Since the time the Mental Health Bill was introduced in Rajya Sabha in 2013, decriminalisation of suicide has been its calling card. However, the legislation travels beyond just that colonial era relic, assuming a rights-based approach to mental healthcare, and creating circumstances for removal of the stigma that is the lot of mental health patients. It is a paradigm shift that the National Health Policy passed by the Union Cabinet earlier this month, shied away from.
The Act lays down that “Every person shall have a right to access mental health care and treatment from mental health services run or funded by the appropriate government. The right to access mental health care and treatment shall mean mental health services of affordable cost, of good quality, available in sufficient quantity, accessible geographically, without discrimination on the basis of gender, sex, sexual orientation, religion, culture, caste, social or political beliefs, class, disability or any other basis and provided in a manner that is acceptable to a person with mental illness and their families and care-givers.”
The range of services specified in the Act includes outpatient and inpatient services, half-way homes, sheltered accommodation, supported accommodation, and provisions for child and old-age mental health services. The Act also contains a provision for the notification of a list of essential medicines, providing which will be the obligation of the relevant government.
The importance of a government making mental healthcare a statutory obligation in a country riven with social taboos and superstitions, and where the idea of dignity for the mental ill is mostly absent, cannot be overstated. Once the Bill receives the President’s assent and becomes law, the central government and state governments will be required to place in Parliament and state legislatures an annual report on the progress in achieving universal access to mental healthcare. At the heart of the Bill is the idea that every person with mental illness has the right to live in, and be part of society, and should not have to live in a mental establishment merely because s/he does not have a family, or the family is not willing to accept him/her. It will be the responsibility of the government to house such a person within a reasonable time in a community-based establishment.
This rights-based approach is a far cry from the “assurance-based approach” of the new National Health Policy, which essentially perpetuates the status quo, pleading that given current constraints of infrastructure and resources, the government cannot institute a “right to health” on the lines of the Right to Education.
Challenges in the way
This is not to say that the government’s arguments against a right to health do not apply to the right to mental health. Between 2% and 5% of Indians are said to be suffering from mental illnesses — in a country of 125 crore, that would be between 2.5 crore and 6.25 crore people. By contrast, the number of trained psychiatrists in the country is between 4,000 and 4,500. And this number is unlikely to go up in a hurry — psychiatry is taught in fewer than 300 medical colleges at the undergraduate level and in 184 at the postgraduate level. Across the country, there are 502 seats in MD Psychiatry. There are no PhD courses in psychiatry, and a little over 100 seats in diploma courses.
Back in 2009, E Mohandas of the Elite Mission Hospital in Koorkkenchery, Thrissur, wrote in the Indian Journal of Psychiatry, “A meta-analysis of 13 epidemiological studies consisting of 33,572 persons reported a total morbidity of 58.2 per 1,000. Another meta-analysis of 15 epidemiological studies reported a total morbidity of 73 per 1,000. The saddest aspect is that the bulk of the affected falls in the 15 to 45 year age group. The existing facilities in the country fall short of the required norms, which makes the situation still worse. The number of psychiatric beds in the country is only about 0.2 per 1,00,000 population and there are only two psychiatrists per 10 lakh population. The major share of psychiatric facilities lies with the government sector (especially mental hospitals), which is centred on certain areas of particular states. The psychiatric services have not yet been integrated into the primary health care system and this leaves large populations in dire need of such facilities, with no hope of effective treatment.”
According to conservative estimates, India needs 12,500 psychiatrists to meet international standards. There is also a shortage of trained psychiatric nurses — just about 3,000 nurses and 2,000 clinical psychologists cater to the entire population of the mentally ill. Another article in the IJP put India’s unmet mental healthcare need at anywhere between a third to half the population. The need of psychiatry paramedics is estimated to be upwards of 50,000 if all patients are to be addressed.
Mental Health Authority
The Bill gives a person suffering from mental illness or anticipating such a disease the right to decide in advance how s/he wants to be treated — including the right not to be treated. The decision is to be certified by a doctor and a mental health board. All mental health establishments have to be registered with central and state mental health authorities. There is also a quasi-judicial body called the Mental Health Review Commission to review advance directives, and to advise the government on the implementation of the Act.