Baby Step In Mental Healthcare

Mental Healthcare Bill passed in the lower house of the parliament proposes positive reform, but lot more needs to be done for the people suffering from mental illness


On 27 March, Lok Sabha, in a unanimous decision, passed the landmark Mental Healthcare Bill, 2016, a legislation seeking to rectify our country’s blatant apathy hitherto towards people suffering from mental afflictions. The bill, which received Rajya Sabha’s approval, last August, in a major step, overturned the archaic and grossly inhumane Section 309 of the Indian Penal Code (which criminalizes attempted suicide). First introduced in August, 2013 in Rajya Sabha by the UPA, the bill, now pending official assent of the president, will repeal the existing Mental Health Act, 1987 upon implementation.

Another big achievement of the bill is the view it adopts of mental illnesses. The progressive move to do away with the old terminology and choosing to replace it with a sound definition sends out a message regarding the inclusive and conducive environment the government is trying to foster. The Bill defines “mental illness” as “a substantial disorder of thinking, mood, perception, orientation or memory that grossly impairs judgment or ability to meet the ordinary demands of life, mental conditions associated with the abuse of alcohol and drugs.” It offers the mentally ill a chance to lead a life with all the basic amenities and facilities granted by the Constitution which everyone else enjoys. It also helps provide basic rights and freedoms to those whose life until now had been marred with social stigma.

Prime Minister Narendra Modi also spoke about the issue of depression in his monthly radio program Mann Ki Baat in which he emphasized the need to create a psychologically conducive environment to ensure people have a chance of leading a healthy life. Stating that depression is definitely not incurable, the prime minister said the first step in the healing process is to acknowledge the problem instead of suppressing it. Modi’s speech is significant in that he aims to lift the cloud enshrouding mental illness and promote dialogue. It also fosters an environment which treats those in suffering, with equal dignity and respect as the rest.

The ‘patient-centric’ bill, however, is not without shortcomings.

The biggest impediment to the proper and widespread implementation of the provisions provided by the bill is the percentage share of the budget allocated to the health sector. With a meager one to two percent of the Union budget dedicated to the entire health sector, India cannot reasonably hope to make a visible change in eradicating the mental health crisis. This is abysmal, compared to developed countries who dedicate 10 to 12 percent of their budget towards providing healthcare.

India spends 0.06 percent of its health budget on mental healthcare, which is significantly less than what Bangladesh spends (0.44 percent). Most developed nations spend above four percent of their budgets on mental health research, infrastructure, frameworks and talent pool, according to this 2011 World Health Organisation (WHO) report.

The bill mandates the provision of medical health services run or funded by the government be available in every district of the country. However, with already inadequate medical infrastructure at district and sub-district levels, the financial burden to be borne by the state governments will be massive unless the central government allocates a larger chunk of the budget to incur the expenditure.

Also, the implementation of the bill will vary across different parts of the country with southern states of Tamil Nadu or Kerala receiving better coverage due to the already adequate primary health infrastructure than the states like Bihar or Uttar Pradesh.

The Advance Directive clause of the healthcare bill has also raised some eyebrows in the medical fraternity. The provision essentially allows the person suffering from mental illness to specify the form of treatment to be provided in advance and also empowers that person to nominate a representative to ensure that directives are being adhered to. The debate surrounding the clause is over the following question: Up to what extent does the bill actually empower the mentally afflicted? It fails to consider the position of those suffering from severe mental disorders (like schizophrenia and psychotic disorder) that refuse to acknowledge their mental state, let alone be capable of making rational decisions and giving consent in writing, regarding their treatment. The bill is being criticized for failing to provide alternate courses of action based on the severity of the mental disease rather than having a generalized process applicable across the spectrum.

The medical healthcare experts have called out the bill on the lack of its practical approach, citing the acute shortage of doctors, especially psychiatrists, clinical psychologists and psychiatrist social workers. A recent WHO report, titled ‘Depression and Other Common Mental Disorders – Global Health Estimates’, estimated that roughly 7.5 percent of India’s population suffers from some form of mental illness (major or minor). The report revealed that the total number of cases recorded in 2015 of depressive disorders were nearly 57 million or 4.5 percent of the population while those of anxiety disorders were roughly 38 million or 3 percent. Immediate expert intervention is required as it is further suggested that this statistic is likely to rise up and affect about 20 percent of the population by 2020.

According to government data, it is estimated that there are 3800 psychiatrists, 898 clinical psychologists, 850 psychiatric social workers and 1500 psychiatric nurses in the country, most of which are working in metropolitan or tier-two cities, ruling out the possibility for people living in districts and sub-districts of getting appropriate medical attention.

According to a 2016 study conducted by National Institute of Mental Health and Neurosciences (Nimhans), a premier medical institute of India, it is estimated that India has just about 40 mental institutions (out of which only 9 are equipped to provide treatment for children) and fewer than 26,000 beds. Another WHO report reveals that for every million people in India, there are just three psychiatrists, and even fewer psychologists, 18 times fewer than the commonwealth norm of 5.6 psychiatrists per 100,000 people.

The data revealed by these reports paints a grim picture of India where, so far, rights and freedoms of those suffering from mental illnesses have not just remained non-existent but the dialogue regarding the same has also been thwarted and brushed under the carpet.

The bill mandates the constitution of a Mental Health Review Board to protect the rights of persons with mental illness and manage advance directives. Along with that, setting up the Central Mental Health Authority at the national level and State Mental Health Authority in every state to maintain registries, training law enforcement and mental health professions on the provisions of the act, and advising the government on all matters relating to mental healthcare and services are also part of the bill. However, as some reports have pointed out, these quasi-judicial bodies at central, state and district level need to be constituted carefully so as to entail proper representation as opposed to earlier instances where boards consisted of religious leaders, and people working with social welfare outnumbering the healthcare professionals.

The bill also contains no mandate for the formation of a review board in order to assess, inspect and report on the health and condition of existing patients in different mental institutions across the country. According to this report in The Wire, Swati Maliwal, chief of Delhi Commission for Women, on a surprise visit earlier this year to Asha Kiran (a government-run home for persons with mental disabilities in Delhi) found inhabitants living in extremely gross and inhumane conditions in a severe case of human rights violation by the management. The sanitation and hygienic conditions were reported to be deplorable with toilets as well as some corridors found covered in urine, excreta and menstrual blood. Such instances are often reported across the nation, yet rarely do these institutions have to face the scrutiny and consequences for their violation of human rights.

The list is not exhaustive but it does indicate that along with plenty right which this bill achieves, it also has its shortcomings. Some minor flaws can be corrected through amendments. But others will take real commitment and intent to see them through. India will have to start spending more on mental healthcare (and health sector in general) since mental health diseases constitute up to 13 percent of the total health burden.  The guidelines and rules for implementation, which have not yet been provided, will determine the effectiveness of the bill in the future. It will be up to the Centre to ensure that the provisions of the bill are implemented and that they do not just stay on the paper as a formality.