Mental health and its care are finally getting some much needed attention. This year the World Health Organisation made depression, arguably one of the leading causes of ill health and disability worldwide, the theme for World Health Day on April 7. In India, last week, the Parliament approved the Mental Health Care Bill, which changes the approach to mental healthcare from the previous Mental Health Act, 1987 that primarily focussed on administrative aspects of care in mental hospitals to a more human rights based approach for people living with mental illness.
The Bill makes the bold move to decriminalise suicide by repealing Article 309 of the Indian Penal Code that made attempted suicide punishable by imprisonment for up to one year. It also provides for mentally ill people to issue advance directives by which they can decide beforehand how they would be treated and nominate representatives – a legal guardian and a caretaker – who can take decisions on their treatment and care in case of their losing understanding of their own illnesses. The bill also makes elaborate provisions to safeguard against coercion in cases of supported admissions, where someone other than the ill person makes a decision for hospitalisation. The Bill encompasses all mental health establishments, including general hospital psychiatry units, private nursing homes and hospitals, and traditional and informal care services, to protect the rights of the mentally ill and maintain a minimum standard of care.
To safeguard the rights of the mentally ill, the Bill has introduced an additional quasi-judicial authority called the Mental Health Review Board. The board has been given a long list of responsibilities. These include registering, revoking, renewing or cancelling advanced directives, scrutinising nominated representatives or even appointing them, reviewing supported admission, addressing rights violations by mental health establishments, and other legal issues related to deficiency in mental health services. All these tasks are required to be decided in a time-bound manner, making the Board’s mandate seemingly Sisyphean.
The drafters of the Bill seem to have assumed that most problems that come before the Board can be solved in a single or a few sittings. However, Board members, who would have other responsibilities, may not be available or might be unable to address all matters that come before them. Just as the Indian legal system has a humongous backlog of pending cases, the Board might very quickly be overwhelmed with the volume of cases to hear.
Where is the investment?
The various advances proposed in the Bill would require significant investment in developing and training human resources, especially to run the Mental Health Review Board that will look into juridical aspects of mental healthcare. The Bill’s provisions are likely to discourage not-for-profit and private enterprises from providing mental healthcare services that have legal implications. As a result, a large number of people requiring mental healthcare could move to the public healthcare system that still needs to be prepared by training and recruiting human resources and investing in mental health infrastructure.
The National Health Policy, 2017, has a target of investing only 2.5% of GDP on health by 2025, while other middle income countries already invest between four and five percent. This financial niggardliness is the primary reason for the appalling state of the public health system in the country. With this amount of investment, it will be nearly impossible to realise the objectives of the Bill, considering that mental health is usually allocated only around 0.06% of the health budget. In other words, the noble objectives of the Bill, will remain just a wish list.
In India, family members have typically borne the burden of care for the mentally ill. At the same time, family members also have been perpetrators of abuse. While the Bill addresses rights-based issues related to treatment and care of mental illness, it overlooks the issue of mental health as a reflection of social perils in a highly inegalitarian society marked by deprivation, poverty and discrimination. As a result, the Bill reinforces a medicalised view of mental illness and misses the opportunity to consider social determinants like inequality and hopelessness and their consequences for mental health. This medicalised approach is like prescribing antidepressants to farmers who are facing an acute agrarian crisis to prevent them committing suicide.
Mohan Rao is professor at the Centre for Social Medicine and Community Health at Jawaharlal Nehru University, Delhi. Anindya Das is assistant professor of psychiatry at the All India Institute of Medical Sciences, Rishikesh.