India's national suicide prevention strategy: An opportunity & challenge
The role of state governments in suicide prevention is critical since annual NCRB data on suicides shows several variances at the state level, thus a ‘one size for all’ approach would be ill-suited.
Over the past decade, India’s mental health legislation and policy framework have seen several positive developments.
In 2014 the National Mental Health Policy was released followed by the introduction of the Mental Healthcare Act, 2017 to repeal the erstwhile Mental Health Act of 1987.
A crucial component missing in this landscape has been a national policy for suicide prevention. However, with the introduction of the National Suicide Prevention Strategy (NSPS) - India’s first- this critical gap too has been filled.
Goal of NSPS
The NSPS has been introduced with the ambitious goal of bringing down suicide mortality in the country by 10%, by 2030. It attempts to adopt a multi-sectoral approach, recognising the role and influence of social determinants on suicidal behaviour, particularly among vulnerable groups, who may be at higher risk of death by suicide.
Some of the immediate objectives of the NSPS include (i) establishing effective surveillance mechanisms for suicide within the next three years; (ii) establishing psychiatric outpatient departments to provide suicide prevention services through the District Mental Health Programme (DMHP) within the next five years; (iii) to integrate a mental well-being curriculum in all educational institutions within the next eight years; and (iv) to strengthen surveillance of suicides for the purpose of monitoring and evaluation to study the effectiveness of the NSPS.
After the Mental Healthcare Act, 2017 (MHCA) came into force, in 2018, the Ministry of Health and Family Welfare constituted a committee to draft a national policy, to comply with the provisions of the MHCA on suicide prevention. It is four years later that the NSPS has been released. The introduction of the strategy, while delayed, is a welcome step, however, there is still much to be desired.
While the policy does attempt to do away with the biomedical approach to suicide prevention and adopts a more intersectoral approach by recognising the role of poverty, financial insecurity, educational pressures, domestic violence, etc., it is concerning that the committee responsible for drafting the NSPS comprised only of psychiatrists, suicide prevention experts and other healthcare professionals. Other key stakeholders such as persons with lived experience and their caregivers, civil society organisations, media personnel and representatives from the departments of education, social justice and welfare, labour and employment, women and child development and rural development and agriculture, were not represented on the drafting committee.
It also remains unclear whether or not these stakeholders were consulted before finalising the draft of the NSPS. Furthermore, the draft policy was not made available in the public domain for feedback and comments from the general public. The whole process, it appears has followed a top-down approach, and the appointment of only mental health professionals and suicide prevention experts to the committee undermines the NSPS’ emphasis on the importance of and need for an intersectoral effort.
Even though the NSPS does attempt to shed the biomedical approach, it does not do so very successfully. Several provisions under the NSPS focus on persons with mental illness rather than the general population, reinforcing the common stereotype and notion that it is only persons with mental illness who die by suicide. This is contrary to evidence from studies across the world which have shown that a majority of those who die by suicide do not have a prior history of mental illness.
For most of history and even today, suicide is typically understood as an individual problem or aberration, of no structural significance, devoid of any relationship with sociocultural, economic, and circumstantial realities. The biomedical lens which reduces suicide to a single factor or mental illness has further perpetuated this notion, framing the public discourse on suicide as a personal tragedy rather than as a manifestation of a complex sociological phenomenon. The NSPS does attempt to challenge these notions but falls short. It only mentions, in passing, the impact of financial insecurity and poverty in suicide prevention and contains no concrete provisions to mitigate these socioeconomic factors, which are known risk factors in suicide prevention.
Despite the lack of representation from stakeholders belonging to other sectors in the consultation and drafting process, the NSPS does identify the roles and responsibilities of specific state actors and stakeholders outside the domain of health, such as the Ministry of Information and Broadcasting to ensure responsible reporting of suicides by the media. What is unclear though is whether these Ministries and in particular the Ministry for Health and Family Welfare - the nodal authority for the implementation of the NSPS - will be provided with any additional budgetary allocation to fulfil the responsibilities assigned to them. Without a separate budget, dedicated solely for the implementation of the NSPS, the policy is likely to face several challenges in implementation.
Challenges and opportunities
An interesting challenge and opportunity that the NSPS presents is with regards to strengthening the existing mental health system in the country and its role in suicide prevention. The NSPS recommends that suicide prevention facilities be made available as a part of the inpatient services provided under the DMHP. A key component under the National Mental Health Programme (NMHP), the DMHP was launched in 1996 and is the country’s only national mental healthcare service delivery programme, aimed at integrating mental health into general healthcare and making it accessible in rural parts of India.
However, despite being introduced almost three decades ago, the DMHP is yet to achieve 100% coverage in the country. In several states, while the DMHP has been established it remains defunct as a result of insufficient funding and human resources. The NMHP too has been marred by similar challenges.
The reliance of the NSPS on the DMHP and NMHP for making available suicide prevention services, given the present state of these programmes, could pose a challenge in realising its goals and objectives. However, it also presents an important opportunity to restructure and strengthen the existing mental healthcare programmes in the country, by ensuring effective implementation.
The effective implementation of the NHMP and DMHP for realising the vision of the NSPS would be a huge boon to the mental health system, however, the reliance on these two programmes, given their current status of implementation could create several obstacles as well.
India is now one of the 29 countries in the world to have adopted a national strategy for suicide prevention. The NSPS does borrow on several good practices from these countries, as well as those recommended by the World Health Organisation, by including elements of public education, responsible media reporting, school-based programmes, improved access to mental health service, crisis intervention, reduced access to lethal means and social and financial security.
While on paper the NSPS does have much to offer, its true test will be effective implementation. Given the quasi-federal structure of governance in India, the union government can only provide a broad strategy, the actual implementation and operationalisation of the NSPS will have to be led by the state governments.
Role of States
The role of state governments in suicide prevention is critical since annual data on suicides collected by the National Crime Records Bureau (NCRB) shows several variances at the state and regional level, thus a ‘one size for all’ approach would be ill-suited. Research and experiences of other countries in implementing suicide prevention programmes have shown that interventions are most effective when they are tailored to the needs of communities, through engagement with and participation of those at lower levels of the governance structure.
The future of the NSPS and its effectiveness will be shaped by the commitment of policymakers not just across the governance ladder, but also across sectors. The NSPS identifies several immediate, intermediate, and long-term objectives; how soon the immediate objectives identified are met will be a telling sign of how successful the NSPS will be in reducing suicides by 10% at the end of the ongoing decade, in India.
Manisha Shastri is a Research Associate; Dr Soumitra Pathare is a Consultant Psychiatrist and Director; both at the Centre for Mental Health Law & Policy, Indian Law Society, Pune
Discussing suicides can be triggering for some. However, suicides are preventable. In case you feel distressed by the content or know someone in distress, call Sneha Foundation - 04424640050 (available 24x7) or iCall, the Tata Institute of Social Sciences' helpline - 02225521111, which is available Monday to Saturday from 8 am to 10 pm.