Rationing – The Legitimacy Problem in Mental Healthcare: Reflections from Kashmir
The healthcare system in Kashmir has, for decades, been functioning amid political upheavals, persistent violence, and state-imposed curfews. Everyday navigation through the consequently fragile and unstable health system has had an enduring psychological impact on the population. The ongoing COVID-19 pandemic, together with the inaccessibility of healthcare – especially of mental health services – raises pertinent questions around their rationing. This article highlights the role of explicit rationing in managing the mismatch between demand and supply in health services.
The allocation of resources for healthcare ends up being one of the more pressing and, often, controversial choices faced by welfare states. The growing pressure on publicly funded services has generated a need to ration them. We attempt to understand the complexities of this allocative decision-making, with reference to Kashmir, where the three-way relationship between rationing, mental healthcare, and human rights has been leading to unbalanced health decisions. The authors also acknowledge the paucity of research in the area, especially in the context of Kashmir, and attempt here to make a contribution in that direction.
understanding healthcare resource rationing
Commonly, “rationing” refers to allocation in fixed quantities, or the provision of a fixed allowance. It connotes a reasonable distribution of resources, carried out fairly and even-handedly. Rationing has been described as ‘the allocation of scarce resources among competing ends.’ However, while that was the sense emphasized within the domain of economics, other scholars observed and developed three further categories to describe the rationing of healthcare: first, the allocation of limited resources and the explicit decisions taken for the purpose – such as denial of healthcare services like expert medical opinions given their expense; second, that taking into consideration the absolute scarcity of resources, as in the allocation of intensive care beds; third, rationing determined by the degree of access to treatment, which is linked with ability to pay. These apply to Kashmir, where cumbersome referral pathways to mental health services, and the inability to pay for treatment, have been prevalent.
Rationing may, then, be regarded as the apportioning of scarce resources (or distribution of such resources) among those who demand and have access to them. Such an approach has even been justified as being in keeping with ethical principles within health systems, globally, during the ongoing pandemic. However, there is an urgent need to revisit the typology of healthcare rationing and to look at different practices – for instance, at how it is unacceptable in high-income countries but tolerated in low- and middle-income countries.
the necessity and inevitability of rationing
We need to observe rationing from a vantage point that lets us focus on two equations: one, its link to the finite and limited supply of healthcare resources (hospitals, medical staff, medicines); and the other, its connection with the demand for access to care – which is potentially infinite. The mechanism of rationing in healthcare becomes necessary to balance the demand and supply of healthcare resources. For instance, a particular treatment may be denied giving clinical reasons, but the underlining factor would be resource-related. Moreover, the political and popular preference for spending on, and access to, public healthcare is one of the foremost reasons for demand outstripping supply – making rationing necessary to maintain equilibrium. Yet rationing as a core component is largely absent from our policies, despite the increased pressure on budgets and the rising costs of healthcare.
Bhatia explains the two kinds of rationing which are routinely practiced in health systems. In implicit rationing, the imposition of barriers such as referrals to specialists, and the use of waitlists, deters healthcare access. Explicit rationing takes into account ‘the efficacy and cost of medical treatment, technology, and other interventions that are subsidized by the government.’ In resource-constrained societies such as India, without effective checks and balances, access through rationing gains significance in situations where affordability is the major determining factor in treatment, notwithstanding the nature of the disease or actual medical needs. We are driven by health budget totals rather than where and how to allocate available funds. An understanding of rationing could enable better responses to those specifics.
rationing in mental healthcare: observations from Kashmir
The rationing of mental health services has been mainly based on economic principles. The continued contesting of mental and somatic illness when it comes to insurance benefits has created a disease hierarchy, which makes the rationing of mental healthcare visible. And a lower allocation of resources in the 2021-2022 budget to mental health services and treatments has also created an environment of access deficit.
The rise in severity of depression, anxiety and stress, and of suicide rates among the people of Kashmir, can be seen against a backdrop of both logistical and economic lack of access to timely interventions. In addition, mental health resources in Kashmir are largely limited to public-funded institutions – and unregulated private mental health support with varied outcomes. Thus, mental healthcare in Kashmir is distributed across places of care (public and private), severity of mental illness conditions, and demographic sections (mainly youth, women and children).
An analysis based on field research reflects:
An engagement with traditional systems wherein mental illness is understood not as illness but as spiritual deficit, and the mental health professional (MHP) is replaced by the local traditional healer. The wide prevalence of this local model is acknowledged, but its effects need further study. Additionally, many people consult other medical professionals instead of going to an MHP, because of the societal stigma associated with mental illness. This makes for a disjointed relationship between access to mental health services on the one hand, and societal stigma on the other, giving rise to efficacy concerns in mental health outcomes. Moreover, the exclusion of mental health conditions from common medical conditions by public health planners in Kashmir is a primary cause of rationing.
No resonance with local contexts. The field of mental health is rapidly growing in Kashmir, with professional interventions done at primary, secondary and tertiary healthcare facilities. There is a growing concern about uniform mental health interventions being delivered in these facilities instead of evidence-based interventions. There is an urgent need in Kashmir to accommodate local contexts, especially socio-cultural factors, in mental health interventions: inadequate psychosocial education, clinical bias (based on age or gender), and the resulting fragmentation of services needs to cease for effective mental health service delivery. Factoring in local contexts would aid in identifying divergence points, and the adoption of different intervention strategies – something that is presently little documented and largely unknown.
Engaging with communities. In Kashmir, we may observe a plethora of awareness programmes, webinars, and outreach activities around mental health every day. The limited availability of mental health services has mobilized community engagement, leading to further community outreach. While capacity building within communities is necessary, professionals in private clinics and hospitals in Kashmir lack rigorous clinical training and clinical experience. Meanwhile, ways must also be found to check the quasi-professionals and non-professionals who are saturating the field and increasingly damaging patient care in the Valley.
With limited resource allocation, a dearth of sustainable mental health services, and no workable alternative mental healthcare models in place, rationing continues to function both at the individual and State level. The authors further note that rationing may therefore be viewed as the conflict between allocation of healthcare resources, and the actual decisions that do not always accommodate the choices available.
Editorial note: The Editorial team engaged in multiple conversations with the authors of this piece. While we would have liked to see more Kashmir-specific data, policy and regulatory measures to contextualise rationing in mental health, we believe that it is important to amplify Kashmiri voices on the same, and are thus carrying the article as it is.
(1) This is based on ongoing field work in South and North Kashmir to study the theoretical context and implementation of the Mental Healthcare Act, 2017.
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(11) Bhatia, Neera. “We Need to Talk about Rationing: The Need to Normalize Discussion about Healthcare Rationing in a Post COVID-19 Era.” Journal of Bioethical Inquiry, vol. 17, no. 4, 9 Nov. 2020, pp. 731–735., doi:10.1007/s11673-020-10051-6. Accessed July 2021. This has also been witnessed in our field study – how referrals have delayed access to mental health care in Kashmir.
(12) Bhatia, Neera. “We Need to Talk about Rationing: The Need to Normalize Discussion about Healthcare Rationing in a Post COVID-19 Era.” Journal of Bioethical Inquiry, vol. 17, no. 4, 9 Nov. 2020, pp. 731–735., doi:10.1007/s11673-020-10051-6. Accessed July 2021. This has also been witnessed in our field study – how referrals have delayed access to mental health care in Kashmir.
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(19) Hussain, Mujtaba, and Jitamanyu Sahoo. “Interview Conducted with Wasim Kakroo, Counsellor at CGWC, IMHANS, Kashmir.
(20) Hussain, Mujtaba, and Jitamanyu Sahoo. “Interview Conducted with Dr. Majid Shafi, Psychiatrist Working in the District Mental Health Program, Pulwama, Jammu & Kashmir.” July 2021.
(21) Hussain, Mujtaba and Jitamanyu Sahoo. “Interview Conducted with Nasir Geelani, Clinical Psychologist.” July 2021.
(22) Hussain, Mujtaba and Jitamanyu Sahoo. “Interview Conducted with Nasir Geelani, Clinical Psychologist.” July 2021.
(23) Hussain, Mujtaba and Jitamanyu Sahoo. “Interview Conducted with Nasir Geelani, Clinical Psychologist.” July 2021.