With the Rajya Sabha passing the Mental Health Care Bill, 2013, on Monday, India took a step towards implementing a legislation that recognises the rights of the mentally ill and aims to protect them. The new law, when passed by the Lok Sabha, will replace the archaic Mental Health Act of 1987.
In a first, the bill has an expansive definition of what constitutes mental illness and recognises the right of mentally ill people to affordable and quality healthcare. Mental health experts, however, are sceptical about how these far-reaching provisions will be implemented.
The reform, however, is much-needed. Critics of the 1987 law had said that it was not much better than the British-era Indian Lunacy Act of 1912. The 1912 Act had revamped the system of mental health services and administration in India, according to an article in the journal Mental Health Reviews. The law removed the so-called mental hospitals from the purview of prison and brought them under central supervision. Crucially, the role of specialists, such as psychiatrists, for treating these patients was recognised. However, at the crux of the law was the need to protect the public from the mentally ill who were considered to be potentially dangerous.
“Conceptually this [the 2013 bill] is a very different bill,” said Vikram Patel, mental health expert and co-director at the Centre for Control of Chronic Conditions at the Public Health Foundation of India. “In the previous Act, the emphasis was to protect society from the mentally ill and so the emphasis was largely on coercive, involuntary treatment of people with mental illnesses, barring them from a variety of civic spaces and rights. Now, the emphasis of this bill is highlighting the rights of the mentally ill and protecting them from abuse and discrimination.”
The new mental healthcare bill defines mental illness as “a substantial disorder of thinking, mood, perception, orientation or memory that grossly impairs judgment, behaviour, capacity to recognise reality or ability to meet the ordinary demands of life, mental conditions associated with the abuse of alcohol and drugs, but does not include mental retardation which is a condition of arrested or incomplete development of mind of a person, specially characterised by subnormality of intelligence”.
This is a much more detailed and extensive definition that the one in the 1987 Act, which states that a mentally ill person is one with “any mental disorder other than mental retardation.”
The ambition of the bill is to universalise access to mental healthcare through services run or funded by the government and to ensure affordable, quality access to treatment.
It also gives mentally-ill people the power to determine their treatment by giving them the right to issue advance directives stating how they want to be treated and by nominating representatives to ensure these directives are carried out. Thirdly, the bill mandates that all insurance companies provide medical insurance for the mentally ill on the same grounds that they would issue insurance for physical illnesses.
And, in perhaps of its most crucial features, it decriminalises suicide, which is currently punishable under Section 309 of the Indian Penal Code. According to the bill, anyone who attempts suicide will be presumed to be mentally ill at the time of committing the act, unless proven otherwise.
The bill also bans illegal restraint or seclusion of mentally ill people and the use of electro-convulsive therapy without anaesthesia or on minors. However, it allows of electro-convulsive therapy for minors, after necessary permissions are sought, if the psychiatrist deems it essential.
Questions of implementation
Those working with mentally-ill patients feel that the bill sounds good in theory, but the problem will be implementing these big ideas.
“It is all good to say that we are going to have universal access to mental health but the reality is that the state itself does not know how many beds are available for people suffering from mental illness,” said Paras Sharma, programme coordinator of a free psychological helpline called iCall at the Tata Institute of Social Sciences in Mumbai. “The second thing is that most states are not even aware of the mental health burden.”
The bill suggests that universal mental health care should be achieved by providing proper access to treatment at the district level. However, Sharma, who works with district-level mental health programmes in Maharashtra, questioned how this would happen.
“Maharashtra is probably the only state that has a semblance of a district-level mental health programme, which is running in 13 districts,” he said. “But only four of the 13 districts are being funded by the government. So how can we talk about district-level access to mental health care when there is no funding?” Sharma said that the bill does not provide for any sort of mental healthcare fund.
While the Centre has produced a visionary document, healthcare is a state subject and delivery of services will vary from state to state, said those working in the mental health sector.
Reports of the Ministry of Health and Family Welfare recognise a treatment gap of 50%-70% for mental health care – which means a majority of those who need treatment and medical attention are not receiving it.
And with significant cuts in the funding for healthcare in the last two union budgets, experts are questioning how the universal mental health care will be implemented.
But the problem runs deeper than lack of funds.
“Even the existing money that is given to district mental health programmes is often not spent and the issue is not of money alone,” said Patel. “It is also a question of the technical capacity of governance and of state governments and officers knowing how to use that money in a way that can maximise coverage and quality care.”
The way forward
According to Sharma, the bill is largely biomedical in its outlook – it caters to the mentally ill who are admitted to healthcare facilities but does not look at common mental illnesses for which people seek counselling but do not need to be institutionalised.
"We need to start recognising mental health specialists apart from psychiatrists and social workers," he said. "We need to open up positions and recruit people at the district level."
Sharma expressed concern about the fact that the bill does not mention specific mechanisms to complain against violations of the law or specific penalties for violators.
Patel, who feels that the new mental health bill is one of the most well thought-through policy documents in recent times, was worried about how it may be diluted going forward.
“We need a very strong accountability system involving the civil society that follows the implementation of the bill, like we have for the Right to Information Act,” said Patel. “What I am hoping is that in every state, you will see groups of consumers, civil society members and mental health professionals coming together to ensure that the state is implementing it in the letter and spirit of the law.