Finally, a progressive mental healthcare Bill

The historic Mental Health Care Bill 2016 was passed in the Lok Sabha on March 27. It also decriminalises suicide because a person who attempts suicide should be presumed to have severe stress, and shall not be punished. Now it will be the Government’s duty to provide care, treatment and rehabilitation to a person who attempts to commit suicide and to reduce the risk of its recurrence. The provisions of the Indian Penal Code can no longer be invoked in this regard.

Another important provision in the Bill is that a person with mental illness can make an advance directive on how he/she wants to be treated and nominate a representative. The Bill has a provision to protect and restore the property rights of mentally ill people. With its focus on community-based treatment, the Bill is a deviation from the 1987 Mental Act that focused on institutionalisation of mental healthcare interventions.

Though health encompasses the physical, spiritual, mental and social dimensions, the tendency is to overemphasise physical health. In its mental health action plan for Europe, the WHO recognised that “Mental health and well-being are fundamental to quality of life, enabling people to experience life as meaningful and to be creative and active citizens. Mental health is an essential component of social cohesion, productivity, peace and stability in the living environment, contributing to social capital and economic development...”

Though the Bill has the potential to promote the well-being of mentally ill persons, mental healthcare planners and policymakers face several challenges. The main challenge is the lack of qualified professionals. Currently the mental health workforce in India is composed of trained professionals in the fields of psychiatric social work, clinical psychology, psychological counselling, medicine (including psychiatrists) and psychiatric nursing.

There is a need to address the abysmal doctor-population ratio in the country. Public health and minimum essential clinical interventions require about 0.1 physicians per 1,000 population and between two and four graduate nurses per physician. The shortage of trained professionals is more felt in the field of mental health.

A recent study by ICMR reveals that in India, the rate of psychiatric disorders in children aged between 4 and 16 years was about 12 per cent. Every year only 550 doctors passed out in the discipline of psychiatry. This amounts to a shortage of 87 per cent. The shortage of psychiatrists and psychiatric social workers is to the extent of 67 per cent and 96 per cent respectively. According to a recent report by the MHFW, “Seven per cent of the population suffers from mental disorders. Over 90 per cent remain untreated. There is less than one psychiatrist available for every four-lakh population.”

Mental health services rely on professional manpower, not equipment or facilities. This necessitates regular and consistent preparation of manpower. Psychiatric nursing is essential. The ideal nurse-patient ratio should be 1:5 in psychiatric care. The possibilities of tele-nursing could be explored. The Government should enable more psychiatric nursing courses.

Under the 12th Plan the MHFW had planned to start counselling services in colleges where students have identifiable mental disorders. Trained counselling psychologists can pick up the danger signals and help avert crisis situations such as suicides. Only those with a postgraduate degree in psychological counselling should provide professional counselling. This is not the case now.

Lack of self-awareness and public awareness on psychological health, psychological disorders and psychological well-being pose challenges. There’s a lot of stigma associated with this, mainly due to the cultural ethos. The general tendency is to hush up instances of mental disorder.

Mental health systems in developed countries focus on prevention and early intervention. The vision statement on the mental health policy of the government of Ireland says, “Service providers should work in partnership with service users and their families, and facilitate recovery and re-integration through the provision of accessible, comprehensive and community-based mental health services.” The Mental Health Care Bill does not offer much on prevention and early intervention.

In the context of healthcare provisions becoming costlier day by day, a system focused on health protection rather than illness care can bring in lot of relief to the Government. Unfortunately, there is under-investment in health protection and illness prevention within our healthcare delivery system. With the new National Health Policy focusing on a healthier India, it is important to design preventive strategies. In the case of mental illnesses too, cost-effective preventive and early intervention is the need of the hour.

It is expected that the passing of the Mental Health Care Bill will lead to legislations with a humane touch. It can help in reducing the stigma of mental illness and in rehabilitating patients who are mostly unemployed and suffer from social stigma and ostracism. By making mental healthcare treatment a legal right, the Bill is progressive and reformist. The implementation of the provisions in this Bill in letter and spirit is crucial for the success of this epoch-making piece of legislation.

The writer is a Bengaluru-based health economist and professor