Transforming Mental Healthcare: A Crude Return-on-Investment Analysis of the Chhattisgarh Community Mental Healthcare Tele-Mentoring Program (CHaMP), India

doi:10.21203/rs.3.rs-4975891/v1

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Research Article

Transforming Mental Healthcare: A Crude Return-on-Investment Analysis of the Chhattisgarh Community Mental Healthcare Tele-Mentoring Program (CHaMP), India

https://doi.org/10.21203/rs.3.rs-4975891/v1

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Background

Mental illness poses a significant public health concern globally, with depressive and anxiety disorders alone costing over $1 trillion annually in lost productivity. In Chhattisgarh, India, a resource-limited state, the Chhattisgarh Community Mental Healthcare Tele-Mentoring Program (CHaMP) is operational to train Primary Care Doctors (PCDs) in mental health diagnosis and treatment. This paper evaluates its economic impact using a crude return on investment (ROI) analysis.

Methods

A total of 2,056 PCDs received over 1,600 hours of training, resulting in the diagnosis and treatment of 51,738 patients with mental health disorders from September 2019 to September 2022. The program's impact was evaluated by comparing costs between consultations at tertiary care hospitals and PHCs, factoring in expenses for travel, food, incidental fees, and wage losses. Stakeholders involved in cost estimations included psychiatrists, government officials, program participants, and beneficiaries. The calculated financial metrics included return on investment (ROI) by calculating the percentage of the net profit by the cost of investment. The initiative's total investment encompassed training materials, salaries, and logistical expenses for trainers visiting districts.

Result

The total project cost was INR 1,19,71,000 (142,706 USD), while the savings from reduced out-of-pocket expenditure and wage losses amounted to INR 5,82,83,182 (694,792 USD), yielding a net profit of INR 4,63,12,182 (552,086 USD) and an ROI of 386%, indicating that the gains from the program's investment are 3.8 times the cost of implementation, yielding significant economic benefits. This means that for every 1 rupee the government invests, the public saves approximately 4 rupees in out-of-pocket expenditure. This demonstrates that the program effectively reduces the cost of providing primary mental healthcare to the community.

Conclusion

The study emphasizes the effectiveness of integrating mental health services into primary healthcare by leveraging technology for training. The provision of community-based care is associated with a significant return on investment. Further studies are needed with formal cost-benefit methods.

return on investment

health systems

primary care

community mental health

telementoring

community intervention

Mental illness is a significant public health concern and a leading cause of disability, with depressive and anxiety disorders alone accounting for more than $1 trillion in lost productivity globally each year. (1) People with mental illness are more likely to be dependent on public services such as healthcare, social welfare, and housing and have increased healthcare costs, as individuals may require ongoing treatment and medication. (2) Although calculating the cost of illness is an uphill task, the recent research focus has gradually shifted to a much more complicated area of cost-effectiveness analysis of a particular intervention. The demands for economics are not limited to commercial interests or cost-saving goals of companies and governments. They also stem from the requirement to make informed decisions in various areas, such as strategy, clinical care, prevention, purchasing, and, most importantly, personalized care. Economic evaluations and related studies can be conducted more accurately with improved data sources, including birth cohorts, comprehensive epidemiological surveys, clinical trials with financial components, and provider/purchaser records. There are already several well-established methods, such as cost-effectiveness analysis, cost-utility analysis, and cost-benefit analysis, to determine the economic impact of an intervention. (3) A particular type of cost-benefit analysis is return-on-investment (ROI) analysis, which is recommended by the World Health Organization (WHO) and the United Nations Development Program (UNDP) for making an investment case for mental health. (4)

In Chhattisgarh, 11.6% of the population has a mental health disorder with a treatment gap of 88.6%, with an average delay of 5 months from illness onset to treatment initiation. The National Mental Health Survey 2015–2016 estimated that the median out-of-pocket expenditure per month for mental health care is approximately 1000–1500 INR, which poses a significant financial strain. In the absence of state or insurance coverage for most families, a large proportion of payments for treatment are out-of-pocket expenses. (5)

Providing health care is a human resource-intensive activity. Owing to the significant deficit in specialized human resources, at the request of the Government of Chhattisgarh, NIMHANS had started a certification training program for primary care doctors (PCDs) [Medical officers (MOs), AYUSH Medical Officers & Rural Medical Assistants (RMA)] throughout the State of Chhattisgarh to enable them to identify, screen and treat/refer cases of mental health disorders, using telemedicine at the primary health care level. This innovative, digitally-driven training program is called the Chhattisgarh Community Mental Healthcare Tele-Mentoring Program (CHaMP). (6) The CHaMP project has been running since 2019 and completed the first training phase in December 2021. It is essential to analyse the effectiveness of the investment in the project, which is necessary to take future directions in mental healthcare for the state of Chhattisgarh and other states of the country. This paper uses ROI analysis to assess the economic impact of CHaMP.

Training program

The CHaMP initiative is a hybrid training program consisting of a 30-hour training module, including 16 hours of onsite training (over two days) and 14 hours of online training per PCD. As of September 2022, the state of Chhattisgarh comprised 28 districts.

Impact of the training

Under CHaMP, all 28 districts were covered from its initiation in July 2019 until September 2022 (spanning three years). A total of 2056 PCDs were trained. More than 1600 hours of training were delivered from the Hub side (NIMHANS, Bengaluru) to the PCDs. A total of 51738 patients were diagnosed with and treated for mental health disorders.

The impact was evaluated on the basis of the difference between the ‘expenditure for one consultation with a psychiatrist at the closest tertiary care hospital’ and the ‘expenditure for a consultation in the nearest PHC after program initiation.’

We have been unable to isolate the program impact to determine if the actual program caused a change in behaviour, as there is a lack of control groups and previous studies. The ROI was calculated via estimations from experts, including program participants, stakeholders, funders/sponsors, organization or department staff, and consumers, through focus groups, and the following data was gathered per person:

1. Cost of consultation

2. Minimum daily wages

3. Cost of the training program

4. Travel, food and accommodation expenses

Estimation of the ROI:

The return on investment is calculated as (7):

ROI = Net profit/cost of the investment * 100

Cost of consultation

To calculate the expenditure for consultation with a psychiatrist, we interviewed five psychiatrists from 5 different cities in Chhattisgarh. They provide consultation to the patients visiting the OPDs and are aware of the approximate expenditure of a patient coming with an attendant from the village.

We asked them about the following domains of this expenditure per person that included:

1. Round-trip travel by public transport,

2. Incidental expenses to meet contingencies on the visit day and,

3. Loss of labour/wage for the patient/attender for the day/s of travel.

In Chhattisgarh, it takes INR 200 for a person on a round-trip public transport journey, averaging 50kms. (8) We estimated that the cost of food for two persons for one day would be approximately INR 250.

Overall, the net out-of-pocket expenditure will be (n = 51738):

51738 x (INR 200 + INR 250) = INR 2,32,82,100 (277,545 USD)

Additionally, one significant loss would have been the daily wage loss. The Chhattisgarh government updated the fixed minimal daily wage every six months. Accordingly, we calculated the number of consultations performed every six months and multiplied it by the minimum wage for a day for two persons. (9) The total amount was INR 3,50,01,082 (417247 USD), as shown in Table 1.

Therefore, the net amount that was spared due to consultation at a PHC would be as follows:

INR 2,32,82,100 + INR 3,50,01,082 = INR 5,82,83,182 (694792 USD).

Table 1

Calculation of minimum daily wages (from July 2019 until September 2022)
Duration	No. of consultations	Minimal daily wage of unskilled labor in INR	Total loss due to loss of wage for a day for two people in INR
July 2019 to March 2020	12555	300 per day	75,33,000
April 2020 to September 2020	11477	341 per day	78,27,314
October 2020 to March 2021	7120	345 per day	49,12,800
April 2021 to September 2021	8504	353 per day	60,03,824
October 2021 to March 2022	6660	357 per day	47,55,240
April 2022 to September 2022	5422	366 per day	39,68,904
Total	51738		INR 3,50,01,082 (417247 USD)

Cost of the training program:

The budget for the project for this duration was INR 1,14,53,000 (136530 USD). The government of Chhattisgarh provided this fund to procure training materials and pay salaries for human resources, i.e., one tele-psychiatrist and two project coordinators.

Travel, food and accommodation expenses of the trainer to Chhattisgarh:

Onsite training was an integral part of the CHaMP project. One trainer from NIMHANS Bengaluru would visit the district headquarters of Chhattisgarh. Over ten days, the trainer trained PCDs from 2 districts. Overall, 14 onsite visits were conducted to cover training PCDs from 28 districts.

The average flight ticket cost from Bengaluru Airport to Raipur Airport is INR 7,000 per person. For travel to Raipur Airport from Bengaluru and to return, the flight fare was INR 14,000.

The government provided transportation from the airport to the district headquarters and training venue, onto the following district, and back to the airport, up to INR 15,000 per trip.

Accommodation and food expenses for the trainer for ten days amounts to INR 15,000 per trip.

Therefore, the overall expenditure for 14 onsite visits was (INR 7000 + INR 15000 + INR 15000) X 14 = INR 5,18,000 (6175 USD)

Therefore, the cost of the investment for the Chhattisgarh Government for the project was as follows:

INR 1,14,53,000 + INR 5,18,000 = INR 1,19,71,000 (142706 USD).

Estimation of ROI:

The ROI is calculated as (7):

ROI = Net profit/Cost of the investment * 100

Net profit is calculated as follows:-

The net amount that was spared due to consultation at a PHC - Cost of investment for the Chhattisgarh Government for the project:

INR 5,82,83,182- INR 1,19,71,000 = INR 4,63,12,182 (552086 USD)

The cost of the investment = INR 1,19,71,000 (142706 USD).

ROI= (INR 4,63,12,182/INR 1,19,71,000)* 100 = 386%

The crude ROI is estimated to be 386%, indicating that the gains from the program's investment are 3.8 times the cost to implement. From this, we infer that for every 1 rupee the government invests, the public would save approximately 4 rupees in their out-of-pocket expenditures. This suggests that the program effectively reduced the cost of providing primary mental healthcare for the community.

This return-on-investment analysis provides some critical observations.

Providing mental healthcare services at the PHC level as part of primary healthcare is no longer a mere theoretical concept. It offers the advantage of in-depth penetration into the community, which has been noted in community psychiatry initiatives in other states of India. In Uttarakhand, 21 PCDs successfully underwent capacity-building training and provided mental healthcare services in the PHCs. (10) In Bihar, 22 PCDs were trained to serve in the community across the state. (11) Similarly, in Chhattisgarh, 2056 PCDs providing valuable services in more than 2000 PHCs in the state were trained over three years. (6)

With the current infrastructure, the ROI of 386% (3.8) is encouraging. A recent systematic review of ROIs for preventive studies in developed countries revealed a median ROI of 4 for interventions performed at the local level. A survey on interventions for depressive disorder produced an ROI of 1.7. The same study estimated that the ROI would be 2.1 if telemedicine services were involved. A 2005 study on healthcare intervention in the US reported that the ROI was 1.15, whereas an intervention study revealed an ROI of 0.85–3.75 in the first year and 7.50-19.34 in the long run. (12)

The utilization of the internet and technology represents a transformative force. Our intervention leveraged the internet to train PCDs through online classrooms and collaborative video consultations. This approach facilitated the provision of standardized training to all participants in the program. Moreover, it afforded PCDs the flexibility to attend classes from the comfort of their homes regularly and engage in patient consultations, even amidst busy out out-patient department (OPD) hours. This initiative significantly benefited the state, ensuring the seamless operation of PHCs without imposing an additional burden on any physician during the training program. Notably, the travel costs calculated can also be close to zero if the state can hire in-house psychiatrists. While this is a challenge, the concept of state digital academies can emerge as a hub for practising PCDs, with an apex digital academy as the mentor becoming a superhub.

The program's enduring advantages are diverse. PCDs, having received training from the program, will persist in delivering consultations for patients with psychiatric issues at PHCs and periodically organizing information, education and communication (IEC) programs within the community. This proactive approach will significantly enhance the delivery of quality healthcare services within the community, diminish the stigma associated with mental health, facilitate early detection of mental illnesses, improve treatment adherence, and ultimately foster enhanced productivity at both the individual and community levels.

By providing treatment to patients at local PHCs, this project aligns with the District Mental Health Program (DMHP) objectives. This ensures that the state meets its legal obligations while achieving significant financial savings through reduced societal expenditure on mental health care. These savings contribute to the overall economic efficiency of the healthcare system and enable the reallocation of resources to other critical areas of public health. Furthermore, the decentralized care delivery model enhances accessibility and equity, ensuring that underserved populations receive timely and appropriate mental health services. This comprehensive strategy underscores the importance of integrating mental health into primary care, fostering a more resilient and sustainable healthcare infrastructure.

In conclusion, this return-on-investment analysis underscores the significant impact of integrating mental healthcare services at the primary healthcare level, particularly through the innovative use of digital technology and capacity-building initiatives for Primary Care Doctors (PCDs). The evidence demonstrates that this approach is a practical and effective solution for expanding mental health services into the community. The impressive ROI of 386% highlights the financial viability of such programs, comparing favorably with similar interventions in developed countries. This model not only enhances the sustainability of mental health services at the local level but also ensures that these services remain accessible and equitable, particularly for underserved populations. The long-term benefits of this initiative are substantial, with trained PCDs continuing to provide essential mental health services, reducing stigma, improving early detection, and fostering better treatment adherence within the community. By aligning with the objectives of the District Mental Health Program (DMHP), this project contributes to significant financial savings and promotes economic efficiency within the healthcare system. Overall, this strategy highlights the critical importance of integrating mental health into primary care, paving the way for a more resilient and sustainable healthcare infrastructure.

Limitations

The limitation of our study is that it only considered only a single profession, that of an unskilled labourer, and further evaluation is needed to ascertain the ROI if other occupations are included. Furthermore, in our ROI calculation, we had to calculate the cost of treatment at the PHCs and district hospitals from our focused group discussion with the doctors in the district hospitals and estimation from experts, which may need to be revised.

Future directions

An impact evaluation study can be planned, which involves visiting the community and providing real-time feedback from the patients (and their caregivers) receiving treatment from the PCDs. Capacity-building programs should be spread nationwide to provide affordable, accessible, and available mental healthcare in the community.

Consent for publication: Not applicable

Availability of data and materials: All data generated or analysed during this study are included in this published article.

Competing interests: The authors declare that they have no competing interests.

Funding: Not applicable

Author contributions:

PM, SM, HS, RP, FAI have made substantial contributions to the conception, analysis, interpretation of data and drafted the work.

AHH, SJ, NM, CNK and SBM have contributed to the design of the work and revised the drafts.

All authors have approved the submitted version (and any substantially modified version that involves the author's contribution to the study);

All authors have agreed both to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

Acknowledgements: The authors would like to acknowledge the National Health Mission, Government of Chhattisgarh for their support in running the program.

Ethics approval and consent to participate: The research study received approval from the Ethics Committee with the assigned approval number NIMHANS/43rd IEC (BEH.SC.DIV.)/2023.

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No competing interests reported.

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You are reading this latest preprint version

Transforming Mental Healthcare: A Crude Return-on-Investment Analysis of the Chhattisgarh Community Mental Healthcare Tele-Mentoring Program (CHaMP), India

Status:

Version 1

Abstract

Background

Methods

Result

Conclusion

Bckground

Methods

Training program

Impact of the training

Estimation of the ROI:

Results

Cost of consultation

Overall, the net out-of-pocket expenditure will be (n = 51738):

51738 x (INR 200 + INR 250) = INR 2,32,82,100 (277,545 USD)

Cost of the training program:

Travel, food and accommodation expenses of the trainer to Chhattisgarh:

Estimation of ROI:

Net profit is calculated as follows:-

ROI= (INR 4,63,12,182/INR 1,19,71,000)* 100 = 386%

Discussion

Conclusion

Limitations

Future directions

Declarations

References

Additional Declarations

Status:

Version 1