental health specialists, are largely concentrated in some states (mainly in the south) and in urban areas and a large proportion are solely in the private sector. Over half of all inpatient beds are located in 40 oddmental hospitals, most of which were built during the colonial years. It is not surprising, then, that the ‘treatment gap’ for mental disorders is large all over the country, but especially so in rural areas, northern states and amongst the socially disadvantaged. While the government or public services are the key providers of care for these populations, and therefore need strengthening, the NGO movement in the country has seen a steady upswing in the lasttwo decades to fill the large gaps. NGOs are driven by a passion towards a certain cause and back it up with commitment and drive. While the reach of their work cannot parallel that of government agencies, the quality of care andtheir efforts in reaching out to the various stakeholders, particularly those who are discriminated against such as persons with mental disorders, gives them a distinct advantage. It is vital, that, We urge the government agenciesto take note of the huge public health implications of mentaldisorder and the lack of organized services for the mentally

ill, and provide support for MHNGOs in the ways proposed above. Given a favorable climate, we are sure that the MHNGO movement in Mental Health will not be a sporadic or isolated phenomenon as it is now, but a more enduring and unified force in the realm of Mental Health in India.

Community mental health care program- by Fortis health care group

Accessibility and a lack of awareness are the twin challengesthat plague the current mental health scenario in India. A majority of our population resides not in metropolitans, but in smaller towns and villages, where mental healthcare services are wanting. The difficulty also arises in trying toinclude mental health related issues in the broader context of concerns such as vulnerable populations, poverty, violence, religion and caste. For those of whom mental healthcare services are available, stigmatization and perceived shame becomes the next barrier towards treatment, as our society abounds with misconceptions regarding mental illness.What we need is a paradigm shift in society's attitude towards mental health by formulating programs that work at the level of the community in collaboration with other publicservice providers like NGO's. Mental health services are bestprovided within the community in which a patient lives. The aim of the Community Mental Health initiative - an integral part of our Corporate Social Responsibility - is to generate awareness and understanding regarding mental health related problems, remove the stigma associated with mental illness and make mental health care available to all. Non-governmental organizations play a pivotal role in filling thegap between existing mental health services and the sizeable need for these services. In collaboration with NGOs working directly within the community, our Community Mental Health program is designed not just to manage, but to prevent mentalillness as well. Within the purview of this program we provide the following services:

• Training services for volunteers working in the community sector

• Knowledge and capacity building interventions for volunteers and personnel on mental health related issues

• Awareness generation activities within the community

• Mental health camps for consultation with specialists onmental health related issues

• Promotion of remedial interventions for mental health related conditions

• Group psychosocial interventions within the community

NGOs in primary health care: a benefit or a threat?- by Jessica Maltha

International Non Governmental Organizations (NGOs) have beenactive in primary health care for many years. The majority ofthese NGOs is based in Western countries and has local branches in developing countries. Most of them run their own projects, some fund and monitor local service-providing NGOs.With many national governments not being able to supply sufficient health care, NGOs are considered to be the best institution for reaching the poor and providing health care in an efficient and cost-effective way. Therefore, large amounts of official funds are being channeled to NGOs active in the health sector. However, there is a growing opinion that NGOs do not live up the expectations and might even makethings worse. As Pfeiffer, who worked for an NGO in Mozambique for many years, states, the current NGO model is deteriorating the public primary health care programmes. Are NGOs indeed a burden to the health care systems in developingcountries?

Reaching the poor

Many NGOs characterize themselves as working for the poorest of the poor.However, despite having good intentions, they seem to fail at this point. An example from Bangladesh described by Zaidi et al. shows that the largest NGOs in the country are reaching less than 20% of landless households andfail to address the actual needs of the people. NGOs are blamed for carrying out projects the way their donors require, instead of using the ideas and knowledge of the local people to fulfill their needs.

Cost-effectiveness and efficiency

When Western donors regard a government as bureaucratic or corrupt, they often prefer to give their money to international NGOs instead. However, there is no proof that international NGOs work more cost-effective and efficiently. On the contrary, they have very high expenses compared to governments and local NGOs, mainly due to the high administrative costs (overhead costs account usually for 30-40% of project funds). Research from East-Timor, India and Bangladesh shows that the work of international NGOs is associated with high costs and that more people will benefit against lower costs if work is handed over to the government or to local NGOs.

Example of good governance: East Timor

After the civil war in East Timor (1975-2001), a government-led district health system was established by the government,international agencies and NGOs. A long term plan was developed based on consensus among all actors and was carriedout mainly by NGOs for the first period of time. In 2002, thegovernment was handed over full responsibility. In East Timor, the standardization of health services and provision

of the same basic package of care throughout the country improved the geographic equality and health care in general, showing that a good national coordination of aid and health care provides sufficient health care to everyone. Legitimacy of the system, trust by external actors, small size of the country and social cohesion in the state were favourable conditions to accomplish this success.

Working environment

Most international NGOs have their own Western staff working in local projects who get paid much more than the local health workers. Pfeiffer calculated that in Mozambique in oneyear, an expatriate earns the equivalent of twenty times the annual salary for a similar job in the national health care system. NGOs that do hire local staff, pay them much more than the national government would. This enhances brain drainwithin the country as locals prefer to work for NGOs instead of for the state.

Expatriates often receive funding for housing in private compounds, transport and personal vacations. As a consequenceof this exclusion from the community, developing a relationship of trust is very difficult. Furthermore, this inequality discourages government health workers, which in turn causes frustration by the NGO workers who see the localsas obstacles to implement their projects. Moreover, it causesunder-the-desk charging by local health workers. And above all it lures away the health workers from the national healthsystem.

Coordinating aid to the health sector

Good coordination of health care and good regulation of aid is important to make sure that health care is provided to everybody at a standard level. Organizational effectiveness

requires learning, communication, initiative and risk-taking.These elements are often absent in bureaucratic and highly formalized structures, which were thought to exist in governments mainly but appear to play a role in lots of international NGOs as well.One of the major problems is that many foreign agencies arrive with their own projects, approved by their donors or head offices, with very specific objectives and targets that have to be met to ensure their funding. This entails that NGOs often neglect the overall functioning of the health care system, thus disregarding the impact of their implemented programmes.As a good example, in Bangladesh, the Bangladesh Population and Health Consortium (BPHC) receives money from international agencies and dividesit among local NGOs. The BPHC coordinates the health servicesthroughout the country, thus making sure that the same package of services is provided to everyone, instead of different standards depending on the different levels of performance of NGOs.

The NGO Code of Conduct for Health Systems Strengthening

NGOs will engage in hiring practices that ensure long-term health system sustainability.

NGOs will enact employee compensation practices that strenghten the public sector.

NGOs pledge to create and maintain human resources training and support systems that are good for the countries where they work.

NGOs will minimize the NGO management burden for ministries.

NGOs will support Ministries of Health as they engage with communities.

NGOs will advocate for policies that promote and supportthe public sector.

Sustainability

There are several things that undermine the sustainability offoreign aid. First and most important is the dependency of

NGOs on their donors. Donors want to see value for money, demonstrated in measurable results. As NGOs depend on these donors to be able to continue their work, they often work with very restricted projects on short-term basis which undermine the broader goals of the health system. A study in Bangladesh by Edwards et al. among four NGOs shows that success is more likely when organizations identify a clear long-term goal at the outset and stick to it over time. Agencies that change their goals too often or try to achieve too many goals often lose their way.

A second problem is the current trend of expatriates moving from contract to contract, trying to make promotion. This results in a high turnover of staff and aid workers letting their own interest prevail, which goes at the expense of establishing a sustainable national public health sector.We can conclude that ,although we can not generalize about all NGOs, it seems that they indeed deteriorate the primary health care system at some points. They create an atmosphere of inequality and exclusion in the community and lure away the health workers from the government health system. Besides, they do not live up the expectations of being more cost-effective and efficient compared to the governmental health system.The main reason for the malfunctioning of international NGOs is the donor dependency, leading to short-term specific goals imposed by donors instead of meeting the needs of the people. This results in unsustainable aid, bureaucracy and high overhead costs. Besides, the current mentality of most expatriates (moving from contract to contract and looking for career options) leads to an instablesituation. NGOs have money and knowledge, but at this moment they are not using it in the right way. To create a sustainable health care system they should cooperate with thestate, creating a long-term plan of a national health care system and making the government the main responsible party after a few years. Aid should be channeled into the country through one national institution that should be able to

divide it without being stuck to short-term direct measurablegoals. NGOs should employ and train as many locals as possible instead of bringing their own expatriates, providingthe same salary as the national health care system does. The example of East Timor shows that it is possible to reach a good functioning health care system in this way in certain countries. Although NGOs do not live up expectations, donors still have more confidence in NGOs than in governments. Donors want to avoid the corruption that takes place in some countries and it is easier for donors to influence NGOs than governments. On the other hand, the corruption in government health care is being worsened by the presence of NGOs, because of the huge inequality in income. Changing the situation will be difficult because of a lack of trust in governments and in the capability of local health workers. However, NGOs should use the experience of governments to establish a long-term plan.

Non-Governmental Organizations and Primary Health Care - 1978

NGOs and Primary Care In May 1977 the World Federation of Public Health Associations (WFPHA) accepted an invitation from the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) to develop a position paper representing views of nongovernmental organizations about primary health care for presentation at the International Conference on Primary Health Care to be held in September 1978 in Alma-Ata, Kazakh, SSR. The WFPHA consulted a large number of nongovernmental organizations (NGOs), both those inofficial relationship with WHO and UNICEF and many other interested NGOs, national and international. The results of these consultations formed the basis for discussion at the IIInternational Congress of the WFPHA, hosted by the Canadian Public Health Association in Halifax, Nova Scotia, in May 1978. The present paper is a synthesis of this process. Thispaper presents the concern and involvement of nongovernmentalorganizations with issues of health and development. It

identifies the range of that commitment and what is needed totranslate it into action. However, it is neither a definitive description nor a complete list of all the programmatic aspects of primary health care. Instead it identifies aspects now requiring greater emphasis and understanding as well as contributions that nongovernmental organizations are able and ready to make in order to achieve primary health care objectives. Nongovernmental organizations endorse the present WHO/UNICEF concept of primary health care. They accept as a fundamental starting point that health care for the preservation and promotion of health is one of the most basic human rights, as declared in the Universal Declaration of Human Rights: "Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing, and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age, or other lack of livelihood in circumstances beyond his control." (Article 25). Their programs, ranging from researchto community-based projects, cover the wide spectrum of humanconcerns and often pioneer in the fields of health and development. NGOs include the strictly professional,specialized, and technical organizations; broadly-based associations of persons or groups organized for a particular purpose (e.g., information and service activities, educational institutions and associations, social welfare organizations, religious groups, women's organizations, youthgroups, trade unions, family planning associations, etc.); and agencies engaged in various types of self-help economic and social development programs. Many are linked to international federations or associations.

In most countries, there are national and/or local citizens' movements, self-help groups, cooperatives, and other associations, some organized on a tribal or ethnic basis, others to meet special needs. In the field of health, NGOs

have long helped to set standards for practice, training, andcontinuing education and to define the role of health workersin national programs. Others have concentrated on a particular disease or activity (e.g. cardiovascular diseases,leprosy, tuberculosis, programs for the disabled, etc…).

The diverse programs and competencies of numerous organizations, not directly involved in health care, also contribute in one way or another to total human development. They include projects to improve nutrition, food production, and housing; provide safe water; promote literacy; provide educational and other instructional materials; further community development; provide training in a broad range of skills; protect the environment; etc. In short, they are helping to create conditions conducive to the protection, promotion, and maintenance of health and the prevention of illness.

Recent years have seen a growing capacity of nongovernmental organizations to develop patterns of cooperation among themselves locally, nationally, and internationally, for consultation and exchange of information, or for joint action.

III. Primary Health Care and Development 1. Integrated Human Development Nongovernmental organizations support the view that the promotion of primary health care must be closely tied to a concern for total human development. The totality of human development and, in fact, a holistic view of health encompasses the physical, mental, social, and spiritual well-being of the individual. III-health comes to rich and poor alike. However, much ill-health is a result of poverty and initself is a serious barrier to breaking out of the bondage ofpoverty. Thus substantial improvements in the well- being of people cannot be expected merely as a result of better healthcare, but requires a whole range of social, economic, political, and cultural activities, i.e., primary health care

must be an integral part of the overall development of society.

Human development cannot be fragmented. Social and economic factors are closely interrelated and interdependent. It is not enough, for example, to disseminate health and nutrition education if land tenure and utilization preclude the production of adequate food for local consumption. It is futile to promote a health insurance scheme if employment opportunities are so limited that participation is beyond thereach of many. Provision of a source of clean water to a community will have an impact on water-borne diseases only insofar as the community is educated in its use and management.

2. Community Participation The integrated approach to human development embodies a concern for "people rather than merely"economic growth." It takes into account the needs and aspirations of the population and aims at providing the community with the means to promote its own well-being and toparticipate in its own health care. All factors that improvethe quality of life must be integrated and made available. Meeting community needs is the basis for the design and implementation of any primary health activity. It calls for the involvement of community members at all stages of planning and implementation of such activities and, in satisfying those needs, promotes a confidence within the community for further involvement in development activities. Initiation of health care services often provides the openingwedge for a broader approach to community development. Efforts to secure the fullest possible participation of the community in all aspects of this process are dictated not merely by considerations of economy and efficiency but by theconviction that this is an enhancement of the individual, a necessary part of achieving a basic human right which is presently unattainable in conditions of poverty. Where the patterns of poverty, dependence, and marginalization are

engrained, a motivational process is needed to create awareness in those who believe there can be no change; that possibilities in fact do exist for change.

There are several approaches to health care and none is universally applicable. The appropriate form of primary health care will vary with the differing needs of the community. There should be a rational balance among the curative, preventive, promotive, and rehabilitative components. Education of the community is essential for maximum use of the "primary" approach and for increasing the responsibility of individual families for their own health care, such as well-informed self-medication and modification of life-styles. Ample opportunities for a self-sustaining style of health care can be realized by relating the health care system to other community development programs, such as fishing and farming cooperatives, credit unions, and insurance schemes. Over-financing of primary health care is as serious a problem as under- financing. It tends to create unsustainable structures and institutions, and to reinforce patterns of dependency. Levels of external assistance must beappropriately limited in order to promote the self- reliant use of local resources.

What NGOs Can Do

At all stages in the development of primary health care programs, NGOs can be effective. Recognition by government of the contributions NGOs can make in supportof primary health care will ensure maximum benefits of these contributions to the national health program.

. NGOs can work for greater understanding and positive attitudes toward primary health care by: (a) promoting dialogue both within and among NGOs; (b) sustaining dialogue with governmental authorities; (c) providing information and creating new ways of explaining primary health care to the general public; and (d) strengtheningmeans of communication to accomplish this.

NGOs can assist national policy formation in the areas of health care and integrated human development. They can present health care needs based on their contacts with communities, and they can also interpret primary health care plans to relevant donor agencies.

NGOs can establish means for greater collaboration and coordination of primary health care activities. This canbe done among NGOs and between them and governments, locally, nationally, and internationally.

. NGOs can contribute to primary health care in many ways through program implementation. They can: (a) provide assistance to develop and/or strengthen local NGO capabilities and activities with particular attention to local community development groups; (b) conduct reviews and assessment of existing health and development programs and assist communities in the exercise of their own role in such reviews; a greater emphasis on evaluative techniques will render all new programs more accountable to real community needs; (c) develop innovative programs placing primary health care in the context of comprehensive human development; (d) ensure that their existing programs and new initiatives promote full participation by individuals and communities in the planning, implementation, and controlof these programs; (e) expand their training efforts torespond to the needs of primary health care programs, e.g., training of health workers, supervisors, administrators, planners, and various agricultural and development workers; included would be training schemes which build on the skills of traditional healers and midwives; (f) extend their efforts to develop locally sustainable and appropriate health technologies and use of resources, with particular attention to energy, water, agriculture, sanitation, and medical care; (g) contribute to the creation of new and effective methods of health education which enable both individuals and communities to assume greater responsibility for their own health; (h) recognize the essential role of women inhealth promotion and in the full range of community development concerns; (i) further extend their capacity to work with poor, disadvantaged, and remote populations, enabling them to break the cycle of

deprivation and in this way contribute to the search forgreater social justice.

Grand Challenges: Integrating Mental Health Care into the Non-Communicable Disease Agenda

As countries develop and progress, health priorities must expand beyond eradication of communicable diseases to includecontrol of non-communicable chronic diseases (NCD). Four primary NCD – cardiovascular disease (mainly heart disease and stroke), type 2 diabetes, some cancers, and chronic respiratory diseases — henceforth referred to as “physical” NCD — are responsible for 35 million deaths annually. They are the leading cause of mortality in the world, much of which is premature and avoidable. Nearly 80% of NCD deaths occur in low- and middle-income countries Over the last 20 years, the burden of disease, i.e., the impact of NCD worldwide as measured by morbidity and mortality, rose from 47% to 54% An aging population, longer life expectancies, population growth, urbanization, and globalization of risk factors have made NCD a threat to worldwide development and economic growth and an urgent global health priority. This article, the third in a series of five, argues that mental health care should be integrated into the NCD agenda, reviewsthe evidence for models of integration in high- and low-income countries, identifies the challenges and opportunitiesfor addressing the rising burden of mental health and NCD, and recommends strategies to advance a more integrated agenda.

Evidence for Integration; the Strong Connection between Mental Illness and NCD

The burden of mental illness has been underestimated, in part, because the links between mental health and other health conditions are not well understood. As the population grows and ages, more individuals live longer with physical NCD and mental illness. These chronic conditions are related

in complex ways. Major modifiable risk factors for NCD, such as poor diet, physical inactivity, tobacco use, and harmful alcohol use, are exacerbated by poor mental health. Mental illness is a risk factor for NCD; its presence increases the chance that an individual will also suffer from one or more chronic illnesses. In addition, individuals with mental health conditions are less likely to seek help for NCD and symptoms may affect adherence to treatment as well as prognosis. Depression and disorders related to alcohol use predict the onset, progression, management, and level of disability associated with the NCD The prevalence of major depression is consistently higher for persons with physical illnesses than for those without these disorders; e.g., 29% with hypertension, 22% with myocardial infarction, 27% with diabetes, and 33% with cancer The odds of noncompliance with medical treatment regimens are three times greater for depressed patients compared with non-depressed patients Health-related quality of life is significantly lower for depressed patients than for patients with asthma, arthritis, and diabetes Alcohol use is causally linked to eight different cancers, and the risk of developing these cancers increases with increased rate of consumption. Similarly, alcohol use is related to many adverse cardiovascular outcomes, including hypertension, hemorrhagic stroke, and atrial fibrillation, and to various forms of liver disease and pancreatitis The life expectancy of patients with psychotic disorders is two decades shorter due to the cardiovascular disease that may co-occur with their mental health condition [10]. Other major co morbidities among psychotic patients include prediabetes and diabetes mellitus.When antipsychotic drugs are prescribed, the risk of weight gain, obesity, type 2 diabetes, and sudden cardiac death increases. The bottom line is that the pathways leading to comorbidity of mental disorders and physical NCD are complex and bi-directional, and care for persons with these conditions needs to be coordinated.

The Collaborative Care Model

The growing burden of NCD and mental disorders demands new ways of organizing health systems and clinical practices to deal with new challenges. As many as 15 to 30% of all patientreferrals for mental health care are made by primary care physicians; mental health care and NCD care should be offeredtogether in primary care platforms A promising strategy is touse a collaborative care model, which restructures the roles of health care providers and introduces a team-based approachto management of chronic and complex medical conditions. Tasks can be shifted and shared with specialists supporting primary care providers and community health workers to routinely identify patients who need care (case finding); assess risk factors; educate patients about their illnesses, risk factors, and treatment; intervene with a combination of brief evidence-based pharmacological and psychosocial treatments; teach self-management skills; monitor patients' progress and adherence to treatment; and follow-up over the long term.The effectiveness of collaborative care in improving quality of care and patient outcomes is well established for single conditions, such as depression in primary care settings .Increasingly, its effectiveness is recognized for the treatment of depression among patients with cancer diabetes and hypertension in high-income countries Evidence also supports the effectiveness of collaborative care in treating patients with alcohol-related disorders. Screening, brief interventions such as motivational interviewing, and referral are feasible and can be effective in primary care settings for treating individuals who engage in high-risk drinking [25],[26]. In 23trials, brief (10- to 15-minute) multi-contact interventions among adults receiving behavioral interventions decreased consumption by 3.6 drinks per week from baseline and reduced heavy drinking episodes by 12%. In addition, 11% more adults compared with control participants reported drinking less than the recommended limits over a 12-month period.

Challenges and Opportunities

We have a challenge and an opportunity: to embed mental health care services into primary health care platforms globally. Although these services are being integrated into some primary care settings in the United States and other high-income countries, the collaborative care model has not been widely adopted. Low- and middle-income countries face greater challenges because of grossly under-resourced primarycare systems and an even weaker mental health infrastructure.Treatment for most mental health conditions is largely provided in large psychiatric hospitals without adequate referral networks in all levels of care and health systemsLimited human resources, lack of training in mental health and NCD care, and fragmentation within the health systems pose significant challenges. However, health care systems in low- and middle-income countries are developing and changing rapidly, creating an opportunity to shape these systems as well as to learn how best to embed mental health services in a variety of different health system environmentsand socio-cultural contexts.

It is now imperative that the mental health and NCD agendas are coordinated to leverage current political and funding commitments, particularly those aimed at reaching the Millennium Development Goals

Use Collaborative Care Approaches in Primary Care Settings.

Management of chronic disease relies on opportunistic case finding, assessment of risk factors, detection of early disease, identification of high-risk status, combined pharmacological and psychosocial interventions, and long-termfollow-up with regular monitoring and promotion of adherence to treatment. Collaborative care models are financially feasible and have the potential to substantially reduce the burden of managing chronic diseases. Many interventions can be managed effectively by non-specialists and lay health care

workers who are supported by specialists. Although implemented in a range of settings, collaborative care modelsare delivered best in primary care settings.

Promote Task-sharing and Task-shifting.

Most current research focuses on task-shifting from mental health specialists, such as psychiatrists, to physicians and nurses. However, a small but growing literature from low- andmiddle-income countries suggests that lay health care workersalso can be effective, especially when providing screening, psycho-education, and brief behavioral interventions. A well-established body of research exists on implementation of evidence-based practices by primary care providers in high-income countries, including interpersonal therapy, cognitive behavioral therapy, behavior activation, and problem-solving therapy for management of depression and anxiety conditions and motivational interviewing for alcohol use disorders. Other evidence suggests these same practices, particularly when simplified, can be effectively delivered by health workers with abbreviated training in low- and middle-income countries. Consider the Unique Social, Political, Cultural, and Health System Environments.

Input from those who live in the communities where collaborative care interventions are implemented can be invaluable in ensuring that the interventions are appropriateand sustainable within local health systems. Local leaders, health providers, caregivers, and patients can provide information about local needs, risk behaviors, and the availability of resources. Where health providers are scarce and family orientation is strong, the engagement of family and other caregivers may also support patients in making healthier lifestyle choices, adhering to treatment regimes, and better managing their chronic conditions. The use of context-appropriate, community partner strategies can empowercommunities to leverage local resources and develop local solutions.

Increase Funding for Primary and Mental Health Care ,and for Research.

Primary health care and mental health care are generally underfunded around the globe, especially in low- and middle-income countries. In-country investments are needed to demonstrate national ownership, which is key to translating these commitments to real policy and system changes. To meet the challenge of providing integrated mental health and physical NCD care at the primary care level, more investmentsare needed to strengthen health care systems, to expand the roles of traditional providers to manage multiple chronic diseases, and to train these individuals for those roles.The evidence for integrating NCD care and mental health care intoprimary care comes largely from studies in high-income countries focused on patients with co-morbid physical NCD anddepression. More research is needed to understand the best strategies for integrating care for chronic illness with carefor a wide range of mental health conditions, particularly alcohol use disorders and severe mental illness, and to address the implementation of collaborative care models into settings in low- and middle-income countries .Efforts to sustain and scale up of efficacious interventions in primary care settings face several challenges. Health workers are already overburdened with many responsibilities, and in many settings, there are not enough resources to regularly supervise lay health workers and to support them with specialist advisors. More research is needed to examine how to best train lay health workers, what tasks can be shifted to what type of provider, coordination of care between NCD and mental health specialists, and what supervision models are needed to support effective implementation particularly in low-resource settings

It can be said that, it has been tested and proved that inclusion of mental health issues in CBR programs is possible, cost effective and help building an environment

where in people with all disabilities access their entitlements and enjoy equal opportunities for full participation in their own communities. A different and better world for all people, including PWMI can be created through community based mental health services, where in the communities understand issues related to mental health, resulting in positive response to the issues. In this scenario the families of people who are mentally ill are vitally involved in bringing change in the attitude of the community. Through these an environment of mutual understanding can be built, where in PWMI enjoy their rights.

About volunteering in India

Volunteering plays and has played an indispensable role in human civilization. Volunteer Service is all about contributing one’s time or talents for helping others for various worthwhile purposes. Volunteering is a two way process of gaining firsthand knowledge, experience and lending a helping hand to society. Volunteering in India is aunique blend of work and cultural submergence as Indian Subcontinent is a conglomerate of different culture, languages, traditions and people. And despite of its high growth rate, India lies in the bottom twenty of Human Development Index. Poverty is commonplace here, and living conditions are too poor to live in. While providing VolunteerService in India, you have a number of options for socio-geographical expeditions integrated with social work and a journey towards inner-self. Here you can enjoy a plethora of ecological variations ranging from rain forests to the great Thar desert, or from world-famous sea coasts to Himalayas. The culture is the oldest and traditions are a conflate of various tramontanes who came here and got merged with ours.

Objectives of the study

explore the need to employ mental health care professionals in nongovernmental organizations to address issues concerning individual’s health ,

To highlight the significance of psychologists in nongovernmental organizations, in order to progress towards social development.

Research problem

To explore the availability of mental health care services in the NGO in concern during the period of volunteer ship