New law can be a game-changer
MENTAL HEALTHCARE ACT From stigma to lack of govt spending, mental healthcare faces many challenges. The success of the Act lies in its implementation
Savitabai, 45, is a single mother living in a remote village in Ahmednagar district, Maharashtra. She works as a daily wage earner on the farmland of a wealthy farmer. Savitabai’s son Dhaval, 20, suffers from bipolar disorder (BPD), a severe mental health condition which is characterised by extreme mood swings— long spells of manic behaviour and bouts of depression. Dhaval’s condition causes severe disruption in his daily routine. Given the severity of his condition, he requires medical care and support especially through phases when his symptoms are most acute.
Savitabai is the sole earner and unable to provide care on a regular basis. Lack of awareness about BPD and the stigma surrounding mental illness do not help matters, and other community members are not forthcoming in their support either. The nearest community health centre, which a psychiatrist attends once a week, is more than 50 km away. Travelling to the centre means losing a day’s wages, something Savitabai can ill afford. The alternative, as suggested by her community, is to get Dhaval treated by the local village faith healer. It is less expensive but it does not assure a positive outcome for Dhaval’s mental health. His symptoms recur despite numerous rituals and ceremonies. Dhaval needs a trained mental health professional who can provide treatment and psycho-social support in the community, but both these services are unavailable locally.
The World Health Organization (WHO) estimates India has only 0.3 psychiatrists, 0.07 psychologists and 0.12 nurses available per 1,00,000 people. The National Mental Health Survey, 2016, estimated that over 85% of people with common mental disorders such as depression or anxiety disorder and 73.6% of people with severe mental disorders such as psychosis or bipolar disorder do not receive any mental healthcare and treatment. There is also a wide variability in availability of mental health services — while urban areas have some services, the situation is dire in rural areas, as the case of Dhaval illustrates. Since the 1980s, the National Mental Health Programme and the District Mental Health Programme have sought to bridge this gap, by integrating mental healthcare at the primary level of the public health system. However, this faces significant implementation challenges and resource constraints. The public mental health system faces infrastructure gaps, financial deficits (India spends less than 1% of its total health budget on mental health) and socio-cultural barriers, such as the stigma that Dhaval’s mental illness carries which results in improper psycho-social support.
Several cases of human rights violations of people with mental illness have been documented over the years, including inappropriate or forced treatment, sub-human living conditions in hospitals, inappropriate use of physical restraints and seclusion in care facilities. In this landscape, the Mental Healthcare Act, 2017 (MHCA) is a historical intervention which, if implemented well, can prove to be a game-changer. Two specific features stand out. First, the act adopts a rightsbased approach. It places obligations on mental health services and prescribes procedures that ensure that mental health professionals offer treatment in accordance with a person’s will and preferences. The law provides for the right to make advance directives— a person may state how they wish to be treated (or not) in the eventuality that they have a mental illness and cannot make decisions for themselves at that point. Additionally, the law recognises an entire gamut of rights relating to confidentiality, access to medical records, protection from cruel treatment and non-discrimination based on social markers, including sexual orientation. These rights are to be protected at all times when a person is undergoing mental healthcare and treatment as an admitted patient or otherwise. Any violation or deficiency in services can be reported before the Mental Health Review Boards. Non-compliance with any of these provisions will result in punishment and imposition of penalties.
Another significant aspect is that this is the first law in India which has man- dated universal mental healthcare for all citizens. Indian legislation until now had not recognised a right to healthcare as a universal right. Access to mental healthcare stresses on affordability, quality, and non-discrimination. How does the law envision this? It offers a decentralised model, placing obligations on the central and state governments to put infrastructure, resources and budgets in place to bridge the deficit in mental health services and facilities. This includes integrating mental healthcare at the primary, secondary and tertiary levels, setting up community-based rehabilitative facilities, offering free mental healthcare to below poverty line families, like Savitabai’s, and providing free essential medicines, among other things. The act also places an obligation on insurance firms to provide health insurance to persons with mental illness on the same basis as other physical illness.
The current mental health landscape in India is bleak, but there are many organisations and individuals working to transform it. Take our experience: Since 2017, we have worked on a project called Atmiyata, which is a community mental health intervention in Mehsana district of Gujarat that trains community volunteers to provide lay counselling, referrals and linkages with social benefits to individuals in distress. Today, our outreach extends to over one million people. Involving the community through scaled-up grassroots-led approach is both an opportunity and a challenge, but it is one way in which stakeholders like us can help actualise the law’s mandate for universal mental healthcare. Pathare is the director of Centre for Mental Health Law and Policy at Indian Law Society, Pune, who assisted the Ministry of Health and Family Welfare in drafting the Mental Healthcare Act, 2017. Kapoor is a lawyer and psychologist working at the Centre.