The Mental Healthcare Bill — approved in the Lok Sabha last week following Rajya Sabha approval in August 2016 — marks a paradigm shift in the care and treatment of persons with mental illness in India. Instead of viewing persons with mental illness as objects of fear, pity and charity, the new Bill recognises them as citizens with health rights, including the right to quality mental health care. The formality of Presidential assent will make it the law of the land and repeal the existing Mental Health Act, 1987.
There are important lessons from the process of its drafting as well as its contents. The Bill underwent wide public consultations from 2010. These include regional consultations and a national consultation attended by nearly 300 stakeholders. Introduced in Parliament by the UPA government in August 2013, the Bill received detailed scrutiny of the Parliamentary Standing Committee for Health (Union Health Minister J.P. Nadda was a member) which recorded evidence of all stakeholders, including groups opposed to the very notion of reform in mental health law. The standing committee’s amendments were accepted by the then UPA government. The NDA government had a relook at the Bill and it was once again approved by the Cabinet. This emphasis on an inclusive law-making process ultimately reflected in the near universal support of MPs cutting across party lines. In a first, Parliament devoted six hours debating and discussing mental health issues. A record number of 29 MPs participated in the debate, without acrimony or disruptions and all expressing support.
Contents of the Bill such as decriminalisation of suicide have received wide coverage and will not be repeated here. After 70 years of doing little, the Bill is a bold attempt by Government to change the narrative around mental illness. MP Shashi Tharoor passionately argued: “We must right long-standing wrongs, even if we have to accept hard truths and reorient our thinking.” The facts: 150 million Indians need treatment for mental illness but nearly 80-90% receive NO treatment (so-called treatment gap). We spend less than 1% of the public health budget on mental health although mental health problems constitute nearly 13% of the health burden. Recognising this historic neglect, the Bill makes provision for universal access to a range of mental health-care services in the community, at the district level, through the public health system. The Bill also makes it compulsory for insurance companies to include mental illness cover in medical insurance policies. These steps will ensure more people get treatment and reduce the treatment gap.
Empowering options
Some concerns have been expressed about the provision of Advance Directive (AD) and Nominated Representative (NR) in the Bill. AD allows all citizens, not just persons with mental illness, to state (when they are well) their treatment choices in the event a future mental illness takes away their ability to make treatment-related decisions. This is not a compulsory requirement but it is a hugely empowering option. No one will be left untreated because they did not write an AD but many will recognise its importance, especially those who are wary of unscrupulous medical practice or who have indeed suffered from such practice in the past. Similarly, the Bill has provisions for individuals to appoint a nominated representative to make decisions on their behalf when they are unwell and cannot make decisions for themselves. This too is an option and if no such appointment is made, family members are the default NR. Both provisions give a measure of control back to individuals with mental illness, particularly women, allowing them to actively participate in decision-making about their care and treatment.
Given the historical context of denial of rights and poor quality treatment to persons with mental illness, this Bill takes an aspirational stance. For some, it may not go far enough; we know there are others for whom it goes too far. The challenge lies in its implementation, not easy, but eminently possible. Mr. Nadda has already promised in the Lok Sabha and on Twitter that “Budget will never be an issue”. All those who have hailed the government for its farsightedness and its acknowledgment of citizens’ rights will now need to work together to ensure that the Mental Healthcare Act, 2017 is implemented with integrity.
Dr. Soumitra Pathare is a consultant psychiatrist & Director, Centre for Mental Health Law and Policy, Indian Law Society, Pune, India. He was closely involved in the drafting of the Mental Healthcare Bill
