All healthcare programs and policies in India fall under the umbrella of the National Health Mission that operates under the Ministry of Health and Family Welfare. We conducted a comprehensive search for programs focused on mental and reproductive health. We analyzed all programs in detail and offer recommendations to improve maternal mental health. We also provided a justification for each option. Across India the health situation differs from state to state. By providing options, we hope policymakers will embrace those best suited to each situation. We structured the policy options around two programs: the NMHP and the Reproductive, Maternal, Neonatal, Child, and Adolescent Health Program (RMNCH + A). We also suggested an implementation strategy in accord with current infrastructure and human resources.

We evaluated the policy options using criteria related to cost–benefit or cost-effectiveness, administrative feasibility, human resources, sustainability, legal provisions, and equity. We also addressed barriers to implementation.

Policy options recommendations

Below we offer three policy options to facilitate formulation and execution of a comprehensive policy that is administratively feasible, cost-effective, socially acceptable, and culturally appropriate.

Policy option 1: better implementation of the existing NMHP

When India launched NMHP in 1982, a key strategy was to integrate mental health with primary healthcare. The initial model lacked clarity, and inadequate funding to lack of funding, skilled human resources, and “managerial skill at the community level” undermined its sustainability. The Ministry of Health and Family Welfare revised the program repeatedly in the process introducing the DMHP [18]. Revisions targeted the most vulnerable and underprivileged populations [18] with objectives to decrease distress, disability, premature mortality associated with mental illness, and enhance recovery from mental illnesses. Other objectives included reducing stigma, promoting community participation, increasing access to mental health care services, ensuring the rights of persons with mental illness, integrating MH with other programs such as rural and child health, staff motivating and empowering them in the workplace, improving infrastructure for mental health service delivery, generating knowledge and evidence for service delivery, and establishing governance, administrative, and accountability mechanisms [18].

The goals, objectives, and strategies under the NMHP and DMHP seem holistic but implementation has been weak (Table 1). If the DMHP is strengthened in all districts and all recommendations of the NMHS were implemented, the NMHP could provide adequate care for maternal mental health and for all other persons with mental illness.

Table 1 Evaluation of policy option 1Policy option 2: integration of the mental health component in RMNCH + A

From the inception of the reproductive and child health program in 1997 to RMNCH + A, the Government of India successfully established a system of healthcare for women to safely manage their reproductive health, pregnancy, and childbirth. Government also launched cash-benefit schemes to ensure that pregnant women would attend their antenatal care visits regularly and prefer institutional delivery over home births. Community health workers such as accredited social health activists, auxiliary nurse midwives, and healthcare workers in primary healthcare centers and community healthcare centers function well as reflected across the country by dwindling rates of maternal and infant mortality. Cash benefits for four antenatal care visits, two postnatal care visits, and institutional delivery offer ‘windows of opportunity’ for the healthcare workers to screen women for perinatal mental illnesses (Table 2).

Table 2 Evaluation of policy option 2

Because the community health care workers are well acquainted with the pregnant women and mothers who hail from the same communities where the workers made door-to-door visits, the women may be more receptive to interventions provided under new policy. South Africa implemented a similar intervention called the Perinatal Mental Health Project that included mental health services for perinatal women in limited resource settings [19].

Policy option 3: inclusion of a “maternal” component in the NMHP

To avoid over-burdening the health care workers involved with the functioning of the RMNCH + A program, a third option could be integration of a dedicated ‘maternal’ component in the NMHP. Thirty-five years of operating the NMHP has generated plans and resources to support addition of a new domain. Successful implementation of the NMHP in some regions, such as the Thiruvananthapuram district in Kerala, demonstrates feasibility. Implementation of DMHP began in 1999 with formation of a district mental health team followed by training of health care workers, and sensitization of communities on mental health issues [19]. The multidisciplinary team provided outreach services, managed complicated cases, and supported community health workers [20]. The district-maintained record books (offline data) for patient records, used available funds, and performed program activities [19]. Availability of psychotropic drugs for treatment proved to be a key feature [19]. All health facilities (including district hospitals, primary, and community healthcare centers) followed standard procurement program procedures (based on guidelines), and according to a requirement raised by the program officials, Government made timely availability of these drugs [20]. The World Health Organization hailed this implementation as a success [20].

Because the burden of maternal mental illnesses is high in the country and has an intergenerational impact, an independent component under the umbrella of the NMHP may prove effective for women who are in dire need of attention of the sort described just above (Table 3).

Table 3 Evaluation of policy option 3

India’s government designed both the RMNCH + A and NMHP to cater to rural as well as urban populations. Thus, we expect both can maintain equity in quality and quantity of services. Because healthcare is often inadequate in rural areas, extra measures will be needed, including periodic monitoring and evaluation to assess the quality of services provided. All three policy options meet the legal requirements of the Mental Healthcare Act of 2017. Even so, success will depend on popular acceptance of the reality of mental health illnesses and their cure through community sensitization.