HOW RWANDA BEAT THE HEALTHCARE CURVE

By Staff Writer Jennifer Grundman

In 1962, Belgium, which had been granted the formerly German colony of Rwanda-Urundi in the Treaty of Versailles, relinquished control of Rwanda. Finally independent, Rwandans elected their new president, a Hutu man named Gregoire Kayibanda. Though no longer under European rule, Rwanda still suffered the effects of German and Belgian realpolitik: When Germany first claimed Rwanda as its colony, it set about concentrating local power in the minority Tutsi ethnic group, which had long enjoyed a peaceful hegemony over the majority group of Hutus. But with the Europeans gone, the tensions between the two groups, exacerbated by Belgian and German meddling, came to a breaking point. With a brutality that presaged the genocide in the mid-1990s, fighting between Hutus and Tutsis erupted sporadically from 1962 to 1973, often resulting in Tutsis either fleeing or being killed. Then, in 1994, Hutu extremists assassinated President Juvenal Habyarimana, who had taken power in 1973 with a vow to end the strife.16 The assassination sparked a premeditated, 100-day genocide that decimated Rwanda’s infrastructure, destroyed its fledgling health care system, and left close to a million Tutsis dead. This history makes it all the more remarkable that today, only a little over 20 years later, the country that most Western powers dismissed and thought would turn into another failed state has become a pioneer in health care and health equity, with 91 percent of its population, as of 2012, with health insurance.

Just after the genocide, Rwanda’s health care system was in desperate straits, with only 198 healthcare professionals in the country to service thousands of people, with rates of HIV — already high before the genocide — rising due to the extremists’ weaponization of rape, and with a paucity of medical training facilities in a largely agricultural population.4 For six years afterward, the government tried to return to the decentralized management of health care that it had used before, but to little benefit. Though in theory the government offered free healthcare to everyone, the underfinanced system’s lack of resources did not provide adequate care. The government tried to support its health centers through high user-fees, yet the ailing system fared no better: In 2001, a survey revealed that only 23 percent of Rwandans used primary care, and infectious diseases, including HIV, were spreading further throughout the population.7

To reverse this slide required forceful, competent government leadership. Rwanda found just that in Paul Kagame, a member of the Rwandan Patriotic Front, a Tutsi-majority political group that had organized in Uganda prior to the genocide and that had invaded Rwanda in an attempt to stanch the carnage in 1994. After a brief stint as vice president, he succeeded President Pasteur Bizimungu after Bizimungu resigned in 2000.4 Soon after his succession came one of Rwanda’s guiding policies for the future, Vision 2020. This document, whose goal is to transform Rwanda into a middle-income country by 2020, is in some ways grounded in the past, even as it looks to the future. Parts of it, such as its focuses on reducing poverty, providing support for all levels — local and national — of health services, and its recognition of health as a factor in economic growth, hearken back to the Declaration of Alma Ata, which was written in 1978 after an international convention sponsored by UNICEF and WHO met in Alma Ata, then part of the Soviet Union.3,15 The Declaration’s goals, among other things, were to promote primary health care, equalize access to health care, and provide support for a bottom-up approach to health care that started with local communities. Since 1978, Rwanda shared the Declaration’s ambitions; yet in 2000, though the country was again ready to implement them, Vision 2020’s mission was hampered by a lack of funds. This meant that widespread food insecurity, along with AIDS and epidemics of other infectious diseases, continued to wreak havoc on Rwandans. In one telling statistic, only 870 of thousands of HIV-positive Rwandans, most of whom were in Kigali, Rwanda’s richest province, received antiretroviral therapy as of December 2002.4,5 If Vision 2020’s ideals were to have even a hint of realization, Rwanda would need far more funding than it had.

Luckily, such an opportunity came in 2002, in the form of The Global Fund to Fight AIDS, Tuberculosis and Malaria, a nonprofit organization dedicated to stopping epidemics of its titular diseases. Paulin Basinga, who works for the Bill and Melinda Gates Foundation, remarked in 2014 that while many countries failed to produce an application for Global Fund, Rwanda was careful not to miss anything — it needed that grant, and the government made sure it would receive it.6 This money was put into a program for voluntary counseling and testing, or VCT, which focused on reducing HIV and AIDS.4 Since then, Rwanda’s efforts to cut rates of HIV have been rewarded: From 2002 to 2015, the prevalence of HIV in Rwanda fell from 4.2 percent to 2.9 percent, following a precipitous drop from 1994’s high of 6.3 percent.9

Global Fund is not the only source of aid for Rwanda — Rwanda has several foreign aid and non-governmental organizations assisting it in its health care goals, yet Rwanda is unique in that it avoids the pitfalls that befall other countries which make use of foreign aid. Basinga noted that there is often a disconnect between the aid coming into a country and the local government’s ability to effectively funnel that aid into its own projects, leading to failure in properly channeling the aid where it is needed. Yet Rwanda’s tight control of its foreign donations and the work of NGOs in the country has reduced inefficiencies in the way foreign help is utilized.6 Indeed, Rwanda’s Ministry of Health is unwavering in its requirement that its partners are financially well-managed, transparent, and accountable, and it declines the aid of any NGOs that refuse to work within Rwanda’s overall plans.5

Another example of Rwanda’s practical use of outside funding is its mutual health insurance schemes, Mutuelles de Santé, which became national policy in 2004.4,18  The goals of Mutuelles are to enable people to receive proper health care by cutting down on financial restrictions, to supplement health facilities’ budgets, and to better the quality of health services.4 Since 2008, Rwandans have been required to have some form of health insurance, with Mutuelles being the largest source of insurance for many. Though all members are technically required to pay annually into Mutuelles, the poorest have their membership subsidized by the government.2

As of 2005, the overall health gains of Rwandans were still unsteady. To address the recurrent problems of high child mortality, untreated illnesses, low life expectancy, and financial barriers to health care, the government formulated the Health Sector Policy and the Health Strategic Plan (2005–2009), which was a reform meant to be “the basis of national health planning and the first point of reference for all actors working in the health sector.” It would also “[set] the health policy objectives, [identify] the priority health interventions for meeting these objectives, [outline] the role of each level in the health system, and [provide] guidelines for improved planning and evaluation of activities in the health sector”.10 To meet its aims, the policy pledged to increase the availability of medications, to enhance the availability of medical professionals, to ensure geographic accessibility to well-maintained hospitals, to augment funding for health services from public sources, to develop better ways to control infectious diseases, and to support communities in forming health care systems.10

In addition to all this, the Health Sector Policy affirmed Rwanda’s support for a decentralized health care system whose focus would be on providing proper health care at the community level.10 Rwanda’s health administration is separated into three tiers, with the top tier responsible for creating national health policies, the second tier comprising 30 administrative districts responsible for their respective district’s hospital and primary care facility, and the third tier composed of primary health care facilities.4 Since the years right before the genocide, Rwanda has maneuvered from a centralized health care system to a decentralized, bottom-up system that holds as its basic unit the community and its primary health care centers. 4,10

To support this vision of decentralization, the Rwandan Ministry of Health launched the National Community Health Policy in 2008, with the desire to provide guidance to communities in reaching international health commitments.12 In part, the policy stresses the importance of community health workers — men and women trained in health topics, who bear responsibility for adapting health standards to the culture and needs of their community. In order to satisfy health objectives, the government’s Community Performance-Based Financing, a program introduced to all 30 districts in 2005, ensures that community health workers and local administrators are paid according to how well their community has met its health targets.12

With most of the Health Sector Strategic Plan’s points met before or on track to be met by 2008, the Rwandan government found itself in need of an updated mission.11 It achieved this through the Health Sector Strategic Plan II, the aim of which was to coordinate health-improvement efforts with the Economic Development and Poverty Reduction Strategy, another government program. The policies’ ultimate purpose was to reach the marks of the Millennium Development Goals, which was a U.N.-led initiative to reduce extreme poverty, combat hunger, improve child mortality rates and maternal health, and fight AIDS and other diseases by 2015.11,20

Though Rwanda was making considerable progress, it was still being hamstrung by an outdated, inefficient way of collecting data: It had up to 450 health collecting data, but the machines used to transmit the information were not connected to the web. As such, everything had to be first placed on a flash drive and then sent monthly to one of the district hospitals. This meant that crucial data that could be used to formulate health policies were being assembled in an agonizingly inefficient and ineffective way. To remedy this, Rwanda’s Ministry of Health partnered with the Integrated Health Systems Strengthening Project, a move that was partly bankrolled by the United States Agency for International Development. In this time, IHSSP trained data managers who would be able to process and analyze incoming data from the new system, which was developed to be user-friendly and focused on the most important data points, among other features. 19

With Rwanda’s data collection process streamlined, IHSSP aided the Ministry of Health in creating the Health Sector Strategic Plan III (2012–2018). Though Rwanda met several of the Millennium Development Goals before 2015, this policy maintains the country’s overall objectives to improve maternal and child health, combat infectious diseases, increase access to health care, and enhance the quality of provided care.14,19

As of 2011, Rwanda had around 45,000 community health workers and a sizeable population of nurses and doctors. Yet the quality of health care still had much to improve upon: Those health care professionals had received either very basic education in health, which was instrumental in cutting down on the rate of infectious disease, or they were general physicians. This left a vacuum in the health care system where specialists were concerned, and the quality of health care suffered for their absence. However, in 2011, the Ministry of Health requested that the Clinton Health Access Initiative, an organization it had worked with in the past, aid the country in creating partnerships with U.S. universities to help train Rwandan medical specialists. Through this plan, named the Human Resources for Health Program, U.S. university faculty members have and will come to Rwanda to train at least 500 physician specialists by 2018.1

Rwanda’s Demographic and Health Survey (2014–2015) confirms the effects of the country’s diffuse efforts to improve public health. For example, the number of children born to women in 2005 was 6.1; in 2014–2015, that number was cut to 4.2. The mortality rate of children under five has also fallen, from 196 out of 1000 children dying in 2000, to 50 out of 1000 in 2014–2015.13 Finally, Rwanda’s life expectancy at birth has risen from 50.781 in 1985 — the highest number before and after the genocide until 2003 — to 63.966 in 2014.8

Yet despite Rwanda’s admirable gains, there remains much to work on. Rwanda is still a poor country, with 63.2 percent of Rwandans living below the poverty line as of 2011.17 Rwanda’s health programs also face a sustainability problem — Rwanda’s reliance on foreign aid that can be precarious in times of global economic crises has proved worrying.21 In addition, the country needs to make continual progress on its fight against infectious diseases, poverty, financial barriers to health care, and many of its other focuses. But from climbing their way back up from the destruction of a civil war and genocide, Rwandans can enjoy their new vantage point.

Image By Evan Blaser

Sources:

  1. Binagwaho, Agnes, Patrick Kyamanywa, Paul E. Farmer, Tej Nuthulaganti, Benoite Umubyeyi, Jean Pierre Nyemazi, Soline Dusabeyesu Mugeni, Anita Asiimwe, Uzziel Ndagijimana, Helen Lamphere Mcpherson, Jean De Dieu Ngirabega, Anne Sliney, Agnes Uwayezu, Vincent Rusanganwa, Claire M. Wagner, Cameron T. Nutt, Mark Eldon-Edington, Corrado Cancedda, Ira C. Magaziner, and Eric Goosby. “The Human Resources for Health Program in Rwanda — A New Partnership.” New England Journal of Medicine 369.21 (2013): 2054-059. Web.
  2. Binagwaho, Agnes, Renate Hartwig, Denyse Ingeri, and Andrew Makaka. Mutual Health Insurance and the Contribution to Improvements in Child Health in Rwanda. N.p.: n.p., n.d. African Development Bank. Web. 25 Nov. 2016.
  3. Declaration of Alma-Ata. N.p.: n.p., Sept. 1978. PDF.
  4. Desmond, Chris, Nadjeda Marques, and Habtamu Fuje. “Case Studies from Rwanda.” The Cost of Inaction: Case Studies from Rwanda and Angola. By Sudhir Anand. Cambridge: Francois-Xavier Bagnoud Center for Health and Human Rights, 2012. 23-53. Print.
  5. Farmer, Paul, Cameron T. Nutt, Claude Sekabaraga, Tej Nuthulaganti, Jonathan L. Weigel, Didi B. Farmer, Antoinette Habinshuti, Soline D. Mugeni, Jean-Claude Karasi, and Peter C. Drobac. “Reduced Premature Mortality in Rwanda: Lessons from Success.” The BMJ(2013): n. pag. The BMJ. The BMJ, 18 Jan. 2013. Web. 26 Nov. 2016.
  6. Insider Conversation: Rwanda — What Is Replicable? – The Science of Global Health: What’s Next? San Diego, California, 7 Jan. 2015. UCSD TV. Web. 20 Nov. 2016.
  7. Kayonga, Caroline. Proc. of Towards Universal Health Coverage in Rwanda. Brookings Global Economy and Development, n.d. Web.
  8. Life expectancy at birth, total (years).” The World Bank. The World Bank, n.d. Web. 28 Nov. 2016.
  9. “Prevalence of HIV, Total (% of Population Ages 15-49).” The World Bank. The World Bank, n.d. Web. 20 Nov. 2016.
  10. Rwanda. Ministry of Health. Health Sector Policy. N.p.: n.p., n.d. World Health Organization. Web. 26 Nov. 2016.
  11. Rwanda. Ministry of Health. Health Sector Strategic Plan: July 2009 – June 2012. Healthy Futures, n.d. Web. 27 Nov. 2016.
  12. Rwanda. Ministry of Health. National Community Health Policy. Www.advancingpartners.org, 2008. Web. 26 Nov. 2016.
  13. Rwanda. Ministry of Health. Rwanda Demographic and Health Survey 2014-15 Key Indicators. Ministry of Health, June 2015. Web.
  14. Rwanda. Ministry of Health. THIRD HEALTH SECTOR STRATEGIC PLAN JULY 2012 – JUNE 2018. N.p., n.d. Web. 28 Nov. 2016.
  15. Rwanda. National Development Planning & Research. Rwanda Vision 2020: Revised 2012. N.p.: n.p., n.d. Web.
  16. “Rwanda.” PBS. PBS, n.d. Web. 25 Nov. 2016.
  17. “Rwanda: Statistics.” UNICEF. UNICEF, n.d. Web.
  18. “Sharing the Burden of Sickness: Mutual Health Insurance in Rwanda.” Bulletin of the World Health Organization 86.11 (2008): 823-24. National Center for Biotechnology Information. Web. 21 Nov. 2016.
  19. THE RWANDAN HEALTH MANAGEMENT INFORMATION SYSTEM: Improving Collection and Management of Health Service Data to Support Informed Decision Making. N.p.: Management Sciences for Health, n.d. PDF.
  20. “UN Millennium Project | About the MDGs.” UN Millennium Project | About the MDGs. UN Secretary General, n.d. Web. 27 Nov. 2016.
  21. Rwanda. Ministry of Health. Health Financing Sustainability Policy. N.p., Mar. 2015. Web.

TOMS AND THE FAILINGS OF THE BUY-ONE-GIVE-ONE MODEL

TOMS AND THE FAILINGS OF THE BUY-ONE-GIVE_ONE MODEL

By Zaid Mansuri
Staff Writer

We as consumers live disconnected from the consequences of our consumption. The things we eat, drink, wear or possess require resources and manufacturing, the consequences of which we would usually like to ignore. In the age of information, consumers are ever more aware of the effects of their consumption, and companies understand that. Retailers tell us what we want to hear; they justify consumerism by promising to negate undesirable byproducts or externalities. Starbucks advertises the use of fair trade beans to assuage guilt for the living conditions of coffee farmers and their families. Go shopping at the mall and you are likely to see advertisements claiming 10% of every purchase will be directed towards charity. These promises are incredibly effective at helping consumers numb the guilt we feel for not doing more to help, but are far less effective at actually helping those for whose struggles we feel guilty.

Shoe brands like TOMS promise to donate one pair of shoes for every pair purchased. To date, TOMS has distributed sixty million pairs of shoes, helping socially-conscious consumers purchase shoes and feel good about providing shoes to a child who needs them. The buy-one-get-one model has been widely embraced by consumers and businesses alike as an effective model for creating both commercial and social value.

The very success of TOMS has encouraged other entrepreneurs to adopt the buy-one-give-one model. Watch company WeWood plants a tree every time you buy a watch. Smile Squared sells and donates toothbrushes. Soapbox gives soap to a needy child with every purchase. Two Degrees Food does the same with food. Online marketplaces, such as Roozt and Given Goods, host hundreds of brands that use a buy-one-give-one model or something similar.

The buy-one-give-one model of business is associated with a lot of feel-good tactics. This business model allows consumers, who may feel disconnected from the problems of the developing world, to engage social problems while still purchasing for themselves. The buy-one-give-one model feels intuitively more human and tangible than most estranged corporate philanthropy. You can look down at your shoes and feel as though some needy child also has a pair thanks to your transaction.

The charity of TOMS seems like a win-win situation, a shining example of charitable capitalism. However, evidence of the dismal consequences of such business models will dismay you. Distribution of aid-in-kind gives economists and experts plenty about which to be very concerned. According to critics, handing out goods creates an inefficient allocation of aid-spending. We are giving things the poor neither want nor need. I may want a nice new pair of TOMS, but the money spent producing a second pair could be put to much better use feeding those who are hungry than providing them with a product identical to the third pair of shoes I own. An oversupply of unneeded resources can lead to a twisted game of white elephant. Developing communities become burdened by a flood of unwanted aid.

Marketplace competition looms as another threat to such forms of charity. “There is definitely a need for footwear in underserved markets,” said Valeria Budinich, Vice President of Ashoka, a nonprofit that supports social entrepreneurs. “But those markets need new technology, production processes and distribution chains that [are specifically designed for] rural areas. Models like TOMS have many great features but aren’t designed to come up with that level of transformation.”[1]

Garth Frazer, an economist at the University of Toronto, published a paper in 2008 examining the impact of used clothing imports in sub-Saharan African countries, asking why bottom-round textile production has not emerged as a leading sector of development in Africa as it did in other developing regions of the world. He found that used apparel donations have had a strongly negative impact on domestic apparel producers in Africa. Using a regression technique known as instrumental variables, Frazer isolated the effect of clothing donations from effects of other potential causes like geographical setting or relative level of development.He found that while imports of cheap clothing benefit consumers, he estimated that used-clothing donations accounted for a 40% decline in production and a 50% decline in employment in the African apparel industry.[2]

TOMS’ efforts are done entirely through non-profit NGOs, non-government organizations. When a consumer buys a pair of shoes, a second pair of shoes is manufactured and shipped to the recipient country where a non-profit acquires and distributes them. TOMS shoes are not customized for the region. This is especially problematic when one considers that, although closed-toe canvas shoes may be effective in some situations, they are not as effective in areas with heavy rainfall or rocky terrain. Unless TOMS is going to pave highways where none exist, a pair of TOMS won’t do much good to those who receive them. These resources could be used to help developing economies in more useful ways. 

In response to withering criticism, TOMS studied the effects of its charitable methods. The company asked a group of academics at the University of California, San Francisco to investigate the social impact of the TOMS’ buy-one-give-one model on local developing economies. They promised that the researchers would be allowed to publish their findings, whatever those might be.[3]

Late in 2012, the economists randomly selected 979 households, comprising of 1578 children across 18 rural communities in El Salvador. Each household received a pair of TOMS’ rubber-soled black canvas shoes. Researchers sought to examine potentially differing effects in communities that received the shoes and communities that did not.

To measure the effects of the shoe donations, researchers attempted to answer two specific questions:

Does donating shoes negatively impact local markets by weakening demand for local shoe vendors?

The researchers tested this by giving two discount coupons to every household in the study, one for a cheap (≤ $10) pair of shoes at a local store, the other for a more expensive (>$10) pair of shoes. The researchers recorded rates of coupon redemption, testing whether redemption was lower in the treated communities. The estimates consistently indicated a small negative impact on local markets. Specifically, local shoe vendors sell about one fewer pair of shoes for about every 20 pairs of shoes donated into a local community, a statistically insignificant amount. The study concluded that shoe donations have no effect on demand for locally-made shoes. 

How do shoe donations impact individual recipients?

The researchers collected data on a wide array of outcomes: schooling attendance, general health, foot health, psychological impacts, and time allocation across an array of activities including schooling, homework, playtime, domestic chores, watching TV, eating and sleeping. They also asked recipients whether they actually wore the shoes and whether they liked them.

The results of the study presented positives and negatives for the TOMS business model. The good news was that 95% of the kids in El Salvador had a favorable impression of the shoes and wore them often: 77% of the children wore them at least 3 days per week, and the most common response by children was wearing them every day.

Good, right? Wrong.

Researchers also found that handing out the free shoes had little to no effect on rates of shoe ownership, general health, foot health or self esteem.  “We thought we might find at least something,” writes Bruce Wydick, one of the academics. He laments in a blog post, “They were a welcome gift to the children…but they were not transformative.”[4]

Despite his findings, Bruce Wydick was open in praise of TOMS. “TOMS is perhaps the most nimble organization any of us has ever worked with, an organization that truly cares about what it is doing, seeks evidence-based results on its program, and is committed to re-orienting the nature of its intervention in order to maximize results. In response to children saying that the canvas loafer isn’t their first choice, they now often give away sports shoes. In response to the appropriateness of their shoes in different contexts, in Mongolia they now give away these cute little kids’ snow boots. In response to the dependency issue, they now want to pursue giving the shoes to kids as rewards for school attendance and performance.”[4]

Companies have sought to change their models as a result of the negative backlash. For every pair of glasses a customer buys, Warby Parker covers the cost of sourcing and producing a second pair of glasses for partners like the social enterprise VisionSpring. VisionSpring, in turn, employs a network of 9,000 sales agents in 13 countries to sell glasses in their communities. The energy bar manufacturer Two Degrees Foods, which donates a meal to a hungry child for every bar purchased, has reinvigorated their program. The group partners with medical organizations to identify children suffering from malnutrition. The business group then contracts with local food manufacturers to produce culturally appropriate food: peanut-based meals in Africa, chickpeas in Pakistan, lentils and grains in India for example. “It’s not only economically better for the communities,” Lauren Walters, one of the company’s founders, told Mother Jones, a nonprofit. “It’s better for the environment, too, since you don’t have to ship the food around the world.”[5]

As for TOMS, the company has chosen to give shoes as rewards for children who join community building projects. In addition, TOMS hopes to see greater social good produced from their sunglasses program. For every pair of sunglasses bought, TOMS Eyewear provides a person in need with a full eye exam by trained medical professionals. Each patient then receives the treatment they need. Even Wydick is looking forward to this program for more life changing social change. However at the end of the day the perennial problem of the one for one shoes persists. The program is aimed at children who want shoes, but are unable to afford them. Footwear, besides being one of the first commodities offered in developing markets, is also one of the first things bought when families have access to money. For children who are too poor to afford shoes, other commodities (food, shelter, health care) would be more effective.

Alternative methods of distributing the shoes could help maximize positive effects on local economies. Economists suggest using money to subsidize the manufacturing of shoes in recipient areas. “If you told me the shoes were being produced and sold locally, helping with unemployment in the area, and they were paying good wages and had good working conditions, then that starts to be more appealing as well,” said Greg Dees, professor of social entrepreneurship at Duke University. “Those kinds of things tackle the underlying problem more.”[1]

The effectiveness of TOMS’ buy-one-give-one model is still in question. Nevertheless, the core idea of buy-one-give-one remains powerful. It allows consumers to engage with the the rest of the developing world in ways other charity programs cannot. To be effective, however, the models must be designed to be organic, sustainable and in line with the needs of recipients. 

  1. Bansal, Sarika. “Shopping for a Better World.” The New York Times. The New York Times, 09 May 2012. Web. 09 Nov. 2016.
  2. Frazer, G. (2008), Used-Clothing Donations and Apparel Production in Africa*. The Economic Journal, 118: 1764–1784. doi:10.1111/j.1468-0297.2008.02190.x
  3. Bruce Wydick, Elizabeth Katz & Brendan Janet. Do in-kind transfers damage local markets? The case of TOMS shoe donations in El Salvador. Journal of Development Effectiveness Volume 6, Issue 3, 2014. DOI: 10.1080/19439342.2014.919012
  4. Wydick, Bruce. “The Impact of TOMS Shoes.” Across Two Worlds. N.p., 16 Mar. 2015. Web. 09 Nov. 2016.
  5. Butler, Kiera. “Do Toms Shoes Really Help People?” Mother Jones. N.p., n.d. Web. 09 Nov. 2016.

Photo by Vivianna_love

MENTAL ILLNESS: INDIA’S SCARLET LETTER


By Nishad Maggirwar
Staff Writer

1.252 billion people, the population of the ever growing nation of India. With almost 18% of the world’s population residing in India, events that occur there tend to have a ripple effect throughout the world. One of the ripples that occurs in this growing nation is India’s inability to deal effectively with its mentally disabled/ill population. India is desperately struggling with its ability to deal effectively with its mentally disabled/ill population not only because of a staggeringly low number of trained mental health professionals, but also due to the outright neglect and public ridicule that these people receive. Mentally ill patients are the scorned population of India, and are not treated like everyday members of society. These people bear the Scarlett Letter upon their existence in society.

Studies done by the National Institute of Mental Health and Neurosciences (NIMHANS) have reported that 13.7% of India’s population have mental health issues, 10.6% are in a dire mental condition, and 1.9% have severe mental disorders (Yasmeen n.pag). Adding on to these statistics, 54% of the severe disorders recorded were Alzheimer’s disease, and 39% was vascular dementia (Koshy n.pag). Although 1.9% does not seem like a large number, keep in mind that 1.9% of India’s population is around 23 million people, which is larger than many South American and European countries. It is quite hard to imagine every person in a nation such as the Netherlands, with a population of around 17 million people, with a crippling mental disorder such as Alzheimer’s disease.

The treatment that mentally ill people receive in India is akin to a toddler’s wild imagination. Mentally ill people are believed to simply be “pretending” that they are disabled in order to receive attention and special treatment, and are somewhat told to simply “stop doing that”. Dr. Kersi Chavda, a senior psychiatrist at P.D. Hinduja Hospital in Mumbai explains how, “an anxiety-ridden or a depressed patient, is usually given tips like, ‘snap out of it’, ‘go for a movie and you will be fine’, or ‘just cheer up;” (“Mental” n.pag). It is as if mental illness is not even regarded as a legitimate illness, for there is a common conception that mental illness isn’t real but rather something someone brings upon themselves. An unsettling number of people believe that mentally ill people can simply get over their problems and move on (Batra n.pag).

“Tum paagal ho”, or “You are crazy” in Hindi, is what is often bluntly said to a mentally ill patient seeking medical help. Mentally ill individuals in India are often subject to public ridicule and discrimination. While people carelessly throw around the words “asylum” and “paagal” (crazy), mentally ill individuals are very hesitant to admit that they are seeing a therapist (“Mental” n.pag). Tannika Majumdar Batra, a resident of India living with bipolar disorder, explains that, “mental illness is seen as a sign of imperfection, humiliation, rejection by family, friends, and relatives” (Batra n.pag). Unfortunately, it has reached the point where mentally ill individuals in India are not a part of everyday society; they are social outcasts. These individuals often find it near impossible to get an adequate job, as explained by Dr. Harish Shetty, of Nityanand Clinic in Mumbai, who points out that “people are thrown out of jobs if they are mentally ill” (“Mental” n.pag). Perhaps the reason why people are so afraid to admit that they are mentally ill, if it isn’t already obvious or determined by a medical professional, is that this exclamation is what attaches the dreaded scarlet letter onto an individual’s life. The situation of mental illness in India has reached a point where suicide takes more lives than any other physical problem (Batra n.pag).

Among the myriad of social problems in India, ranging from human rights abuses to backwards ideologies that stunt the technological advancement of the nation, the outright neglect to take care of mentally ill patients, the clear lack of facilities capable of providing help, and the social stigma attached to mental disorders are definitely notable social issues. This stigma has given rise to the reality that 80% of people with crippling mental disorders, such as vascular dementia, do not quickly receive any form of care. Many of these people have been sick for over 12 months before finally acquiring low quality medical attention (Yasmeen n.pag).

India is a nation with many medical professionals, but among those medical professionals, there is only 1 psychiatrist for every 400,000 Indians (Koshy n.pag). In addition to this, there are less than 10,000 mental health care takers (social workers, psychologists, and psychiatrists) in the entire subcontinent (Koshy n.pag). Perhaps this is due to the fact that mental health is not of importance to India’s health agenda, which is quite surprising seeing as over 23 million individuals are suffering from serious psychological disorders. As a result of India’s rejection of this issue as pertinent, those seeking to pursue careers as mental health professionals are not in luck because there are only 1,022 college seats for people wanting to enter the field (Mascarenhas n.pag).

The future of India’s mental health patients looks grim because as the population of India increases to new heights, the aforementioned statistics are only going to increase unless the nation opens its eyes to the millions of people who are quietly suffering and waiting for some form of medical assistance. A clear example of India’s negligence towards this pressing issue is the lack  of mental health hospitals in certain parts of the country. Six states in the northern and eastern regions of India with a cumulative population of 56 million people, do not have access to a single mental health hospital (Mascarenhas n.pag). To put this into perspective, South Africa has a population of around 53 million people. Those who do not receive medical attention, and succumb to their mental illness, turn to suicide. Due to the lack of helplines and anti-depression resources, suicide rates have been increasing lately. In fact, three to four people in Mumbai commit suicide every day, despite knowing that suicide is a criminal act in India (“Mental” n.pag).

However, there is some light in this darkness since  the District Mental Health Programme (DMHP) is making some efforts to change this morbid reality. The DMHP is a governmental organization under the NMHP (National Mental Health Programme), who are focused on providing mental care to patients in various states across India. The quality of care varies from state to state because different regions in India have different local policies. It is possible that medical attention can be restricted due to restrictions on funding, not enough employment, and low motivation (Mascarenhas n.pag). Adding onto this, 40% of patients seeking medical attention must travel over six miles to get care from DHMP services (Mascarenhas n.pag). When considering the large number of impoverished people in India, this commute will most likely occur by foot.

It is extremely confounding how such a forward moving nation has neglected such a large demographic, and has seemingly allowed suicide rates to increase every year. It is appalling how the Government of India still believes that mental illness is not a legitimate illness, and has not appropriated funds and effort to help suffering individuals. A hospital in Mumbai was described to have its mental health ward located near its most neglected area; the morgue (“Mental” n.pag). The Government of India needs to institute major reforms to its health agenda in order to save millions of Indians from being outcasts, and brining their diseases into the light.

Works Cited

“Are Mental Health Facilities in India Adequate?” The Times of India. The Times of India, 29 Dec. 2014. Web. 31 Oct. 2016.

Batra, Tannika Majumdar. “Dealing with the Loneliness of Mental Illness in India.” International Bipolar Foundation. International Bipolar Foundation, n.d. Web. 31 Oct. 2016

Koshy, Jacob. “World Mental Health Day: India’s Mental Health Crisis in Numbers.” The Huffington Post. The Huffington Post, 10 Oct. 2015. Web. 31 Oct. 2016.

Mascarenhas, Anuradha. “Mental Illness India’s Ticking Time Bomb, Only 1 in 10 Treated.” The Indian Express. The Indian Express, 19 May 2016. Web. 31 Oct. 2016.

Yasmeen, Afshan. “India Needs to Talk about Mental Illness.” The Hindu. The Hindu, 23 Oct. 2016. Web. 31 Oct. 2016.

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